j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Review of stoma site and midline incisional hernias after stoma reversal Mylan T. Nguyen, MS,a,b Uma R. Phatak, MD,a Linda T. Li, MD,b Stephanie C. Hicks, PhD,c Jennifer M. Moffett, MD, MS,b Nestor A. Arita, BS,b Rachel L. Berger, BA,b Lillian S. Kao, MD, MS,a and Mike K. Liang, MDa,* a
Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas Department of General Surgery, Baylor College of Medicine, Houston, Texas c Dana Farber Cancer Institute, Boston, Massachusetts b
article info
abstract
Article history:
Background: The incidence of incisional hernias after stoma reversal is not well reported.
Received 2 December 2013
The aim of this study was to systematically review the literature reporting data on inci-
Received in revised form
sional hernias after stoma reversal. We evaluated both the incidence of stoma site and
24 January 2014
midline incisional hernias.
Accepted 24 January 2014
Methods: A systematic review identified studies published between January 1, 1980, and
Available online xxx
December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies
Keywords:
were excluded. Assessment of risk of bias, detection method, and essential study-specific
Incisional hernia
characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done.
Stoma
Results: Sixteen studies were included in the analysis; 1613 patients had 1613 stomas
Ostomy
formed. Fifteen studies assessed stoma site hernias and five studies assessed midline
Reversal
incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3%
Takedown
(range 0%e33.9%) and for midline incisional hernias was 44.1% (range 8.7%e58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. Conclusion: Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Stomas are routinely created by surgeons to divert stool from distal pathology. Once the distal process has resolved, the intention is to reverse the stoma. Although a powerful preventative and treatment tool, the creation of a stoma and its
subsequent reversal are associated with complications, including anastomotic leaks, wound infection, and incisional hernias. The development of an incisional hernia presents numerous problems for the patient, including pain, discomfort, increasing size, incarceration/strangulation, and the need for further operations to repair the hernia [1].
* Corresponding author. Department of General Surgery, University of Texas Health Science Center at Houston, Houston, TX 77030. Tel.: þ315 214 1530; fax: þ713-566-4242. E-mail addresses: [email protected], [email protected] (M.K. Liang). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.01.046
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e6
Fig e Systematic review.(Color version of figure is available online)
Although it is known that there is a risk of incisional hernias after stoma reversal, the reported prevalence of the complication is highly variable and possibly underestimated. The aim of this study was to systematically review literature reporting data on incisional hernias after stoma reversal to investigate and identify factors that affect the reported incidence of stoma site and midline incisional hernia formation.
2.
Methods
2.1.
Search methods for the identification of studies
A literature search following the Preferred Reporting Items of Systematic-Reviews and Meta-Analyses (PRISMA) guidelines was done of the MEDLINE database, using PubMed and OvidSP, and Cochrane Databases with the following MeSH terms: (colostomy or ileostomy or stoma or ostomy or enterostomy) AND (reversal or closure or takedown) [2]. These searches were restricted according to the following MeSH limits: (1) January 1, 1980, to December 31, 2012; (2) Human; (3) Adults 19e44 and 45þ years; and (4) English articles. A search of the references of captured articles was also performed. Titles, abstracts, and entire articles were reviewed by two independent reviewers and discrepancies were resolved by consensus among the authors.
2.2.
Inclusion and exclusion criteria
Articles were eligible for review if it reported the rate of either stoma site or midline hernias after jejunostomy, ileostomy, or colostomy reversal. Articles that included pediatric cases, case reports, case series with 2 y of follow-up, used both clinical and radiographic imaging to identify incisional hernias, and included information
Table 4 e Midline incisional hernias. Article author, year Bhangu, 2012 [5] Cingi, 2008 [6] Moffet, 2013 [14] Khoury, 1996 [10] Vermeulen, 2010 [19] d ¼ not reported.
