peristomal hernia: the case for extraperitoneal colostomy garnet blatchford, m.d

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  • Slide 1
  • PERISTOMAL HERNIA: THE CASE FOR EXTRAPERITONEAL COLOSTOMY Garnet Blatchford, M.D.
  • Slide 2
  • I have no disclosures to report
  • Slide 3
  • EXTRAPERITONEAL COLOSTOMY OLD CONCEPT, BUT FORGOTTEN? Principles and Practice of Surgery for the Colon, Rectum and Anus, Gordon/Nivatvongs role of extraperitoneal colostomy uncertain Complications of Colon & Rectal Surgery, Hicks/Beck no mention Colon and Rectal Surgery - Corman no mention for colostomy, only ileostomy ASCRS textbook-extraperitoneal extreme lateral mesenteric closure
  • Slide 4
  • FACTORS IN PARACOLOSTOMY HERNIA Poor technique Lateral to rectus Trephine size Fascial fixation Closure of lateral space High intra-abdominal pressure Obesity Constipation Chronic cough Prostate enlargement
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  • Slide 6
  • INTRAPERITONEAL COLOSTOMY
  • Slide 7
  • EXTRAPERITONEAL COLOSTOMY
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  • EXTRAPERITONEAL VS INTRAPERITONEAL COLOSTOMY Goligher 1958: Br J Surg Vol 46,196:7-8 Goligher 1976 DCR: 19:342-366 251 patients ComplicationsIntraperitoneal n=162 Extraperitoneal n=89 Pericolostomy hernia 288 Prolapse102 Recession10 Stenosis63 Fistula10 Total4613
  • Slide 9
  • PROBABILITY OF COLOSTOMY COMPLICATION IN INTRAPERITONEAL COLOSTOMIES # of patients Crude Rate (%) Actuarial Rate (%) Years Paracolosto my hernia 4321.236.710 Skin2411.817.411 Prolapse115.411.813 Obstruction115.413.713 Stenosis104.97.310 Retraction31.5NA- Fistula21.0NA Life Table Analysis of Stomal Complications Following Colostomy, Phillips RKS DCR 37:916-920 (1994)
  • Slide 10
  • META-ANALYSIS OF EXTRA VS INTRA Seven retrospective studies with a combined total of 1,071 patients (250 extraperitoneal colostomy and 821 intraperitoneal colostomy) There was a significantly lower rate of parastomal hernia (odds ratio, 0.41; 95% confidence interval, 0.23-0.73, p = 0.002) in the extraperitoneal colostomy group the occurrences of bowel obstruction and prolapse were not significantly different between the two groups. Int J Colorectal Dis.Int J Colorectal Dis. 2012 Jan;27(1):59-64
  • Slide 11
  • LAPRASCOPIC EXTRAPERITONEAL COLOSTOMY 12 patients with lap extraperitoneal colostomy No peristomal hernias 10 patients with lap intraperitoneal colostomy 4 peristomal hernias (33%), occurred at 24, 36, 48 and 72 months Laparoscopic extraperitoneal colostomy in elective abdomino-perineal resection. Leroy J, Colorectal Dis (2012)
  • Slide 12
  • OMAHA EXPERIENCE 223 Patients undergoing APR for cancer Open APR in 209(94%), robotic/lap in 14(6%) June 2001-July 2013, seven colorectal surgeons Retrospective chart review Males 123 (55%), Females 100 (45%) 183 had intraperitoneal colostomy made 40 had extraperitoneal colostomy made
  • Slide 13
  • OMAHA STOMA STUDY DemographicIP (n=183EP (n=40)P value Age (yr)66.262.8NS Gender (M/F)102/8921/19NS BMI28.024.60.002 ComorbidityIP (%)EP (%)P value Smoker64(34.9)12(30)NS COPD12(6.5)1(2.5)NS DM25(13.7)1(2.5)NS Other hernia15(8.2)1(2.5)NS BPH9(4.9)2(5)NS Hypothyroid19(9.8)2(5)NS
  • Slide 14
  • OMAHA STOMA STUDY SurgeonAPR nIP n (%)BMIEP n (%)BMI 1.4326 (60)28.117 (40)24 2.4934 (69)25.715 (31)24.9 3.3534 (97)25.7 1 (3)26.5 4.4037 (92)28.8 3 (8)25.6 5.1716 (94)28.2 1 (6)23.1 6.2827 (96)20.4 1 (4)19.7 7.10 7 (70)25.1 2 (10)29.1
  • Slide 15
  • OMAHA STOMA STUDY VariableIP n=183EP n=40P value Stoma complications 4520.006 -Prolapse20NS -Stoma necrosis20NS -Obstruction01NS -Diverticulitis01NS - Peristomal hernia 410