EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention—With ESCP and EAES Participation

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention.Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders.Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients’ preferences and values, cost and resources considerations, acceptability, equity and feasibility.Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia.Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity

Retrospective observational study on the incidence of incisional hernias after colorectal carcinoma resection with follow-up CT scan

Incisional hernia (IH) is the most frequent complication after colorectal carcinoma (CRC) resection. The incidence depends on the method of follow-up, where ultrasound yields a significant number of additional hernias compared to clinical examination alone. Not many studies have evaluated the value of computed tomography (CT) to diagnose IH. The CorreCT study is a retrospective cohort study of IH after CRC surgery by clinical examination and by CT, as reported in the medical files. Additional independent reviewing of all CTs by two radiologists was performed. From the oncological database (2004-2008) of the hospital, 598 patients with CRC were identified. The data of 448 consecutive patients who underwent surgery were analyzed. Tumors were resected by laparotomy in 366 patients (81.7 %), by laparoscopy in 76 patients (17.0 %) and by laparotomy after conversion in 6 patients (1.3 %). A clinical follow-up by the surgeon in 282 patients (62.9 %) with a mean duration of 33 months, yielded 49 patients with IH (17.4 %). The mean time of IH diagnosis (T1) was 19 months. Only 16 patients (33 %) underwent a hernia repair. For 363 patients (81.0 %), CT follow-up was available for a mean period of 30 months. In 84 patients (23.1 %), an IH was diagnosed with a mean T1 of 21 months. The review of all CTs by two independent radiologists yielded additional IH in 19 and 21 patients, respectively, increasing the IH rate to 29.1 and 29.7 %, respectively, and with a decrease in mean T1 to 14 months. The inter-observer agreement between the radiologists had a Kappa-statistic of 0.73 (95 % CI 0.65-0.81). For those patients with disagreement between the radiologists, a final agreement was made during an additional reviewing session of both radiologists, increasing the IH rate to 35.0 %. Comparing clinical follow-up, routine CT follow-up, and reassessed CT follow-up we found a statistically significant difference between the three methods of IH detection (p < 0.0001). CT follow-up can identify significantly more IH than clinical examination alone, in particular if the radiologist focuses on IH development. Furthermore, we showed that focused CT evaluation diagnosed IH 7 months earlier than routine CT and 5 months earlier than clinical follow-up alone

Incidence of parastomal and incisional hernia following emergency surgery for Hinchey III-IV diverticulitis:a systematic review

Abstract Purpose: The aim of this systematic review was to evaluate the risk of parastomal (PSH) and incisional hernias (IH) after emergency surgery for Hinchey III–IV diverticulitis, with comparison between the Hartmann procedure and other surgical techniques. Methods: The Cochrane Library, Embase, PubMed (MEDLINE), Web of Science and Scopus databases were systematically searched. The primary endpoint was parastomal hernia incidence. The secondary endpoint was incisional hernia incidence. Results: Five studies (four randomized controlled trials and one retrospective cohort) with a total of 699 patients were eligible for inclusion. The PSH rate was 15%–46% for Hartmann procedure, 0%–85% for primary anastomosis, 4% for resection, and 2% for laparoscopic lavage. The IH rates were 5%–38% for Hartmann procedure, 5%–27% for primary anastomosis, 9%–12% for primary resection, and 3%–11% for laparoscopic lavage. Conclusions: Both the parastomal and incisional hernia incidences are poorly evaluated and reported, and varied greatly between the studies

Retrospective observational study on the incidence of incisional hernias after reversal of a temporary diverting ileostomy following rectal carcinoma resection with follow-up CT scans

