Systematic Review and Meta-analysis of Prophylactic Mesh During Primary Stoma Formation to Prevent Parastomal Hernia.

Abstract

Implantation of mesh at the time of stoma formation may reduce the rate of parastomal hernia. Until recently, the evidence has been limited to only a few small randomized controlled trials. We present an updated systematic review and meta-analysis to assess the effect of mesh prophylaxis on rates of parastomal hernia. We examine ongoing and unpublished trials via online registries and propose recommendations for future research. MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2016 for published randomized controlled trials. Sixteen international trial registries were inspected for ongoing and unpublished trials. Randomized controlled trials comparing mesh versus no mesh on the incidence of parastomal hernia after colostomy or ileostomy formation were selected. The primary outcome measure was rate of parastomal hernia at least 12 months after stoma formation. Secondary outcomes included rates of stoma-related complications. Of 3005 studies identified, 7 randomized controlled trials (432 patients) were eligible for inclusion in the final analysis. All were at high risk of bias. Mesh reduced the incidence of clinically detected parastomal hernia (10.8% vs 32.4%; p = 0.001) (risk ratio, 0.34; 95% CI, 0.18-0.65; I = 39%) and the rate of radiologically detected parastomal hernia (34.6% vs 55.3%; p = 0.01) (risk ratio, 0.61; 95% CI, 0.42-0.89; I = 44%). No increase in the incidence of stoma-related complications was observed with the use of prophylactic mesh. Results from ongoing and unpublished randomized controlled trials are expected, but few will report on alternative mesh types or surgical techniques. Heterogeneity of interventions, small patient populations, and a high risk of bias seen in all studies implicate cautious interpretation of the results. Mesh prophylaxis at the time of stoma formation appears safe and effective in preventing parastomal hernia; however, limitations of the primary evidence justify larger, more rigorous randomized controlled trials.