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中华疝和腹壁外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (01) : 96 -104. doi: 10.3877/cma.j.issn.1674-392X.2023.01.023

循证医学

预防性放置补片对预防造口旁疝疗效的Meta分析
龚泽众1, 朱万骥1, 任延英1, 徐朝辉1, 曲慧1, Hyok Ju Ri1, 张帆1, 邵帅1, 陈鑫1,†()   
  1. 1. 116023　辽宁省，大连医科大学附属第二医院疝与结直肠外科
  • 收稿日期:2022-03-22 出版日期:2023-02-18
  • 通信作者: 陈鑫

Meta-analysis of the efficacy of prophylactic mesh placement in the prevention of parastomal hernia

Zezhong Gong1, Wanji Zhu1, Yanying Ren1, Zhaohui Xu1, Hui Qu1, Hyok Ju Ri1, Fan Zhang1, Shuai Shao1, Xin Chen1,†()   

  1. 1. Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian 116023, China
  • Received:2022-03-22 Published:2023-02-18
  • Corresponding author: Xin Chen
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引用本文：

龚泽众, 朱万骥, 任延英, 徐朝辉, 曲慧, Hyok Ju Ri, 张帆, 邵帅, 陈鑫. 预防性放置补片对预防造口旁疝疗效的Meta分析[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(01): 96-104.

Zezhong Gong, Wanji Zhu, Yanying Ren, Zhaohui Xu, Hui Qu, Hyok Ju Ri, Fan Zhang, Shuai Shao, Xin Chen. Meta-analysis of the efficacy of prophylactic mesh placement in the prevention of parastomal hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(01): 96-104.

目的

系统评价肠造口时预防性放置补片对预防造口旁疝及术后造口并发症的临床疗效。

方法

计算机检索Web of Science、PubMed、Embase、The Cochrane Library、CNKI、CBM、WanFang Data和VIP数据库。搜索预防性放置补片对造口旁疝影响的随机对照试验（RCT），搜索时限均从建库至2022年3月，最早建库时间可至1997年。由2名研究人员独立筛选文献、提取资料并评价纳入研究的偏倚风险，同时使用RevMan 5.3和Stata15软件进行分析。

结果

最终纳入17篇RCT研究，共1307例患者，其中补片组（预防性放置补片）患者657名，对照组（行传统造口手术）患者650名，随访时间12~67个月。Meta分析结果显示：最大随访年限内补片组造口旁疝发生率24.0%（158/657）较对照组42.9%（279/650）明显更低（RR=0.55，95% CI 0.40~0.76，I2=64%，P<0.01），补片组与对照组在造口脱垂（RR=0.69，95% CI 0.46~1.04，I2=0%，P=0.08）、造口感染（RR=0.87，95% CI 0.35~2.17，I2=0%，P=0.77）、造口坏死（RR=0.83，95% CI 0.45~1.54，I2=0，P=0.56）、造口狭窄（RR=1.61，95% CI 0.78~3.34，I2=0%，P=0.20）及造口二次手术（RR=0.78，95% CI 0.52~1.16，I2=0%，P=0.22）的发生率差异无统计学意义。亚组分析中，研究中心数量是文章异质性的主要原因之一，而手术方式、补片位置、补片类型及随访时间均非异质性主要来源。

结论

肠造口手术时预防性放置补片可有效减少造口旁疝的发生，且不会增加发生造口并发症的风险，具有潜在的临床推广价值。但仍需长期随访的大样本RCT对结果予以验证。

关键词: 造口旁疝, 补片, 结肠造口术, 随机对照试验, Meta分析
Objective

To study the clinical efficacy of prophylactic mesh placement during primary enterostomy in preventing parastomal hernia and postoperative stoma complications.

Methods

Databases including Web of Science, PubMed, Embase, The Cochrane Library, CNKI, CBM, WanFang Data and VIP were searched to collect randomized controlled trials (RCTs) that reported the efficacy of prophylactic mesh placement on the incidence of parastomal hernia from inception to March 2022, the earliest time of these databases' inception is 1997. Two reviewers independently screened, extracted data and evaluated quality according to the established inclusion and exclusion criteria. Revman 5.4 software and STATA 15 software were used to conduct the meta-analysis.