Number of midline incision
Midline hernia
% Hernia
Midline incisional hernias and repair method
59 31 65 46 35
26 18 36 4 8
44.1 58.1 55.4 8.7 22.9
d d 7 midline hernias; method of treatment not reported d d
6
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e6
regarding potential confounders like wound closure method [9,14,18]. A prospective observational or comparative study would be the best approach to assessing the incidence of hernia formation after stoma reversal. However, in this review, no studies used this approach. There is need for further highquality studies to assess the true rate of hernia formation after stoma reversal. This study was limited by a number of factors. First, there was significant heterogeneity among the studies. There was significant clinical variability in practice patterns reported in the studies. Second, the overall quality of the studies was low with the vast majority of studies having a moderate to high risk of bias. Because of this, we did not feel that it was appropriate to pool or analyze the data any further. Any metaanalysis on the subject would be poor in quality.
[2]
[3]
[4]
[5]
[6]
[7]
5.
Conclusion
Taking into account the quality of the studies, this review has found that one in three patients undergoing a stoma site reversal develops an incisional hernia at the stoma site and one in two patients that require a laparotomy incision for stoma reversal develops a midline incisional hernia. This is a substantial risk of adverse outcome. High-quality studies with long follow-up duration and standardized outcome definitions are recommended to further analyze the incidence, treatment, and prevention of incisional hernias after stoma reversal.
[8]
[9] [10]
[11]
[12] [13]
Acknowledgment [14]
Authors contributions: M.T.Ndconceiving and designing, collecting data, interpreting data, writing manuscript, approving final version of manuscript. U.R.P.ddesigning, interpreting data, revising, approving final version. L.T.L.ddesigning, interpreting data, revising, approving final version. S.C.H.ddesigning, analyzing, interpreting data, revising, approving final version. J.M.M.ddesigning, interpreting data, revising, approving final version. N.A.A.ddesigning, interpreting data, revising, approving final version. R.L.Bddesigning, interpreting data, revising, approving final version. L.S.K.ddesigning, interpreting data, revising, approving final version. M.K.L.dconceiving and designing, interpreting data, revising, approving final version.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[15] [16]
[17] [18]
[19]
[20]
[21]
[22] [23]
[1] Snyder CW, Graham LA, Vick CC, Gray SH, Finan KR, Hawn MT. Patient satisfaction, chronic pain, and quality of
[24]
life after elective incisional hernia repair: effects of recurrence and repair technique. Hernia 2011 Apr;15:123. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377. Bakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg 2004;21:277. Bhangu A, Fletcher L, Kingdon S, Smith E, Nepogodiev D, Janjua U. A clinical and radiological assessment of incisional hernias following closure of temporary stomas. Surgeon 2012 Dec;10:321. Cingi A, Solmaz A, Attaallah W, Aslan A, Aktan AO. Enterostomy closure site hernias: a clinical and ultrasonographic evaluation. Hernia 2008 Aug;12:401. D’Haeninck A, Wolthuis AM, Penninckx F, D’Hondt M, D’Hoore A. Morbidity after closure of a defunctioning loop ileostomy. Acta Chir Belg 2011 May-Jun;111:136. Garcı´a-Botello SA, Garcı´a-Armengol J, Garcı´a-Granero E, et al. A prospective audit of the complications of loop ileostomy construction and takedown. Dig Surg 2004;21:440. Guzma´n-Valdivia G. Incisional hernia at the site of a stoma. Hernia 2008 Oct;12:471. Khoury DA, Beck DE, Opelka FG, Hicks TC, Timmcke AE, Gathright JB Jr. Colostomy closure. Ochsner Clinic experience. Dis Colon Rectum 1996 Jun;39:605. Krand O, Yalti T, Berber I, Tellioglu G. Early vs. delayed closure of temporary covering ileostomy: a prospective study. Hepatogastroenterology 2008 Jan-Feb;55:142. Lewis P, Bartolo DC. Closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 1990 Jul;72:263. Mala T, Nesbakken A. Morbidity related to the use of a protective stoma in anterior resection for rectal cancer. Colorectal Dis 2008 Oct;10:785. Moffett JM, Nguyen MT, Davila JA, et al. Incisional hernia following stoma reversal: a call for prevention. In submission. Platell C, Barwood N, Makin G. Clinical utility of a defunctioning loop ileostomy. ANZ J Surg 2005 Mar;75:147. Rosen MJ, Cobb WS, Kercher KW, Sing RF, Heniford BT. Laparoscopic restoration of intestinal continuity after Hartmann’s procedure. Am J Surg 2005 Jun;189:670. Saha AK, Tapping CR, Foley GT, et al. