European Hernia Society guidelines on prevention and treatment of parastomal hernias

A Commentary to this article was published

A Commentary to this article was published

A Commentary to this article was published

A Commentary to this article was published

A Commentary to this article was published

Abstract

Background

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.

Methods

The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.

Results

End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.

Conclusion

An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

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Acknowledgements

The guidelines development group would like to thank Sarah Squire, representative of the Colostomy Association of the UK, and Wendy Osborne and Judy Hanley, representatives of the Association of Stoma Care Nurses UK, for their valuable input. Dr. William Hope, MD, FACS, Prof. Bruce Ramshaw, MD, FACS and Prof. Willem Bemelman, MD, PhD, are greatly acknowledged for performing the external assessments.

Funding

The project ‘European Hernia Society Guidelines on Prevention and Treatment of Parastomal Hernias’ was initiated and sponsored by the European Hernia Society.

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Correspondence to S. A. Antoniou.

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SAA declares no conflict of interest. FA declares no conflict of interest. JGA declares no conflict of interest. DB declares no conflict of interest. FB declares no conflict of interest. HTB declares no conflict of interest. KB declares no conflict of interest. JC declares conflict of interest not directly related to the submitted work (personal fees from Johnson & Johnson Ethicon, personal fees from BARD Davol). DC declares conflict of interest not directly related to the submitted work (grants and personal fees from W.L. Gore, personal fees from BARD Davol, personal fees from Johnson & Johnson and personal fees from MSD). UAD declares no conflict of interest. RHF declares no conflict of interest. CFL declares no conflict of interest. BH declares no conflict of interest. FH declares no conflict of interest. AH declares no conflict of interest. AJ declares no conflict of interest. LFK declares no conflict of interest. JRL declares no conflict of interest. IKL declares no conflict of interest. MLC declares conflict of interest not directly related to the submitted work (personal fees from Johnson & Johnson and personal fees from BARD Davol). MM declares conflict of interest not directly related to the submitted work (personal fees from Springer, personal fees from Aspide, grants and personal fees from Bard, personal fees from Braun, personal fees from Cook, grants and personal fees from Covidien, personal fees from Ethicon and personal fees from W.L. Gore) and he serves as co-editor of Hernia. AM serves as executive editor of Hernia. SMC declares conflict of interest not directly related to the submitted work (personal fees from Bard, personal fees from Gore, personal fees from Medtronic and personal fees from Olympus). MP declares no conflict of interest. TR declares no conflict of interest. NS declares conflict of interest not directly related to the submitted work (grants and personal fees from Medtronic). MS declares no conflict of interest. MS declares no conflict of interest. CS declares no conflict of interest. FEM declares conflict of interest not directly related to the submitted work (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).

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The complete lists of excluded articles for each introductory question and each key question are available from the corresponding author.

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Antoniou, S.A., Agresta, F., Garcia Alamino, J.M. et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia 22, 183–198 (2018). https://doi.org/10.1007/s10029-017-1697-5

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keywords

  • Parastomal hernia
  • Stoma
  • Ostomy
  • Prevention
  • Treatment
  • Recurrence