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Parastomal hernia: investigation and treatment
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Parastomal hernia is a common stoma complication causing the patient considerable inconvenience. The patient becomes aware of a bulge around the stoma, but a bulge is not always a parastomal hernia and diagnostics must be performed to enable differential treatment. It is difficult to distinguish between a bulge and a hernia. Results based on clinical examination and computerised tomography (CT) in the supine position, have not been convincing. Three-dimensional intrastomal ultrasonography (3D US) is a novel technique shown to be promising in the assessment of stoma complaints. Two studies were performed to determine inter- and intra-observer reliability as well as the validity of 3D US as an alternative to CT when assessing stoma complaints.

There are numerous options for the treatment of parastomal hernia, but none has been shown superior. In the recent decades the use of mesh in the repair of incisional and inguinal hernia has become routine. New materials must be evaluated as there are potential morbidity and even mortality risks with mesh repair. As recurrence of a parastomal hernia is an even greater challenge, the method of choice should have a low risk for recurrence. A prospective multicenter study was performed to evaluate safety and recurrence rate when using Parastomal Hernia Patch BARDTM (PHP), a mesh specially designed for parastomal hernia repair.

A stoma has a profound impact on the patient´s daily life, both physical and psychological. A parastomal hernia with its associated risk for leakage and incarceration worsens the situation. Patient driven assessment of healthcare outcome is important if we are to improve medical care. A quality of life (QoL) survey was performed to assess the impact of parastomal bulging and hernia on the patient´s daily life.

Methods

Forty patients were investigated and the 3D US images were twice evaluated by two or three physicians to assess inter- and intra-observer reliability. Totally 20 patients with stoma complaints requiring surgery were examined with CT and 3D US prior to surgery. The findings were compared with the intraoperative findings – regarded as the true outcome.

Fifty patients with parastomal hernia requiring surgery were enrolled from three hospitals. Patients were followed up one month and one year after repair using PHP.

Patients still alive in 2008 who had been operated between1996 and 2004 for rectal cancer in Uppsala/Örebro-, Stockholm/Gotland-, and Northern Regions (986 patients) and registered in the Swedish Rectal Cancer Registry (SRCR) were invited to fill in four QoL questionnaires.

Results

Inter-observer agreement using 3D US reached 80% for the last 10 patients examined, with a kappa value of 0.70. Intra-observer agreement for two examiners was 80% and 95%. The learning curve levelled out at 30 patients. Both CT and 3D US showed high sensitivity and specificity when compared with intraoperative findings.

After surgery for parastomal hernia with a PHP, the complication rate at one month was 30% and recurrence rate at one year was 22%. Twelve patients were reoperated within one year.

In the QoL study, 31.5% of the patients with a stoma reported a bulging or a hernia. 11.7% had been operated for parastomal hernia. A hernia or a bulge gave rise to significantly more pain and impaired stoma function. Overall QoL was inferior in patients with a permanent stoma compared to a group without a stoma.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 38 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1707
Keyword [en]
Parastomal, hernia, 3D US, ultrasonography, mesh, QoL, rectal cancer, stoma
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-103325ISBN: 978-91-7601-241-3 (print)OAI: oai:DiVA.org:umu-103325DiVA: diva2:812886
Public defence
2015-06-12, Aulan Konferenscentrum, Sunderby sjukhus, Luleå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-05-22 Created: 2015-05-20 Last updated: 2015-05-22Bibliographically approved
List of papers
1. Intrastomal 3D ultrasound: an inter- and intra-observer evaluation
Open this publication in new window or tab >>Intrastomal 3D ultrasound: an inter- and intra-observer evaluation
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2013 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 28, no 1, 43-47 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to determine intra- and interobserver reliability in 3D intrastomal ultrasound imaging of parastomal hernia and protrusion. A total of 40 patients were investigated. Two or three physicians evaluated the images twice, 1 month apart. Inter-observer agreement was 72 % with a kappa value 0.59. For the last 10 patients there was an agreement of 80 % with a kappa value of 0.70. Intraobserver agreement was 80 % for one observer and 95 % for the other. The learning curve levelled out at around 30 patients. Considering the learning curve of 30 patients, 3D intrastomal ultrasound is a reliable investigation method. 3D intrastomal ultrasonography has the potential to be the investigation of choice to differentiate between a bulge, a hernia, or a protrusion.

Place, publisher, year, edition, pages
Springer-Verlag New York, 2013
Keyword
Intrastomal, Intraobserver, Interobserver, 3D ultrasound, Evaluation
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-66414 (URN)10.1007/s00384-012-1526-3 (DOI)000313442400006 ()
Available from: 2013-02-22 Created: 2013-02-19 Last updated: 2017-12-06Bibliographically approved
2. A comparison between intrastomal 3D ultrasonography, CT scanning and findings at surgery in patients with stomal complaints
Open this publication in new window or tab >>A comparison between intrastomal 3D ultrasonography, CT scanning and findings at surgery in patients with stomal complaints
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2014 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 29, no 10, 1263-1266 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Since there are no reliable investigative tools for imaging parastomal hernia, new techniques are needed. The aim of this study was to assess the validity of intrastomal three-dimensional ultrasonography (3D) as an alternative to CT scanning for the assessment of stomal complaints.

METHOD: Twenty patients with stomal complaints, indicating surgery, were examined preoperatively with a CT scan in the supine position and 3D intrastomal ultrasonography in the supine and erect positions. Comparison with findings at surgery, considered to be the true state, was made.

RESULTS: Both imaging methods, 3D ultrasonography and CT scanning, showed high sensitivity (ultrasound 15/18, CT scan 15/18) and specificity (ultrasound 2/2, CT scan 1/2) when judged by a dedicated radiologist. Corresponding values for interpretation of CT scans in routine clinical practice was for sensitivity 17/18 and for specificity 1/2.

CONCLUSION: 3D ultrasonography has a high validity and is a promising alternative to CT scanning in the supine position to distinguish a bulge from a parastomal hernia.

Place, publisher, year, edition, pages
Springer, 2014
Keyword
Hernia, Parastomal, 3D ultrasonography, CT scan, Ultrasound, Intrastomal
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-91716 (URN)10.1007/s00384-014-1944-5 (DOI)000342076000012 ()24986139 (PubMedID)
Available from: 2014-08-14 Created: 2014-08-14 Last updated: 2017-12-05Bibliographically approved
3. Parastomal hernia repair with intraperitoneal mesh
Open this publication in new window or tab >>Parastomal hernia repair with intraperitoneal mesh
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2015 (English)Manuscript (preprint) (Other academic)
Publisher
51+4 p.
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-103309 (URN)978-91-7601-241-3 (ISBN)
Available from: 2015-05-20 Created: 2015-05-20 Last updated: 2015-05-21
4. Quality of life with permanent stoma after rectal cancer surgery
Open this publication in new window or tab >>Quality of life with permanent stoma after rectal cancer surgery
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-103324 (URN)
Available from: 2015-05-20 Created: 2015-05-20 Last updated: 2015-05-21

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