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European Hernia Society guidelines on prevention and treatment of parastomal hernias

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An Invited commentary to this article was published on 04 January 2018

An Invited Commentary to this article was published on 13 November 2017

An Invited Commentary to this article was published on 13 November 2017

An Invited Commentary to this article was published on 13 November 2017

An Invited Commentary to this article was published on 13 November 2017

Abstract

Background

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.

Methods

The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.

Results

End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.

Conclusion

An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

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Acknowledgements

The guidelines development group would like to thank Sarah Squire, representative of the Colostomy Association of the UK, and Wendy Osborne and Judy Hanley, representatives of the Association of Stoma Care Nurses UK, for their valuable input. Dr. William Hope, MD, FACS, Prof. Bruce Ramshaw, MD, FACS and Prof. Willem Bemelman, MD, PhD, are greatly acknowledged for performing the external assessments.

Funding

The project ‘European Hernia Society Guidelines on Prevention and Treatment of Parastomal Hernias’ was initiated and sponsored by the European Hernia Society.

Author information

Authors and Affiliations

  1. Department of General Surgery, University Hospital of Herakion, Crete, Greece

    S. A. Antoniou

  2. Department of General Surgery, ULSS19 del Veneto, Adria, RO, Italy

    F. Agresta

  3. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK

    J. M. Garcia Alamino

  4. Clinic of Abdominal, Thoracic and Pediatric Surgery, Klinikum Mittelbaden/Balg, Baden-Baden, Germany

    D. Berger

  5. Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium

    F. Berrevoet

  6. Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK

    H.-T. Brandsma

  7. Department Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland

    K. Bury

  8. Herniacenter Dr. Muschaweck/Dr. Conze, Munich, Germany

    J. Conze

  9. Herniacenter Dr. Muschaweck/Dr. Conze, London, UK

    J. Conze

  10. Department of General, Visceral and Transplant Surgery, University Hospital, RWTH Aachen University, Aachen, Germany

    J. Conze

  11. Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera dei Colli, Naples, Italy

    D. Cuccurullo

  12. Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Wuerzburg, Germany

    U. A. Dietz

  13. Certified Hernia Center, Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria

    R. H. Fortelny

  14. Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland

    C. Frei-Lanter

  15. Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands

    B. Hansson

  16. Department of Surgery, Zealand University Hospital, Køge, Denmark

    F. Helgstrand

  17. National Bowel Research Centre, The Royal London Hospital, London, United Kingdom

    A. Hotouras

  18. Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden

    A. Jänes

  19. Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands

    L. F. Kroese

  20. Surgical Department, Innlandet Hospital Trust, Gjøvik, Norway

    J. R. Lambrecht

  21. Department of Surgery, Maria Middelares Hospital, Ghent, Belgium

    I. Kyle-Leinhase & F. E. Muysoms

  22. Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain

    M. López-Cano

  23. Department of Colorectal Surgery, Beaujon Hospital, Assistance publique-Hôpitaux de Paris, Université Paris VII, Clichy, France

    L. Maggiori

  24. Department of General Surgery, Buccheri La Ferla Hospital, Palermo, Italy

    V. Mandalà

  25. Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium

    M. Miserez

  26. Department of Surgery, Skåne University Hospital, Malmö, Sweden

    A. Montgomery

  27. University Hospital Virgen del Rocío, Sevilla, Spain

    S. Morales-Conde

  28. Digestive Surgery Department, CHU Nîmes, Nîmes, France

    M. Prudhomme

  29. Department of Surgery, Division of Gastroenterology, Medical Research Center, Oulu University Hospital, Oulu, Finland

    T. Rautio

  30. Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, UK

    N. Smart

  31. 2nd Department of Radiology, Medical University of Gdansk, Gdańsk, Poland

    M. Śmietański

  32. Department of General Surgery and Hernia Centre, District Hospital in Puck, Puck, Poland

    M. Śmietański

  33. Department of Rehabilitation, Józef Piłsudski University of Physical Education in Warsaw, Warsaw, Poland

    M. Szczepkowski

  34. Clinical Department of General and Colorectal Surgery, Bielanski Hospital, Warsaw, Poland

    M. Szczepkowski

  35. Department of Surgery, University of Genoa, Genoa, Italy

    C. Stabilini

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  1. S. A. Antoniou
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  2. F. Agresta
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  32. F. E. Muysoms
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Corresponding author

Correspondence to S. A. Antoniou.

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SAA declares no conflict of interest. FA declares no conflict of interest. JGA declares no conflict of interest. DB declares no conflict of interest. FB declares no conflict of interest. HTB declares no conflict of interest. KB declares no conflict of interest. JC declares conflict of interest not directly related to the submitted work (personal fees from Johnson & Johnson Ethicon, personal fees from BARD Davol). DC declares conflict of interest not directly related to the submitted work (grants and personal fees from W.L. Gore, personal fees from BARD Davol, personal fees from Johnson & Johnson and personal fees from MSD). UAD declares no conflict of interest. RHF declares no conflict of interest. CFL declares no conflict of interest. BH declares no conflict of interest. FH declares no conflict of interest. AH declares no conflict of interest. AJ declares no conflict of interest. LFK declares no conflict of interest. JRL declares no conflict of interest. IKL declares no conflict of interest. MLC declares conflict of interest not directly related to the submitted work (personal fees from Johnson & Johnson and personal fees from BARD Davol). MM declares conflict of interest not directly related to the submitted work (personal fees from Springer, personal fees from Aspide, grants and personal fees from Bard, personal fees from Braun, personal fees from Cook, grants and personal fees from Covidien, personal fees from Ethicon and personal fees from W.L. Gore) and he serves as co-editor of Hernia. AM serves as executive editor of Hernia. SMC declares conflict of interest not directly related to the submitted work (personal fees from Bard, personal fees from Gore, personal fees from Medtronic and personal fees from Olympus). MP declares no conflict of interest. TR declares no conflict of interest. NS declares conflict of interest not directly related to the submitted work (grants and personal fees from Medtronic). MS declares no conflict of interest. MS declares no conflict of interest. CS declares no conflict of interest. FEM declares conflict of interest not directly related to the submitted work (grants, personal fees and non-financial support from Medtronic, grants and personal fees from Johnson & Johnson, grants and personal fees from Dynamesh, personal fees from Cousin Biotech and personal fees from BARD Davol).

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The complete lists of excluded articles for each introductory question and each key question are available from the corresponding author.

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Antoniou, S.A., Agresta, F., Garcia Alamino, J.M. et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia 22, 183–198 (2018). https://doi.org/10.1007/s10029-017-1697-5

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