Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation

A parastomal hernia is defined as an incisional hernia related to a stoma and belongs to the most common stoma-related complications. Many factors concerning the operative technique which are considered to influence the incidence of parastomal herniation have been investigated. However, it remains unclear whether the enterostomy should be placed through or lateral to the rectus abdominis muscle in order to prevent parastomal herniation and other important stoma complications for people undergoing abdominal wall enterostomy.

To assess if there is a difference regarding the incidence of parastomal herniation and other stomal complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy.

In October and November 2012 we searched for all types of published and unpublished randomized and non-randomized studies with no restriction on language, date or country (search dates in brackets). We searched the bibliographic databases The Cochrane Library (4 October 2012), MEDLINE (1 October 2012), EMBASE (10 October 2012), LILACS (29 November 2012), and Science Citation Index Expanded (4 October 2012). We also searched the reference lists of all relevant studies and the trial registers ClinicalTrials.gov (9 October 2012), World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal (10 October 2012), as well as three additional trial registers not included in the ICTRP (27 November 2012).

Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications.

Two authors independently assessed study quality and extracted data. Data analyses were conducted according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Cancer Group (CCCG). Quality of evidence was rated according to GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Nine retrospective cohort studies with a total of 761 participants met the inclusion criteria. All included studies reported results for the primary outcome (parastomal herniation), and one study also reported data on one of the secondary outcomes (stomal prolapse). None of the included studies compared the two interventions with regard to other secondary outcomes.There was neither a significant difference in terms of the risk for parastomal herniation (risk ratio (RR) 1.29; 95% confidence interval (CI) 0.79 to 2.1) nor with regard to the occurrence of stomal prolapse (RR 1.23; 95% CI 0.39 to 3.85). An I² value of 65% indicated substantial statistical heterogeneity in the meta-analysis.

The poor quality of the included evidence does not allow a robust conclusion regarding the objectives of the review. This review highlights a clear uncertainty as to the relative merits of either approach. There is a need for randomized trials to evaluate the effectiveness of the lateral pararectal versus the transrectal approach in preventing parastomal herniation and other stoma-related morbidity in people requiring enterostomy placement.