Results

A total of 17 RCTs (1307 patients) were identified and included in the meta-analysis, with 657 patients in the mesh group with prophylactic mesh placement and 650 patients in the control group who underwent traditional ostomy surgery. Follow-up of included studies varies from 12 to 67 months. Overall, the incidence of parastomal hernia in the mesh group (24.0%, 158/657) was much lower than that in the control group (42.9%, 279/650) (RR=0.55, 95% CI 0.40~0.76, I2=64%, P<0.01). There are no significant differences in the stoma prolapse (RR=0.69, 95% CI 0.46~1.04, I2=0%, P=0.08), stoma infection (RR=0.87, 95% CI 0.35~2.17, I2=0%, P=0.77), stoma necrosis (RR=0.83, 95% CI 0.45~1.54, I2=0, P=0.56), stoma stenosis (RR=1.61, 95% CI 0.78~3.34, I2=0%, P=0.20) and stoma needing repairment (RR=0.78, 95% CI 0.52~1.16, I2=0%, P=0.22). Subgroup analyses indicated that the number of study centers is one of the main reasons for article heterogeneity, while the surgical method, patch location, patch type and follow-up time were not the main sources of heterogeneity.

Conclusions

Prophylactic mesh placement during primary enterostomy can effectively decrease the occurrence of parastomal hernia, and will not increase the incidence of postoperative complications at the same time. However, a large RCT with long-term follow-up is still needed to verify the results.