Wounds resulting from the closure of temporary stomas have a high risk of developing an incisional hernia (IH) with incidences around 30 % in studies designed to investigate this outcome. A temporary diverting ileostomy (TDI) is often used in patients after low anterior resection (LAR) for rectal cancer. The OSTRICH study is a retrospective cohort study of rectal cancer patients who had a LAR with a reversed TDI and at least one CT scan during follow-up. Two radiologists independently evaluated all abdominal CT scans to diagnose IH at the ileostomy wound and additionally, IH at the laparotomy site. From the oncological database of rectal cancer patients treated from 2003 till 2012 (n = 317) a cohort of 153 patients that fulfilled the inclusion criteria was identified. Rectal cancer resection was performed by laparoscopy in 53 patients (34.6 %) and by laparotomy in 100 patients (65.4 %). A total of 17 IH (11.1 %) was diagnosed at the former stoma site after a mean follow-up of 2.6 years. Of these, 8 IH were in patients who had a laparoscopic LAR (15.1 %) and 9 IH in patients who had an open LAR (9.0 %) (Fisher's exact test; p = 0.28). IH on the other abdominal wall incisions was reported in 69 patients (45.1 %). Of these, 10 patients underwent laparoscopic rectal surgery (18.9 %) and in 59 patients had open rectal surgery (59.0 %) (Fisher's exact test; p < 0.0001). We found a lower number of incisional hernias (11.1 %) after reversal of ileostomies than expected from the literature. In contrast to the findings at the ileostomy site, a very high frequency of IH (59.0 %) after LAR by laparotomy was found, which was significantly higher than after laparoscopic LAR

A prospective, multicenter, observational study on quality of life after laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh according to the European Registry for Abdominal Wall Hernias Quality of Life Instrument

Background: There is an increasing interest in patient-reported outcome measurement to evaluate hernia operations. Several hernia-specific quality of life (QoL) scales have been proposed, but none are constructed for preoperative assessment. Methods: The European Registry for Abdominal Wall Hernias (EuraHS) proposed the short, 9-question EuraHS-QoL instrument for assessment pre- and postoperatively. The EuraHS-QoL was evaluated in a prospective, multicenter validation study alongside the Visual Analogue Scale, Verbal Rating Scale, and Carolina Comfort Scale (https://clinicaltrials.gov; NCT0193 6584). Results: We included 101 patients undergoing unilateral laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh. Clinical follow-up at 12 months was 87% complete. The EuraHS-QoL score shows good internal consistency (Cronbach's alpha >=.90), good test-retest reliability (Spearman correlation coefficient r >= 0.72), and high correlation for pain with the Visual Analogue Scale, the Verbal Rating Scale, the Carolina Comfort Scale pain scale (r between 0.64 and 0.86), and for restriction of activity with the Carolina Comfort Scale movement scale (r between 0.65 and 0.79). Our results show significant improvement in quality of life at 3 weeks compared with preoperative and further significant improvement at 12 months (P 75 %) or with a 95%) in the majority of the patients. Conclusion: The EuraHS-QoL instrument is a short and valid patient-reported outcome measurement following groin hernia repair. Laparoscopic inguinal hernia repair with ProGrip laparoscopic, self-fixating mesh results in a favorable outcome and significant improvement of quality of life compared with the preoperative assessment

Definitions for loss of domain: an international Delphi consensus of expert surgeons

Background No standardized written or volumetric definition exists for ‘loss of domain’ (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. Methods A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. Results Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. Conclusions Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities

Medialization after combined anterior and posterior component separation in giant incisional hernia surgery, an anatomical study

