title: Prevention of parastomal herniation with biologic/composite prosthetic mesh: a systematic review and meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  Parastomal herniation is a frequent complication of stoma formation and can be difficult to repair satisfactorily, making it a recognized cause of significant morbidity. A systematic review with meta-analysis of randomized clinical trials was performed to determine the benefits and risks of mesh reinforcement versus conventional stoma formation in preventing parastomal herniation.
  
  
  METHODS
  Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, and reference lists. The primary outcome was the incidence of parastomal herniation. The secondary outcomes were the incidence of parastomal herniation requiring surgical repair, postoperative morbidity, and mortality. Meta-analysis was performed using a random-effects model. The risk ratio (RR) was estimated with 95% confidence intervals (CI) based on an intention-to-treat analysis.
  
  
  RESULTS
  Three trials with 129 patients were included. Composite or biologic mesh was used in either the preperitoneal or sublay position. Mesh reinforcement was associated with a reduction in parastomal herniation versus conventional stoma formation (RR 0.23, 95%CI 0.06 to 0.81; p = 0.02), and a reduction in the percentage of parastomal hernias requiring surgical treatment (RR 0.13, 95%CI 0.02 to 1.02; p = 0.05). There was no difference between groups in stoma-related morbidity (2 of 58, 3.4% in the mesh group versus 2 of 57, 3.5% in the conventional group; p = 0.97), nor was there any mortality related to the placement of mesh.
  
  
  CONCLUSIONS
  Composite or biologic mesh reinforcement of stomas in the preperitoneal/sublay position is associated with a reduced incidence of parastomal herniation with no excess morbidity. Mesh reinforcement also demonstrates a trend toward a decreased incidence of parastomal herniation requiring surgical repair.
authors.affiliation: Academic Surgical Unit, Barts and The London School of Medicine and Dentistry, Whitechapel, London, United Kingdom. sanjayawijeyekoon@hotmail.co.uk
authors.forename: Sanjaya Prabhath
authors.initials: SP
authors.lastname: Wijeyekoon
authors.forename: Kurinchi
authors.initials: K
authors.lastname: Gurusamy
authors.forename: Khalid
authors.initials: K
authors.lastname: El-Gendy
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Chan
mesh_terms: D000328:Adult; D016001:Confidence Intervals; D005260:Female; D006547:Hernia / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control*; D059685:Herniorrhaphy; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D018570:Risk Assessment; D055502:Secondary Prevention; D013526:Surgical Mesh; D054047:Surgical Stomas / Q000009:adverse effects*; D015996:Survival Rate; D013536:Suture Techniques / Q000009:adverse effects; D016896:Treatment Outcome