Comparing the effectiveness of prophylactic strategies for parastomal hernia prevention: a network meta-analysis

Parastomal hernia (PSH), a common ostomy complication, significantly impairs patient quality of life. Various prophylactic strategies, including surgical (mesh reinforcement) and non-surgical (abdominal wall strengthening exercises, AWSE) interventions, have been proposed, but their comparative effectiveness is unclear. This network meta-analysis primarily assessed PSH incidence.

Following PRISMA guidelines, we conducted a systematic review and network meta-analysis. Searches in PubMed, Embase and Web of Science identified randomised controlled trials (RCTs) and observational studies comparing prophylactic PSH prevention strategies. Data on PSH incidence were extracted. Network meta-analysis estimated odds ratios (ORs) and 95% confidence intervals (CIs). Effectiveness was determined by PSH incidence reduction, comparing all prophylactic interventions against a transrectal colostomy control group. Interventions were ranked using surface under the cumulative ranking curve probabilities.

The analysis included 73 studies (30 RCTs, 44 observational; 7473 patients). Funnel mesh was the most effective intervention (OR 0.09, 95% CI 0.05-0.17), followed by Stapled Mesh stomA Reinforcement Technique (SMART) (OR 0.16, 95% CI 0.05-0.48) and AWSE (OR 0.18, 95% CI 0.08-0.39). Subgroup analyses confirmed consistency in findings across study designs but highlighted variability in ileal conduits due to limited data. Heterogeneity was moderate (τ² = 0.21, I² = 36.1%).

Funnel mesh could be the most effective measure for high-risk patients, while extraperitoneal colostomy (ES) and AWSE may be a practical and scalable alternative. Further high-quality RCTs are needed to validate these findings and refine clinical guidelines for PSH prevention.