Background: To obtain tension-free closure for giant incisional hernia repair, anterior or posterior component separation is often performed. In patients with an extreme diameter hernia, anterior component separation and posterior component separation may be combined. The aim of this study was to assess the additional medialization after simultaneous anterior component separation and posterior component separation. Methods: Fresh-frozen post mortem human specimens were used. Both sides of the abdominal wall were subjected to retro-rectus dissection (Rives-Stoppa), anterior component separation and posterior component separation, the order in which the component separation techniques were performed was reversed for the contralateral side. Medialization was measured at 3 reference points. Results: Anterior component separation provided most medialization for the anterior rectus sheath, posterior component separation provided most medialization for the posterior rectus sheath. After combined component separation techniques total median medialization ranged between 5.8 and 9.2 cm for the anterior rectus sheath, and between 10.1 and 14.2 cm for the posterior rectus sheath (depending on the level on the abdomen). For the anterior rectus sheath, additional posterior component separation after anterior component separation provided 15% to 16%, and additional anterior component separation after posterior component separation provided 32% to 38% of the total medialization after combined component separation techniques. For the posterior rectus sheath, additional posterior component separation after anterior component separation provided 50% to 59%, and additional anterior component separation after posterior component separation provided 11% to 17% of the total medialization after combined component separation techniques. Retro-rectus dissection alone contributed up to 41% of maximum obtainable medialization. Conclusion: Anterior component separation provided most medialization of the anterior rectus sheath and posterior component separation provided most medialization of the posterior rectus sheath. Combined component separation techniques provide marginal additional medialization, clinical use of this technique should be carefully balanced against additional risks

Open versus robotic-assisted laparoscopic posterior component separation in complex abdominal wall repair

Abstract Background: Transversus abdominis release (TAR) is a surgical technique used in the treatment of complex ventral hernias. The aim of this study was to compare outcomes of open (oTAR) versus robotic-assisted (rTAR) posterior component separation by TAR. Methods: Consecutive patients at two European hernia centres who underwent bilateral TAR were included. The primary endpoint was the duration of postoperative hospital stay. Results: Data from 90 rTAR and 79 oTAR operations were evaluated. Patient demographics were similar between groups in terms of age, sex, BMI, and co-morbidities. There were more smokers, and hernias were larger in the oTAR group (width 8.7 cm versus 10.0 cm; P = 0.031, length 11.6 cm versus 14.1 cm; P = 0.005). Duration of postoperative hospital stay was significantly shorter in the rTAR group (3.4 days versus 6.9 days; P &lt; 0.001). Short-term serious complications (Clavien–Dindo grade III and above) were more frequent (20.3 per cent versus 7.8 per cent; P = 0.018), and there were more surgical site infections (12.7 per cent versus 3.3 per cent; P = 0.010) in the oTAR group. During a median follow-up of 19 months in the rTAR group and 43 months in the oTAR group, reoperation (4.4 per cent versus 8.9 per cent; P = 0.245), and recurrence rates (5.6 per cent versus 5.1 per cent; P &gt; 0.009) were similar. Conclusion: Patients with ventral incisional hernias who undergo bilateral rTAR had significantly shorter postoperative hospital stays and fewer short-term complications compared with patients undergoing bilateral oTAR

Insight into the methodology and uptake of EAES guidelines: a qualitative analysis and survey by the EAES Consensus & Guideline Subcommittee

Background: Over the past 25 years, the European Association for Endoscopic Surgery (EAES) has been issuing clinical guidance documents to aid surgical practice. We aimed to investigate the awareness and use of such documents among EAES members. Additionally, we conceptually appraised the methodology used in their development in order to propose a bundle of actions for quality improvement and increased penetration of clinical practice guidelines among EAES members. Methods: We invited members of EAES to participate in a web-based survey on awareness and use of these documents. Post hoc analyses were performed to identify factors associated with poor awareness/use and the reported reasons for limited use. We further summarized and conceptually analyzed key methodological features of clinical guidance documents published by EAES. Results: Three distinct consecutive phases of methodological evolvement of clinical guidance documents were evident: a “consensus phase,” a “guideline phase,” and a “transitional phase”. Out of a total of 254 surgeons who completed the survey, 72% percent were aware of EAES guidelines and 47% reported occasional use. Young age and trainee status were associated with poor awareness and use. Restriction by colleagues was the primary reason for limited use in these subgroups. Conclusions: The methodology of EAES clinical guidance documents is evolving. Awareness among EAES members is fair, but use is limited. Dissemination actions should be directed to junior surgeons and trainees