Role of Parastomal Hernias in the Development of Stoma Site Incisional Hernia after Ileostomy Closure
Catherine C. Beauharnais1, Nicholas M. Sweeney2, Allison Crawford1, Karim Alavi1, Jennifer S. Davids1, Justin A. Maykel1, Paul R. Sturrock1
1UMASS Chan Medical School, Worcester, Massachusetts, United States, 2Rutgers University, New Brunswick, New Jersey, United States
Objectives: Incisional hernia (IH) rates after stoma closure can be as high as 50%. Studies evaluating parastomal hernias as risk factors for stoma site IH are sparse. This analysis aims to determine the role of asymptomatic and clinically significant parastomal hernias, respectively, in the development incisional hernia on long-term follow-up.
Design: This was a retrospective cohort study of patients who underwent ileostomy closure between 2015 and 2020 at a single institution. Demographics, intra- and peri-operative factors, as well post-operative outcomes up to 5 years, were collected by chart review. Parastomal hernias were categorized as: 1) clinically significant if they were either reported by patient or documented on surgeon physical exam prior to reversal and 2) asymptomatic if they were detected intra-operatively at the time of ileostomy closure. Proportions were compared with the chi-square test; Cox proportional hazards models controlling for pre-selected clinically relevant variables were used to evaluate outcomes.
Setting: Tertiary care academic medical center.
Patients: A total of 250 patients were reviewed with a median follow-up time of 20 months, IQR 4-41 months. Our sample had a median age of 58 years (IQR 47-66), was primarily Caucasian (n=226, 91%) and non-Hispanic (n=223, 95%).
Intervention: None
Main Outcome Measures: Incisional hernia rates following ileostomy closure
Results: Twenty-two patients (8.8%) had clinically significant parastomal hernias prior to ileostomy closure. There were 41 cases of asymptomatic parastomal hernias that were detected intra-operatively. Higher proportions of patients with symptomatic parastomal hernias developed IH by year 5 (37% vs. 5.4%, p<0.001); this was not observed for asymptomatic hernias (23% vs. 15%, p=0.3). Clinically significant parastomal hernias were associated with a 13.6 increased hazard of developing an incisional hernia by year 5 ( 95% CI 5.6-33.1, p<0.0001) on univariate analysis. This association was maintained on multivariable analysis (HR 11.9, 95% CI 5.1-33.1, p<0.0001) after controlling for older age, surgical site infection (SSI) and obesity. Asymptomatic parastomal hernias were not associated with increased hazard of IH by year 5 (HR =0.9, 0.3-2.7, p=0.9).
Conclusion: Clinically significant parastomal hernias were associated with higher incisional hernia rates on long-term follow. This was, however, not observed with asymptomatic hernias detected intra-operatively. Patients with symptomatic parastomal hernias are likely more suitable for interventions aimed at minimizing incisional hernias after ileostomy closure.
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