Key words: Parastomal hernia, Mesh, Colostomy, Randomized controlled trials, Meta-analysis
图1 文献检索流程及结果注：所检索的数据库及检出文献数具体如下：Web of Science（n=191）、PubMed（n=194）、The Cochrane Library（n=1）、Embase（n=282）、CNKI（n=16）、CBM（n=3）、WanFang Data（n=21）和VIP（n=12）
表1 纳入的随机对照研究文献的基线资料
作者 发表年 研究中心 样本量(例) 性别比例(男:女) 平均年龄(岁) 体质量指数(kg/m2) 随访时间(月) 补片类型 手术方式 补片位置 诊断依据
类别 国家 A B A B A B A B
Hammond[12] 2008 单中心 英国 10 10 3: 7 4:6 50.0 42.6 26.3 26.3 12 生物 开放 腹膜前 临床、超声
Prudhomme[16] 2020 多中心 法国 98 101 57:41 57:44 70.5 67.2 24.5 25.6 24 合成 开放/腹腔镜 腹直肌后 临床、CT
Fleshman[17] 2014 多中心 美国 55 58 30:25 29:29 59.1 60.3 24.7 26.2 24 生物 开放/腹腔镜 腹直肌后 临床、CT
Odensten[18] 2019 多中心 瑞典 114 118 74:40 62:56 69.9 69.7 26.3 26.1 12 合成 开放 腹直肌后 临床、CT
Târcoveanu[19] 2014 单中心 罗马尼亚 20 22 NR NR NR NR NR NR 24 合成 开放 腹直肌后 临床、超声、CT
Brandsma[20] 2017 多中心 荷兰 72 78 43:29 48:28a 63.5 63.0 26.8 26.5 12 合成 开放 腹直肌后 临床、CT
Jänes[21] 2009 单中心 瑞典 27 27 15:12 16:11 71.0 70.0 27.0 26.0 60 合成 开放 腹直肌后 临床
Lambrecht[22] 2015 多中心 挪威 32 26 22:10 21: 5 63.0 64.0 25.5 24.6 40 合成 开放 腹直肌后 临床、CT
López-Cano[23] 2012 单中心 西班牙 19 17 11: 8 7:10 65.9 72.2 27.5 26.3 12 合成 腹腔镜 腹膜内 CT
López-Cano[24] 2016 多中心 西班牙 24 28 21: 3 16: 8b 67.3 70.5 26.9 25.3 26 合成 腹腔镜 腹膜内 CT
Mäkäräinen-Uhlbäck[25] 2020 多中心 芬兰 20 15 11: 9 9: 6 68.7 70.1 25.1 27.5 65 合成 腹腔镜 腹膜内 临床、CT
Serra-Aracil[26] 2009 单中心 西班牙 27 27 19: 5c 16:8d 67.2 67.5 27.3 25.6 29 合成 开放 腹直肌后 临床、CT
Vierimaa[27] 2015 多中心 芬兰 35 35 18:17 19:16 65.1 67.1 25.4 26.2 12 合成 腹腔镜 腹膜内 临床、CT
Correa Marinez[28] 2021 多中心 瑞典/丹麦 63 74 42:21 43:31 72.0 68.0 24.7 26.3 12 合成 开放/腹腔镜 腹直肌后 临床、CT
袁炜嗣[29] 2016 单中心 中国 41 41 26:15 20:21 65.0 65.0 22.4 23.6 12 合成 腹腔镜 腹膜内 临床、CT
崔冀[30] 2009 单中心 中国 30 30 NR NR NR NR NR NR 36 合成 腹腔镜 腹膜内 临床、超声、CT
任荣[31] 2021 单中心 中国 30 30 17:13 16:14 62.6 62.3 NR NR 36 合成 腹腔镜 腹直肌前 CT
图2 各项随机对照研究文献偏倚风险
图3 总体研究风险偏倚情况
图4 造口旁疝发生率比较的森林图
图5 造口旁疝发生率的发表偏倚漏斗图
图6 造口脱垂发生率的森林图
图7 造口感染发生率的森林图
图8 造口坏死发生率的森林图
图9 造口狭窄发生率的森林图
图10 造口二次手术率的森林图
表2 关于造口旁疝发生率的亚组分析
亚组分析   文献数量 补片组 对照组 RR(95% CI) 异质性(I2) P值
手术方式 开放 7 46/282 105/287 0.27(0.11~0.65) 75% P<0.01
腹腔镜 7 54/198 107/192 0.51(0.34~0.75) 52% P=0.05
补片位置 腹膜内 6 46/168 89/162 0.50(0.38~0.65) 59% P<0.01
腹直肌后 9 104/449 169/650 0.64(0.52~0.78) 69% P<0.01
补片类型 合成补片 15 153/598 269/587 0.56(0.48~0.66) 69% P<0.01
生物补片 2 5/59 10/63 0.56(0.21~1.47) 19% P=0.27
研究中心 单中心 8 34/203 108/203 0.32(0.23~0.44) 42% P=0.10
多中心 9 124/454 171/447 0.71(0.59~0.86) 59% P=0.01
随访时间 1年 7 95/328 145/327 0.48(0.34~0.68) 68% P<0.01
  >1年 10 72/340 152/334 0.31(0.22~0.44) 68% P<0.01
[1]
Vonk-Klaassen SM, De Vocht HM, Den Ouden ME, et al. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review[J]. Qual Life Res, 2016, 25(1): 125-133.
[2]
Tam KW, Wei PL, Kuo LJ, et al. Systematic review of the use of a mesh to prevent parastomal hernia[J]. World J Surg, 2010, 34(11): 2723-2729.
[3]
Prevention and treatment of parastomal hernia: a position statement on behalf of the Association of Coloproctology of Great Britain and Ireland[J]. Colorectal Dis, 2018, 20 Suppl 2: 5-19.
[4]
Tiernan J, Cook A, Geh I, et al. Use of a modified Delphi approach to develop research priorities for the association of coloproctology of Great Britain and Ireland[J]. Colorectal Dis, 2014, 16(12): 965-970.
