Modified Sugarbaker enhances parastomal hernia repair

CHICAGO – Patients who underwent modified laparoscopic Sugarbaker parastomal hernia repair were a third less likely to experience recurrence as those repaired with other surgical techniques in a multicenter, retrospective study in 62 patients.

The recurrence rate was 16.6% for the modified Sugarbaker technique, compared with 61% for keyhole repair, 69.2% for ostomy relocation, and 33.3% for open repair (P value < .001). Median follow-up was 16.6 months, 19.6 months, 16.4 months, and 27.2 months (P = .748).

In an adjusted Cox proportional hazards regression model, the Sugarbaker technique (hazard ratio, 0.28; P = .021) and body mass index (HR, 1.09; P = .013) were the only significant predictors of time to hernia recurrence.

Using the Kaplan-Meier method, 80% of Sugarbaker patients would be recurrence free at 2 years vs. about 60% of those in the other groups (log-rank P = .021), Mr. Francis DeAsis, a research assistant from NorthShore University Health in Evanston, Ill., reported at the annual meeting of the Central Surgical Association.

The findings are in keeping with prior Sugarbaker studies involving 177 repairs between 2005 and 2013, reporting recurrence rates between 4% and 20% and morbidity of 12%-43%, he said.

Morbidity was 40% among the 25 Sugarbaker repairs in the current analysis, significantly lower than that in the Keyhole, relocation, and open repair groups (40% vs. 83.3%, 61.5%, 83.3%; P = .005).

“Based on our results and others, we’d like to suggest that the Sugarbaker approach should be the primary option for treating parastomal hernia,” Mr. DeAsis said.

The study provides “further proof that no other technique available results in a durable repair compared to the Sugarbaker technique for these challenging hernias,” senior study author Dr. Michael Ujiki, director of minimally invasive surgery at NorthShore, said in an interview.

The Sugarbaker technique typically involves a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb. Modifications at NorthShore included use of polytetrafluoroethylene mesh with a 5-cm overlap of the defect and, if possible, primary closure of the defect. A catheter is occasionally used to identify the correct ostomy limb, but most importantly, a laparoscopic approach is utilized in order to decrease wound infections and quicken the return to daily activities, Dr. Ujiki said. “We also avoid cautery and diligently look for other incidental hernias at the prevision incisions.”

Ileus (> 3 days) was the most common complication in all groups: Sugarbaker (4/25), keyhole (9/18), relocation (3/13), and open (1/6). Only one death occurred; in the open group.

Discussant Dr. Matthew Goldblatt, with the Medical College of Wisconsin in Milwaukee, questioned how many patients also had ventral hernias and whether this was a complicating factor in ileus or length of stay and whether the fascia was closed primarily during keyhole repair or the mesh simply placed as a bridge, as this can impact failure rates.

Dr. Ujiki responded that some patients had concomitant ventral hernias and that they simply used a larger piece of mesh to cover both hernias. Primary closure was not part of the keyhole repair early in the 10-year series, spanning 2004 to 2014, but ultimately was performed in about half of patients in the keyhole group.

“I don’t think that there’s going to be a difference between the two in terms of recurrence, but I can’t say for sure,” he added.

At this point, the group does not use prophylactic mesh placement at the time the ostomy is created, to avoid infections.

Finally, the audience asked whether the investigators are willing to accept a 16% recurrence rate, a fourfold increase over the best reported result with a modified Sugarbaker technique.

“With these hernia repairs, to me a 16% recurrence rate is outstanding and I think it will only get better,” Dr. Ujiki said.

The series includes every patient on which they’ve performed a Sugarbaker and thus, represents their learning curve, which may not be the case with other series, he noted.

Dr. Ujiki left the audience with two bits of advice to hasten the learning curve: leave at least 5 cm of overlap because the mesh will shrink down and keep the stitches close to the mesh without cutting off the bowel.

pwendling@frontlinemedcom.com

CHICAGO – Patients who underwent modified laparoscopic Sugarbaker parastomal hernia repair were a third less likely to experience recurrence as those repaired with other surgical techniques in a multicenter, retrospective study in 62 patients.

The recurrence rate was 16.6% for the modified Sugarbaker technique, compared with 61% for keyhole repair, 69.2% for ostomy relocation, and 33.3% for open repair (P value < .001). Median follow-up was 16.6 months, 19.6 months, 16.4 months, and 27.2 months (P = .748).

In an adjusted Cox proportional hazards regression model, the Sugarbaker technique (hazard ratio, 0.28; P = .021) and body mass index (HR, 1.09; P = .013) were the only significant predictors of time to hernia recurrence.

Using the Kaplan-Meier method, 80% of Sugarbaker patients would be recurrence free at 2 years vs. about 60% of those in the other groups (log-rank P = .021), Mr. Francis DeAsis, a research assistant from NorthShore University Health in Evanston, Ill., reported at the annual meeting of the Central Surgical Association.

The findings are in keeping with prior Sugarbaker studies involving 177 repairs between 2005 and 2013, reporting recurrence rates between 4% and 20% and morbidity of 12%-43%, he said.

Morbidity was 40% among the 25 Sugarbaker repairs in the current analysis, significantly lower than that in the Keyhole, relocation, and open repair groups (40% vs. 83.3%, 61.5%, 83.3%; P = .005).

“Based on our results and others, we’d like to suggest that the Sugarbaker approach should be the primary option for treating parastomal hernia,” Mr. DeAsis said.

The study provides “further proof that no other technique available results in a durable repair compared to the Sugarbaker technique for these challenging hernias,” senior study author Dr. Michael Ujiki, director of minimally invasive surgery at NorthShore, said in an interview.

