Prophylactic mesh for prevention of parastomal hernia: A meta-analysis of randomized controlled trials

Sunil V Patel, MD, Msc1, Sami A Chadi, MD, MSc2, Steve D Wexner, MD2. 1Kingston General Hospital, 2Cleveland Clinic Florida

Introduction: The purpose of this meta-analysis is to determine if prophylactic placement of mesh in those undergoing stoma creation reduces the odds of developing a parastomal hernia.

Methods and Procedures: A meta-analysis was completed, after searching both EMBASE (1946 – 2015) and MEDLINE (1946 – 2015).  Randomized controlled trials were included in our analysis if they assessed the placement of prophylactic mesh vs. non placement in patients undergoing stoma formation.  We included both biologic and synthetic mesh, as well as any technique for mesh placement (preperitoneal, sublay).  The primary outcome was parastomal hernia formation at >1 year of follow up.  Secondary outcomes included parastomal hernia requiring surgical repair and perioperative complications.  Subgroup analyses were planned to assess the effect of biologic vs. synthetic mesh, mesh position (sublay vs. preperitoneal) and method of diagnosis of parastomal hernia (clinical vs. imaging).  Heterogeneity was explored using the I2 statistic.  Risk of bias of included studies was assessed as per the Cochrane Handbook. The quality of evidence was evaluated using the GRADE criteria.

Results: After title, abstract and full article screening, a total of 7 randomized controlled trials, with 395 participants, fit the inclusion criteria.  Included studies had similar patient characteristics between groups. Four of 7 studies had a high risk of bias, while the other 3 had unclear risk of bias.  Two studies used biologic mesh. Three studies used a preperotineal placement of mesh, while 4 studies used a sublay mesh placement.  The pooled analysis showed a significant decrease in the odds of developing a parastomal hernia in the prophylactic mesh group (OR 0.19, 95%CI 0.10 – 0.34, I2 = 47%).  There was no evidence that placement of mesh increased the odds of complications (OR 1.54, 95%CI 0.78 – 3.05, I2 = 53%) or the odds of patients requiring surgical intervention (3 Studied, OR 0.76, 95%CI 0.27 – 2.14, I2 0%).  The quality of evidence was determined to be moderate.

Limitations: Moderate heterogeneity was seen in the assessed primary and secondary outcomes, which could not be explained through subgroup analysis.

Conclusions: There is moderate quality of evidence to suggest that prophylactic mesh reduces the odds of parastomal hernia in those requiring a stoma.  There is no evidence to suggest that placement of mesh reduces the odds of surgical repair of parastoma hernia or increases odds of complications.

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