[5]
Antoniou SA, Agresta F, Garcia Alamino JM, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias[J]. Hernia, 2018, 22(1): 183-198.
[6]
Ripoche J, Basurko C, Fabbro-Perray P, et al. Parastomal hernia. A study of the French federation of ostomy patients[J]. J Visc Surg, 2011, 148(6): e435-441.
[7]
Carne PW, Robertson GM, Frizelle FA. Parastomal hernia[J]. Br J Surg, 2003, 90(7): 784-793.
[8]
Shabbir J, Britton DC. Stoma complications: a literature overview[J]. Colorectal Dis, 2010, 12(10): 958-964.
[9]
Israelsson LA.[Parastomal hernia treatment with prosthetic mesh repair][J]. Chirurg, 2010, 81(3): 216-221.
[10]
Van Dijk SM, Timmermans L, Deerenberg EB, et al. Parastomal Hernia: Impact on Quality of Life?[J]. World J Surg, 2015, 39(10): 2595-2601.
[11]
Styliński R, Alzubedi A, Rudzki S. Parastomal hernia-current knowledge and treatment[J]. Wideochir Inne Tech Maloinwazyjne, 2018, 13(1): 1-8.
[12]
Hammond T M, Huang A, Prosser K, et al. Parastomal hernia prevention using a novel collagen implant: a randomised controlled phase 1 study[J]. Hernia, 2008, 12(5): 475-481.
[13]
Cross AJ, Buchwald PL, Frizelle FA, et al. Meta-analysis of prophylactic mesh to prevent parastomal hernia[J]. Br J Surg, 2017, 104(3): 179-186.
[14]
Patel SV, Zhang L, Chadi SA, et al. Prophylactic mesh to prevent parastomal hernia: a meta-analysis of randomized controlled studies[J]. Tech Coloproctol, 2017, 21(1): 5-13.
[15]
Zhu J, Pu Y, Yang X, et al. Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis[J]. Gastroenterol Res Pract, 2016, 2016: 1694265.
[16]
Prudhomme M, Rullier E, Zaher L, et al. End Colostomy With or Without Mesh to Prevent a Parastomal Hernia(GRECCAR 7): A Prospective, Randomized, Double Blinded, Multicentre Trial[J]. Ann Surg, 2021, 274(6): 928-934.
[17]
Fleshman JW, Beck DE, Hyman N, et al. A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies[J]. Dis Colon Rectum, 2014, 57(5): 623-631.
[18]
Odensten C, Strigård K, Rutegård J, et al. Use of Prophylactic Mesh When Creating a Colostomy Does Not Prevent Parastomal Hernia: A Randomized Controlled Trial-STOMAMESH[J]. Ann Surg, 2019, 269(3): 427-431.
[19]
Târcoveanu E, Vasilescu A, Cotea E, et al. Parastomal hernias-clinical study of therapeutic strategies[J]. Chirurgia(Bucur), 2014, 109(2): 179-184.
[20]
Brandsma HT, Hansson BM, Aufenacker TJ, et al. Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial[J]. Ann Surg, 2017, 265(4): 663-669.
[21]
Jänes A, Cengiz Y, Israelsson L. A Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study[J]. World J Surg, 2009, 33(1): 118-121, discussion 122-113.
[22]
Lambrecht JR, Larsen SG, Reiertsen O, et al. Prophylactic mesh at end-colostomy construction reduces parastomal hernia rate: a randomized trial[J]. Colorectal Dis, 2015, 17(10): O191-197.
[23]
López-Cano M, Lozoya-Trujillo R, Quiroga S, et al. Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial[J]. Hernia, 2012, 16(6): 661-667.
[24]
