Radiological progression of end colostomy trephine diameter and area

Abstract

BackgroundDevelopment of a parastomal hernia is common following abdominoperineal excision (APE). The true incidence is difficult to assess fully owing to differing lengths of follow‐up and techniques used to assess herniation; radiological or clinical. The primary aim of this study was to evaluate colostomy diameter by studying the rate of change of axial and sagittal trephine diameters, trephine area, and the ratio of the trephine over time. A secondary aim was to investigate variation in trephine area and variables affecting parasternal hernia over time.MethodsSerial CT scans performed after APE from January 2006 to December 2014 were reviewed. Variables analysed included age, sex, trephine position relative to rectus abdominis muscle (RAM), type of incision for stoma creation, and axial and sagittal trephine diameters measured on follow‐up CT. A Bayesian hierarchical modelling framework was used to examine the relationship of trephine diameters, area and ratio over time.ResultsOf 112 patients undergoing APE, 103 were eligible for analysis; this included 91 colostomies (88·3 per cent) through the RAM and 12 (11·7 per cent) lateral to the RAM. Median age of the patients was 68 years. Sixty patients (58·3 per cent) had a circular and 43 (41·7 per cent) a cruciate incision for stoma creation. The sagittal trephine diameter increased by 0·22 (95 per cent credible interval 0·12 to 0·32) mm/month for both sexes. Women reported a significant increase in axial trephine diameters; the male : female ratio difference was −0·17 (−0·30 to −0·03) mm/month and for trephine areas −6·21 (0·96 to 13·7) mm2/month. Patient age, colostomy trephine location and shape of incision were not statistically significant variables for parasternal hernia.ConclusionFemale sex was the only variable affecting the rate of increase in axial trephine diameter and trephine area over time.

Stoma location and Parastomal Hernia. A Virtual Simulation Approach.

“…Thus, the present simulations predict trephine enlargements that, on the average, are more pronounced for stomas located lateral to the RA muscle. This result is in apparent contradiction with the findings by Ho et al 2 , who found no statistically significant relation between the rate of trephine size progression and stoma position. Notwithstanding, these authors acknowledged as a limitation of their data analysis the fact that only 11.7% of patients had a stoma created lateral to the RA muscle.…”

Clinical and Radiologic Predictors of Parastomal Hernia Development After End Colostomy

“…Instrumentation, such as a template, that can help create an aperture less than 10 cm 2 or less than 50 mm in the largest dimension may reduce the frequency of PSH. Colostomy trephines increase over time [16], so the intraoperatively created aperture size should be significantly smaller than 10 cm2 or 50 mm in the largest dimension. Furthermore, prophylactic mesh placement may help reduce the frequency of PSH development when a relatively large abdominal wall defect at the colostomy site cannot be prevented, such as in patients with an ileus of the colon.…”

Virtual simulation of the biomechanics of the abdominal wall with different stoma locations

“…The use of a stoma incision (trephine) of a diameter not larger than 25 mm was suggested under the assumption that PH were unlikely to develop for a small trephine provided that its size did not increase with time 16 . However, a more recent study showed that enlargement of the trephine, regardless of its original size, took place in almost every surveyed ostomy patient and that most patients developed PH even though the median trephine diameter of the patient cohort was below 25 mm 2 . Other surgical practices, such as an extraperitoneal exteriorization of the stoma (extraperitoneal tunneling of the stoma between the peritoneum and the AW) have been suggested for the prevention of PH.…”

“…One of the most common complications of ostomies is the appearance of a parastomal hernia (PH) after the construction of the stoma. Even though PH is a very frequent problem (with reported incidences as high as 1 or 2 when identified by computed tomography) it is difficult to treat and has a huge impact on the quality of life of patients who suffer from it 3 – 6 . In recent years, there has been a striking interest in the prevention of PH with prosthetic meshes 7 – 13 .…”