The Sugarbaker technique typically involves a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb. Modifications at NorthShore included use of polytetrafluoroethylene mesh with a 5-cm overlap of the defect and, if possible, primary closure of the defect. A catheter is occasionally used to identify the correct ostomy limb, but most importantly, a laparoscopic approach is utilized in order to decrease wound infections and quicken the return to daily activities, Dr. Ujiki said. “We also avoid cautery and diligently look for other incidental hernias at the prevision incisions.”

Ileus (> 3 days) was the most common complication in all groups: Sugarbaker (4/25), keyhole (9/18), relocation (3/13), and open (1/6). Only one death occurred; in the open group.

Discussant Dr. Matthew Goldblatt, with the Medical College of Wisconsin in Milwaukee, questioned how many patients also had ventral hernias and whether this was a complicating factor in ileus or length of stay and whether the fascia was closed primarily during keyhole repair or the mesh simply placed as a bridge, as this can impact failure rates.

Dr. Ujiki responded that some patients had concomitant ventral hernias and that they simply used a larger piece of mesh to cover both hernias. Primary closure was not part of the keyhole repair early in the 10-year series, spanning 2004 to 2014, but ultimately was performed in about half of patients in the keyhole group.

“I don’t think that there’s going to be a difference between the two in terms of recurrence, but I can’t say for sure,” he added.

At this point, the group does not use prophylactic mesh placement at the time the ostomy is created, to avoid infections.

Finally, the audience asked whether the investigators are willing to accept a 16% recurrence rate, a fourfold increase over the best reported result with a modified Sugarbaker technique.

“With these hernia repairs, to me a 16% recurrence rate is outstanding and I think it will only get better,” Dr. Ujiki said.

The series includes every patient on which they’ve performed a Sugarbaker and thus, represents their learning curve, which may not be the case with other series, he noted.

Dr. Ujiki left the audience with two bits of advice to hasten the learning curve: leave at least 5 cm of overlap because the mesh will shrink down and keep the stitches close to the mesh without cutting off the bowel.

pwendling@frontlinemedcom.com

CHICAGO – Patients who underwent modified laparoscopic Sugarbaker parastomal hernia repair were a third less likely to experience recurrence as those repaired with other surgical techniques in a multicenter, retrospective study in 62 patients.

The recurrence rate was 16.6% for the modified Sugarbaker technique, compared with 61% for keyhole repair, 69.2% for ostomy relocation, and 33.3% for open repair (P value < .001). Median follow-up was 16.6 months, 19.6 months, 16.4 months, and 27.2 months (P = .748).

In an adjusted Cox proportional hazards regression model, the Sugarbaker technique (hazard ratio, 0.28; P = .021) and body mass index (HR, 1.09; P = .013) were the only significant predictors of time to hernia recurrence.

Using the Kaplan-Meier method, 80% of Sugarbaker patients would be recurrence free at 2 years vs. about 60% of those in the other groups (log-rank P = .021), Mr. Francis DeAsis, a research assistant from NorthShore University Health in Evanston, Ill., reported at the annual meeting of the Central Surgical Association.

The findings are in keeping with prior Sugarbaker studies involving 177 repairs between 2005 and 2013, reporting recurrence rates between 4% and 20% and morbidity of 12%-43%, he said.

Morbidity was 40% among the 25 Sugarbaker repairs in the current analysis, significantly lower than that in the Keyhole, relocation, and open repair groups (40% vs. 83.3%, 61.5%, 83.3%; P = .005).

“Based on our results and others, we’d like to suggest that the Sugarbaker approach should be the primary option for treating parastomal hernia,” Mr. DeAsis said.

The study provides “further proof that no other technique available results in a durable repair compared to the Sugarbaker technique for these challenging hernias,” senior study author Dr. Michael Ujiki, director of minimally invasive surgery at NorthShore, said in an interview.

The Sugarbaker technique typically involves a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb. Modifications at NorthShore included use of polytetrafluoroethylene mesh with a 5-cm overlap of the defect and, if possible, primary closure of the defect. A catheter is occasionally used to identify the correct ostomy limb, but most importantly, a laparoscopic approach is utilized in order to decrease wound infections and quicken the return to daily activities, Dr. Ujiki said. “We also avoid cautery and diligently look for other incidental hernias at the prevision incisions.”

Ileus (> 3 days) was the most common complication in all groups: Sugarbaker (4/25), keyhole (9/18), relocation (3/13), and open (1/6). Only one death occurred; in the open group.

Discussant Dr. Matthew Goldblatt, with the Medical College of Wisconsin in Milwaukee, questioned how many patients also had ventral hernias and whether this was a complicating factor in ileus or length of stay and whether the fascia was closed primarily during keyhole repair or the mesh simply placed as a bridge, as this can impact failure rates.

Dr. Ujiki responded that some patients had concomitant ventral hernias and that they simply used a larger piece of mesh to cover both hernias. Primary closure was not part of the keyhole repair early in the 10-year series, spanning 2004 to 2014, but ultimately was performed in about half of patients in the keyhole group.

“I don’t think that there’s going to be a difference between the two in terms of recurrence, but I can’t say for sure,” he added.

At this point, the group does not use prophylactic mesh placement at the time the ostomy is created, to avoid infections.

Finally, the audience asked whether the investigators are willing to accept a 16% recurrence rate, a fourfold increase over the best reported result with a modified Sugarbaker technique.

“With these hernia repairs, to me a 16% recurrence rate is outstanding and I think it will only get better,” Dr. Ujiki said.

The series includes every patient on which they’ve performed a Sugarbaker and thus, represents their learning curve, which may not be the case with other series, he noted.

Dr. Ujiki left the audience with two bits of advice to hasten the learning curve: leave at least 5 cm of overlap because the mesh will shrink down and keep the stitches close to the mesh without cutting off the bowel.

pwendling@frontlinemedcom.com