López-Cano M, Serra-Aracil X, Mora L, et al. Preventing Parastomal Hernia Using a Modified Sugarbaker Technique With Composite Mesh During Laparoscopic Abdominoperineal Resection: A Randomized Controlled Trial[J]. Ann Surg, 2016, 264(6): 923-928.
[25]
Mäkäräinen-Uhlbäck EJ, Klintrup KHB, Vierimaa MT, et al. Prospective, Randomized Study on the Use of Prosthetic Mesh to Prevent a Parastomal Hernia in a Permanent Colostomy: Results of a Long-term Follow-up[J]. Dis Colon Rectum, 2020, 63(5): 678-684.
[26]
Serra-Aracil X, Bombardo-Junca J, Moreno-Matias J. Randomized, controlled, prospective trial of the use of mesh to prevent parastomal hernia[J]. Dis Colon Rectum, 2009, 52(9): 1676.
[27]
Vierimaa M, Klintrup K, Biancari F, et al. Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy[J]. Dis Colon Rectum, 2015, 58(10): 943-949.
[28]
Correa Marinez A, Bock D, Erestam S, et al. Methods of Colostomy Construction: No Effect on Parastomal Hernia Rate: Results from Stoma-const-A Randomized Controlled Trial[J]. Ann Surg, 2021, 273(4): 640-647.
[29]
袁炜嗣, 庄丹, 林锡汉, 等. 预防性应用防粘连补片对结肠造口术后造口旁疝发生率的影响[J/OL]. 中华疝和腹壁外科杂志(电子版), 2016, 10(6): 421-424.
[30]
崔冀, 向军, 黄美近, 等. 应用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定对造口旁疝的预防[J]. 中华胃肠外科杂志, 2009, 12(5): 480-482.
[31]
任荣, 刘文鹏, 常亚男, 等. 腹腔镜经腹会阴联合Onlay法置入补片预防直肠根治术后远期造口旁疝的疗效[J/OL]. 中华疝和腹壁外科杂志(电子版), 2021, 15(6): 660-663.
[32]
Kroese LF, De Smet GH, Jeekel J, et al. Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia[J]. Dis Colon Rectum, 2016, 59(7): 688-695.
[33]
Pilgrim C H, Mcintyre R, Bailey M. Prospective audit of parastomal hernia: prevalence and associated comorbidities[J]. Dis Colon Rectum, 2010, 53(1): 71-76.
[34]
汤艳平, 殷小敏, 刘芷静, 等. 以造口治疗师为主导的医、护、患共同参与造口术前定位对造口并发症的影响[J]. 护理实践与研究, 2021, 18(12): 1830-1834.
[35]
吴立胜. 造口旁疝修补术的演变和焦点问题[J]. 中华消化外科杂志, 2022, 21: 1191-1196.
[36]
Hansson BM, Slater NJ, Van Der Velden AS, et al. Surgical techniques for parastomal hernia repair: a systematic review of the literature[J]. Ann Surg, 2012, 255(4): 685-695.
[37]
Bayer I, Kyzer S, Chaimoff C. A new approach to primary strengthening of colostomy with Marlex mesh to prevent paracolostomy hernia[J]. Surg Gynecol Obstet, 1986, 163(6): 579-580.
[38]
Darehzereshki A, Goldfarb M, Zehetner J, et al. Biologic versus nonbiologic mesh in ventral hernia repair: a systematic review and meta-analysis[J]. World J Surg, 2014, 38(1): 40-50.
[39]
Silverman RP, Li EN, Holton 3rd LH, et al. Ventral hernia repair using allogenic acellular dermal matrix in a swine model[J]. Hernia, 2004, 8(4): 336-342.
[40]
An G, Walter RJ, Nagy K. Closure of abdominal wall defects using acellular dermal matrix[J]. J Trauma, 2004, 56(6): 1266-1275.
[41]
唐健雄, 黄磊, 李绍杰. 生物材料在腹壁疝治疗中的现状和前景[J]. 中华消化外科杂志, 2020, 19(7): 720-724.
[42]
张国林, 帕尔哈提·阿布都热依木. 腹膜前间隙与腹腔内补片置入层次对治疗切口疝的疗效比较[J/OL]. 中华疝和腹壁外科杂志(电子版), 2021, 15(6): 613-616.
[43]
Roussel B, Mulieri G, Gauzolino R, et al. Parastomal hernia[J]. J Visc Surg, 2012, 149(5 Suppl): e15-19.
[44]
Kokotovic D, Bisgaard T, Helgstrand F. Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair[J]. JAMA, 2016, 316(15): 1575-1582.
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