Summary for patients: European Hernia Society guidelines on prevention and treatment of parastomal hernias
Who developed these guidelines?
The European Hernia Society (EHS) is a non-profit making international scientific forum that focuses on abdominal wall surgery. The EHS devotes itself to improving patient care by the study of both scientific and clinical related matters in the field of hernia.
What is the problem and what is known about it so far?
Hernias are a common complication following stoma surgery. When a stoma is formed it passes through the abdominal muscles which cause a potential point of weakness. Ideally, the muscles fit snugly around the stoma but sometimes they come away, causing a hernia. A hernia can have a large impact on the quality of life for an ostomate, leading to problems with stoma function and appliance security as well as pain. The EHS decided to write guidelines for prevention and treatment of parastomal hernias due to the lack of current evidence and recommendations. They felt decisions on treatment should not just be based on research evidence but also on individual patients’ preferences, factors specific to their case, the doctor’s perspective, available resources and any other special circumstances. The guidelines take into account expected benefits and potential adverse effects of prevention and treatment strategies with a view to choosing the best option for each patient.
How did the EHS develop these recommendations?
The EHS reviewed available evidence on benefits and harms of different prevention and treatment options to come up with recommendations to be considered alongside patients individual circumstances.
What did the authors find?
Overall there is a lack of current evidence on parastomal hernia prevention and treatment. Future clinical trials hope to address this to provide a more accurate idea of how well treatments work. It is estimated that 30–50% of stoma patients will develop a hernia with a higher incidence in those with an end colostomy compared to a loop colostomy or loop ileostomy. More research is needed to look at incidence in those with an end ileostomy or ileal conduit (urostomy) as these figures are unknown. Diagnosis of a hernia can be difficult and there is no gold standard examination to detect one. A CT scan or ultrasound may be used if the doctor is uncertain. The guidelines committee recommends the use of mesh when a permanent end colostomy is formed, as there is strong evidence to suggest this helps prevent a hernia. However, more research is needed to see if this recommendation also applies to ileostomy and ileal conduit formation. Some doctors and patients choose a non surgical approach to hernia management. Watchful waiting as its known, may be preferred by a patient not wanting to undergo more surgery. High recurrence rates following parastomal hernia repair and the lack of symptoms in many patients makes a conservative approach more attractive but risk of strangulation and the hernia becoming larger may lead to emergency surgery. There is little evidence to support or disagree with watchful waiting, so no recommendation is made by the guidelines committee. Decisions should continue to be based on individual cases. When a hernia is surgically repaired evidence shows that there is a higher risk of recurrence if mesh is not used, although individual circumstances and mesh-associated adverse effects must be considered to use the best method for each patient.
What does the EHS recommend that patients and doctors do?
Each patient’s case should be reviewed, taking the guidelines into consideration but the best treatment plan should be decided with a combination of the evidence-based recommendations along with any factors specific to that patient.
What are the cautions related to these recommendations?
The present guidelines provide an evidence-based approach to the diagnosis and management of parastomal hernias. There is a lack of evidence on several topics that are expected to be addressed by future trials.
Compliance with ethical standards
Conflict of interest
Dr. Muysoms reports grants, personal fees and non-financial support from Medtronic, grants and personal fees from Johnson & Johnson, grants and personal fees from Dynamesh, personal fees from Cousin Biotech and personal fees from BARD Davol outside the submitted work. Sarah E. Squire and Stavros A. Antoniou had nothing to disclose.
Source of funding
This project was funded by the European Hernia Society.
This study did not need approval from the local ethical committee.
Human and animal rights
This study does not contain any studies with participants or animals performed by any of the authors.
Informed consent was not required for this study.