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis 2009 Oct;11:866. Schreinemacher MH, Vijgen GH, Dagnelie PC, Bloemen JG, Huizinga BF, Bouvy ND. Incisional hernias in temporary stoma wounds: a cohort study. Arch Surg 2011 Jan;146:94. Vermeulen J, Leijtens JW, Mannaerts GH. Reversal of Hartmann’s procedure after perforated diverticulitis through the stomal side without additional incisions: the SIR procedure. Dig Surg 2010;27:391. Li L, Hicks SC, Davila JA, et al. Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment metaanalysis. In Submission. Cingi A, Cakir T, Sever A, Aktan AO. Enterostomy site hernias: a clinical and computerized tomographic evaluation. Dis Colon Rectum 2006 Oct;49:1559. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985 Jan;72:70. Khaira HS, Lall P, Hunter B, Brown JH. Repair of incisional hernias. J R Coll Surg Edinb 2001 Feb;46:39. Fink C, Baumann P, Wente MN, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg 2014 Jan;101:51.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Review of stoma site and midline incisional hernias after stoma reversal Mylan T. Nguyen, MS,a,b Uma R. Phatak, MD,a Linda T. Li, MD,b Stephanie C. Hicks, PhD,c Jennifer M. Moffett, MD, MS,b Nestor A. Arita, BS,b Rachel L. Berger, BA,b Lillian S. Kao, MD, MS,a and Mike K. Liang, MDa,* a
Department of General Surgery, University of Texas Health Science Center at Houston, Houston, Texas Department of General Surgery, Baylor College of Medicine, Houston, Texas c Dana Farber Cancer Institute, Boston, Massachusetts b
article info
abstract
Article history:
Background: The incidence of incisional hernias after stoma reversal is not well reported.
Received 2 December 2013
The aim of this study was to systematically review the literature reporting data on inci-
Received in revised form
sional hernias after stoma reversal. We evaluated both the incidence of stoma site and
24 January 2014
midline incisional hernias.
Accepted 24 January 2014
Methods: A systematic review identified studies published between January 1, 1980, and
Available online xxx
December 31, 2012, reporting the incidence of incisional hernia after stoma reversal at either the stoma site or at the midline incision (in cases requiring laparotomy). Pediatric studies
Keywords:
were excluded. Assessment of risk of bias, detection method, and essential study-specific
Incisional hernia
characteristics (follow-up duration, stoma type, age, body mass index, and so forth) was done.
Stoma
Results: Sixteen studies were included in the analysis; 1613 patients had 1613 stomas
Ostomy
formed. Fifteen studies assessed stoma site hernias and five studies assessed midline
Reversal
incisional hernias. The median (range) incidence of stoma site incisional hernias was 8.3%
Takedown
(range 0%e33.9%) and for midline incisional hernias was 44.1% (range 8.7%e58.1%). When evaluating only studies with a low risk of bias, the incidence for stoma site incisional hernias is closer to one in three and for midline incisional hernias is closer to one in two. Conclusion: Stoma site and midline incisional hernias are significant clinical complications of stoma reversals. The quality of studies available is poor and heterogeneous. Future prospective randomized controlled trials or observational studies with standardized follow-up and outcome definitions/measurements are needed. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Stomas are routinely created by surgeons to divert stool from distal pathology. Once the distal process has resolved, the intention is to reverse the stoma. Although a powerful preventative and treatment tool, the creation of a stoma and its
subsequent reversal are associated with complications, including anastomotic leaks, wound infection, and incisional hernias. The development of an incisional hernia presents numerous problems for the patient, including pain, discomfort, increasing size, incarceration/strangulation, and the need for further operations to repair the hernia [1].
