This letter is available via Open Access. Click on the Publisher URL to access via the publisher's site.Published

Brook, Antonia

Daniels, Ian R.

De Haes, Femke

Mansfield, Steve

Smart, Neil J.

Published.This letter is available via Open Access. Click on the Publisher URL to access via the publisher's site

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Your viewsThe Editor-in-Chief welcomes topical corre-spondence from readers relating to articlespublished in BJS Open. Letters should besubmitted via ScholarOne Manuscripts and,if accepted, will be published online.Incidence of and risk factors forstoma-site incisional herniationafter reversalDOI: 10.1002/bjs5.50165We read with interest the work ofAmelung and colleagues, recently pub-lished in the journal1. This retrospectivecohort identified several factors associ-ated with increased hernia risk followingostomy closure. However, we identifiedconsiderable heterogeneity within thegroups included in their analysis, partic-ularly patients with hernias at the site ofboth ileostomies and colostomies, andvariable indications for their construc-tion. It is notable that twice as manypatients with a colostomy presentedwith hernia compared with those withan ileostomy. The technique of surgicalclosure was not standardized, leading topotential confounding effects of meth-ods, sutures and technique. To gain aproper understanding of risk factorsfor stoma-site hernia development, wesuggest more robust stratification ofthese factors. Perhaps the data could beanalysed to compare the factors asso-ciated with stoma-site hernia by stomatype reversed.It is interesting that hypertension isassociated with abdominal wall failure,a relationship previously identified inour own work following loop ileostomyclosure2. The significance of BMI andhypertension appear to be overtakingsmoking as a risk factor, as smokingwas not a significant factor in this ana-lysis or others2,3. Optimizing BP andweight reduction are logical ways toreduce the incidence of hernia, as wellas the selective use of prophylactic meshimplants in high-risk patients. Furtherwork is required to assess mechanismsrelated to hernia recurrence and hyper-tension. Mounting evidence now sug-gests the main predictor of failure is thepatient, not the surgeon, and, of course,both parties can work together to reducerisks.DisclosureThe authors declare no conflict ofinterest.A. J. Brook, F. De Haes, N. J. Smart,S. D. Mansfield and I. R. DanielsExeter Surgical Health Service ResearchUnit, Royal Devon and Exeter Hospital,Barrack Road, Exeter EX2 5DW, UKdradambrook@gmail.com@ExeterHeSRU1 Amelung FJ, de Guerre LEVM,Consten ECJ, Kist JW, Verheijen PM,Broeders IAMJ et al. Incidence of andrisk factors for stoma-site incisionalherniation after reversal. BJS Open2018; 2: 128–134.2 Brook AJ, Mansfield SD, Daniels IR,Smart NJ. Incisional hernia followingclosure of loop ileostomy: the mainpredictor is the patient, not thesurgeon. Surgeon 2018; 16: 20–26.3 Fazekas B, Fazekas B, Hendricks J,Smart N, Arulampalam T. Theincidence of incisional herniasfollowing ileostomy reversal incolorectal cancer patients treated withanterior resection. Ann R Coll SurgEngl 2017; 99: 319–324.Authors’ reply: One-year outcomesfor congenital diaphragmatic herniaDOI: 10.1002/bjs5.50168We agree that developing a core out-come set for congenital diaphragmatichernia would be an important step for-ward in the field. To achieve this wewill need to collaborate with parents,patients, neonatologists, paediatric sur-geons, fetal medicine doctors, nurses,policy-makers and other professionalscaring for these babies.With regard to the limitations of thestudy, these were presented extensivelyin the Discussion, but we still hope thispaper will give original and accurateinformation to the scientific community.S. GiulianiDepartment of Specialist Neonatal andPaediatric Surgery, Great Ormond StreetHospital for Children, Great OrmondStreet, London WC1N 3JH, UKe-mail: stefano.giuliani@gosh.nhs.ukOne-year outcomes for congenitaldiaphragmatic herniaDOI: 10.1002/bjs5.50169We commend the detailed analyses pre-sented by Wang et al., and support theuse of routinely collected data such asthose from Hospital Episode Statistics(HES) for interrogating surgical out-comes. Reducing unwarranted variationis a priority for the National Health Ser-vice and has been the subject of initia-tives such as the Getting It Right FirstTime (GIRFT) programme in paediatricsurgery.Wang and colleagues’ findings strikea similar note to work we have doneusing HES data in paediatric surgery1,2;together they highlight the challengesof detecting statistically and clinicallysignificant differences in outcome wheninvestigating rare conditions. The keyfor future study has to be the devel-opment of robust, composite outcomemeasures that are both clinically relevantand important to patients and families.We highlight the limitations of HESdata and the need to guard against‘overinterpretation’: Wang et al. usedICD-10 codes for postnatal pulmonaryhypertension (PPHN) and pulmonaryhypoplasia to investigate their effectson outcome. It is almost certain thatthese codes were completed somewhatarbitrarily at discharge, and it couldbe argued that all babies with con-genital diaphragmatic hernia (CDH)have PPHN and pulmonary hypopla-sia anyway; these analyses thereforeseem unhelpful. Furthermore, a centre’soutcomes are likely to be determinedlargely by how severely affected thebabies they are looking after are. Thiscase-mix severity will be influencedgreatly by whether or not a centre hasinborn babies (rather than those wellenough to be transferred in), patterns oftermination of pregnancy, and whetheror not babies are transferred for special-ist care, for instance for extracorporealmembrane oxygenation. HES data lack© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd BJS Open 2019; 3: 415–416This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,provided the original work is properly cited.

Incidence of and risk factors for stoma-site incisional herniation after reversal

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Incidence of and risk factors for stoma-site incisional herniation after reversal

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