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Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Objective

To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data.

Background

Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation.

Methods

A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects.

Results

From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I2 = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups.

Conclusions

There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

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Author information

Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, McMaster University, St. Joseph’s Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada

    Tyler McKechnie MD, Yung Lee MD, Aristithes Doumouras MD MPH, Nalin Amin MD, Dennis Hong MD MSc & Cagla Eskicioglu MD MSc

  2. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Jay Lee BSc, Aristithes Doumouras MD MPH, Nalin Amin MD, Dennis Hong MD MSc & Cagla Eskicioglu MD MSc

  3. Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada

    Aristithes Doumouras MD MPH, Nalin Amin MD, Dennis Hong MD MSc & Cagla Eskicioglu MD MSc

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  1. Tyler McKechnie MD
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Contributions

Conception and design of the study—all authors.

Acquisition of data—McKechnie, Lee.

Analysis and interpretation of data—all authors.

Drafting and revision of the manuscript—all authors.

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Correspondence to Cagla Eskicioglu MD MSc.

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Appendix. PRISMA 2020 checklist

Appendix. PRISMA 2020 checklist

Section and Topic

Item #

Checklist item

Location where item is reported

TITLE

Title

1

Identify the report as a systematic review

1

ABSTRACT

Abstract

2

See the PRISMA 2020 for Abstracts checklist

3

INTRODUCTION

Rationale

3

Describe the rationale for the review in the context of existing knowledge

4,5

Objectives

4

Provide an explicit statement of the objective(s) or question(s) the review addresses

5

METHODS

Eligibility criteria

5

Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses

5,6

Information sources

6

Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted

5

Search strategy

7

Present the full search strategies for all databases, registers and websites, including any filters and limits used

5

Selection process

8

Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process

5–7

Data collection process

9

Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process

7

Data items

10a

List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect

6,7

10b

List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information

6,7

Study risk of bias assessment

11

Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process

8

Effect measures

12

Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results

8,9

Synthesis methods

13a

Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5))

8,9

13b

Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions

8,9

13c

Describe any methods used to tabulate or visually display results of individual studies and syntheses

8

13d

Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used

8,9

13e

Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression)

8,9

13f

Describe any sensitivity analyses conducted to assess robustness of the synthesized results

9

Reporting bias assessment

14

Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases)

9

Certainty assessment

15

Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome

NA

RESULTS

Study selection

16a

Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram

9,10

16b

Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded

9

Study characteristics

17

Cite each included study and present its characteristics

9

Risk of bias in studies

18

Present assessments of risk of bias for each included study

12

Results of individual studies

19

For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots

10

Results of syntheses

20a

For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies

12

20b

Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect

9–12

20c

Present results of all investigations of possible causes of heterogeneity among study results

10

20d

Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results

9–12

Reporting biases

21

Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed

12

Certainty of evidence

22

Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed

NA

DISCUSSION

Discussion

23a

Provide a general interpretation of the results in the context of other evidence

12,13

23b

Discuss any limitations of the evidence included in the review

15

23c

Discuss any limitations of the review processes used

15

23d

Discuss implications of the results for practice, policy, and future research

14,15

OTHER INFORMATION

Registration and protocol

24a

Provide registration information for the review, including register name and registration number, or state that the review was not registered

NA

24b

Indicate where the review protocol can be accessed, or state that a protocol was not prepared

NA

24c

Describe and explain any amendments to information provided at registration or in the protocol

NA

Support

25

Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review

3

Competing interests

26

Declare any competing interests of review authors

2

Availability of data, code and other materials

27

Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review

NA

  1. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

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McKechnie, T., Lee, J., Lee, Y. et al. Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg 26, 486–502 (2022). https://doi.org/10.1007/s11605-021-05174-z

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  • DOI: https://doi.org/10.1007/s11605-021-05174-z

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