* Corresponding author. Department of General Surgery, University of Texas Health Science Center at Houston, Houston, TX 77030. Tel.: þ315 214 1530; fax: þ713-566-4242. E-mail addresses: [email protected], [email protected] (M.K. Liang). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.01.046
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e6
Fig e Systematic review.(Color version of figure is available online)
Although it is known that there is a risk of incisional hernias after stoma reversal, the reported prevalence of the complication is highly variable and possibly underestimated. The aim of this study was to systematically review literature reporting data on incisional hernias after stoma reversal to investigate and identify factors that affect the reported incidence of stoma site and midline incisional hernia formation.
2.
Methods
2.1.
Search methods for the identification of studies
A literature search following the Preferred Reporting Items of Systematic-Reviews and Meta-Analyses (PRISMA) guidelines was done of the MEDLINE database, using PubMed and OvidSP, and Cochrane Databases with the following MeSH terms: (colostomy or ileostomy or stoma or ostomy or enterostomy) AND (reversal or closure or takedown) [2]. These searches were restricted according to the following MeSH limits: (1) January 1, 1980, to December 31, 2012; (2) Human; (3) Adults 19e44 and 45þ years; and (4) English articles. A search of the references of captured articles was also performed. Titles, abstracts, and entire articles were reviewed by two independent reviewers and discrepancies were resolved by consensus among the authors.
2.2.
Inclusion and exclusion criteria
Articles were eligible for review if it reported the rate of either stoma site or midline hernias after jejunostomy, ileostomy, or colostomy reversal. Articles that included pediatric cases, case reports, case series with 2 y of follow-up, used both clinical and radiographic imaging to identify incisional hernias, and included information
Table 4 e Midline incisional hernias. Article author, year Bhangu, 2012 [5] Cingi, 2008 [6] Moffet, 2013 [14] Khoury, 1996 [10] Vermeulen, 2010 [19] d ¼ not reported.
Number of midline incision
Midline hernia
% Hernia
Midline incisional hernias and repair method
59 31 65 46 35
26 18 36 4 8
44.1 58.1 55.4 8.7 22.9
d d 7 midline hernias; method of treatment not reported d d
6
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e6
regarding potential confounders like wound closure method [9,14,18]. A prospective observational or comparative study would be the best approach to assessing the incidence of hernia formation after stoma reversal. However, in this review, no studies used this approach. There is need for further highquality studies to assess the true rate of hernia formation after stoma reversal. This study was limited by a number of factors. First, there was significant heterogeneity among the studies. There was significant clinical variability in practice patterns reported in the studies. Second, the overall quality of the studies was low with the vast majority of studies having a moderate to high risk of bias. Because of this, we did not feel that it was appropriate to pool or analyze the data any further. Any metaanalysis on the subject would be poor in quality.
[2]
[3]
[4]
[5]
[6]
[7]
5.
Conclusion
Taking into account the quality of the studies, this review has found that one in three patients undergoing a stoma site reversal develops an incisional hernia at the stoma site and one in two patients that require a laparotomy incision for stoma reversal develops a midline incisional hernia. This is a substantial risk of adverse outcome. High-quality studies with long follow-up duration and standardized outcome definitions are recommended to further analyze the incidence, treatment, and prevention of incisional hernias after stoma reversal.
