MODIFIED SUGARBAKER VERSUS KEYHOLE REPAIR FOR PARASTOMAL HERNIA. A SYSTEMATIC REVIEW AND UPDATED META-ANALYSIS OF COMPARATIVE STUDIES.
Andrew M. Fleming*1, Alisa L. Phillips1, Justin A. Drake1, Megan G. Gross1, Danny Yakoub2, Elizabeth H. Wood1
1Surgery, The University of Tennessee Health Science Center, Memphis, TN; 2Mayo Clinic Department of Surgery, Eau Claire, WI
Parastomal hernia (PSH) is a debilitating complication of stoma creation. PSH repair with mesh reduces recurrence rates in open and laparoscopic settings. Recent comparative studies conflict previously pooled data on optimal mesh repair technique. This study aims to perform an updated systematic review and meta-analysis examining PSH recurrence rates after Sugarbaker (SB) and keyhole (KH) repairs.
A systematic review of multiple online databases was performed according to PRISMA 2020 guidelines. Studies comparing SB and KH repair techniques were included. Pooled mean differences (MD), odds ratios (OR), and risk ratios (RR) with 95% confidence intervals (CI) were calculated. Study bias and heterogeneity were assessed. Study quality was analyzed using MINORS criteria with higher scoring studies evaluated in subgroup analysis. Additional subgroup analysis of modern studies was performed.
10 comparative studies published between 2004 and 2021 from 5 countries were included for analysis comprising 347 SB repairs and 246 KH repairs. There were no differences in patient age, sex, or BMI between the groups. Three studies reported data on bleeding and surgical site infections (SSI). There was no difference between the groups regarding surgical site infection (OR 0.78; CI 0.3-2.07; P=0.62) or postoperative bleeding (OR 0.83; CI 0.22-3.12; P=0.78). SB repairs were significantly less often associated with PSH recurrence when compared to KH repairs (OR 0.38; CI 0.18-0.78; P=0.008) (Figure 1A). There was not significant heterogeneity among the studies (I2 = 32%; P=0.15). Quality analysis revealed a median MINORS score of 11 (range 6-16). Subgroup analysis of studies with MINORS scores above the median revealed no significant difference in PSH recurrence between the two groups (OR 0.43; CI 0.12-1.51; P=0.19) (Figure 1B). Additional subgroup analysis of studies performed after the previously published pooled analysis (2015-2021) revealed no significant difference in PSH recurrence between the two groups (OR 0.58; CI 0.24-1.38; P=0.22) (Figure 1C).
Though there were lower rates of PSH recurrence with SB repairs on overall analysis, this phenomenon disappeared when analyzing modern studies and studies with higher MINORS scores. Randomized controlled trials with contemporary cohorts would help further evaluate these repairs and minimize potential bias.
Figure 1. Comparison of parastomal hernia recurrence rates between keyhole repairs and modified Sugarbaker repairs. 1A – Meta-analysis of all included comparative studies revealed significantly more PSH recurrences among the KH repair group. 1B – Subgroup meta-analysis of studies with higher MINORS scores revealed no significant difference in PSH recurrence between the groups. 1C – Subgroup meta-analysis of studies performed after the previously published pooled analysis (2015-2021) revealed no significant difference in PSH recurrence between the two groups.
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