[8]
[9] [10]
[11]
[12] [13]
Acknowledgment [14]
Authors contributions: M.T.Ndconceiving and designing, collecting data, interpreting data, writing manuscript, approving final version of manuscript. U.R.P.ddesigning, interpreting data, revising, approving final version. L.T.L.ddesigning, interpreting data, revising, approving final version. S.C.H.ddesigning, analyzing, interpreting data, revising, approving final version. J.M.M.ddesigning, interpreting data, revising, approving final version. N.A.A.ddesigning, interpreting data, revising, approving final version. R.L.Bddesigning, interpreting data, revising, approving final version. L.S.K.ddesigning, interpreting data, revising, approving final version. M.K.L.dconceiving and designing, interpreting data, revising, approving final version.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[15] [16]
[17] [18]
[19]
[20]
[21]
[22] [23]
[1] Snyder CW, Graham LA, Vick CC, Gray SH, Finan KR, Hawn MT. Patient satisfaction, chronic pain, and quality of
[24]
life after elective incisional hernia repair: effects of recurrence and repair technique. Hernia 2011 Apr;15:123. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377. Bakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg 2004;21:277. Bhangu A, Fletcher L, Kingdon S, Smith E, Nepogodiev D, Janjua U. A clinical and radiological assessment of incisional hernias following closure of temporary stomas. Surgeon 2012 Dec;10:321. Cingi A, Solmaz A, Attaallah W, Aslan A, Aktan AO. Enterostomy closure site hernias: a clinical and ultrasonographic evaluation. Hernia 2008 Aug;12:401. D’Haeninck A, Wolthuis AM, Penninckx F, D’Hondt M, D’Hoore A. Morbidity after closure of a defunctioning loop ileostomy. Acta Chir Belg 2011 May-Jun;111:136. Garcı´a-Botello SA, Garcı´a-Armengol J, Garcı´a-Granero E, et al. A prospective audit of the complications of loop ileostomy construction and takedown. Dig Surg 2004;21:440. Guzma´n-Valdivia G. Incisional hernia at the site of a stoma. Hernia 2008 Oct;12:471. Khoury DA, Beck DE, Opelka FG, Hicks TC, Timmcke AE, Gathright JB Jr. Colostomy closure. Ochsner Clinic experience. Dis Colon Rectum 1996 Jun;39:605. Krand O, Yalti T, Berber I, Tellioglu G. Early vs. delayed closure of temporary covering ileostomy: a prospective study. Hepatogastroenterology 2008 Jan-Feb;55:142. Lewis P, Bartolo DC. Closure of loop ileostomy after restorative proctocolectomy. Ann R Coll Surg Engl 1990 Jul;72:263. Mala T, Nesbakken A. Morbidity related to the use of a protective stoma in anterior resection for rectal cancer. Colorectal Dis 2008 Oct;10:785. Moffett JM, Nguyen MT, Davila JA, et al. Incisional hernia following stoma reversal: a call for prevention. In submission. Platell C, Barwood N, Makin G. Clinical utility of a defunctioning loop ileostomy. ANZ J Surg 2005 Mar;75:147. Rosen MJ, Cobb WS, Kercher KW, Sing RF, Heniford BT. Laparoscopic restoration of intestinal continuity after Hartmann’s procedure. Am J Surg 2005 Jun;189:670. Saha AK, Tapping CR, Foley GT, et al. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis 2009 Oct;11:866. Schreinemacher MH, Vijgen GH, Dagnelie PC, Bloemen JG, Huizinga BF, Bouvy ND. Incisional hernias in temporary stoma wounds: a cohort study. Arch Surg 2011 Jan;146:94. Vermeulen J, Leijtens JW, Mannaerts GH. Reversal of Hartmann’s procedure after perforated diverticulitis through the stomal side without additional incisions: the SIR procedure. Dig Surg 2010;27:391. Li L, Hicks SC, Davila JA, et al. Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment metaanalysis. In Submission. Cingi A, Cakir T, Sever A, Aktan AO. Enterostomy site hernias: a clinical and computerized tomographic evaluation. Dis Colon Rectum 2006 Oct;49:1559. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985 Jan;72:70. Khaira HS, Lall P, Hunter B, Brown JH. Repair of incisional hernias. J R Coll Surg Edinb 2001 Feb;46:39. Fink C, Baumann P, Wente MN, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg 2014 Jan;101:51.
