EP684 - Simultaneous treatment of complex incisional hernia and stoma reversal

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Purpose/Background: Ventral hernia repair is a common procedure, with over 386,000 operations annually in the United States. Patients with a stoma face challenges such as skin irritation (76%), pouch leakage (62%), offensive odor (59%), reduced pleasurable activities (54%), and depression/anxiety (53%). Returning viscera to the abdominopelvic cavity can cause abdominal compartment syndrome, and performing an anastomosis risk leaks. Due to limited high-level evidence, standardized guidelines for concurrently performing these procedures are lacking.

Methods/Interventions: This retrospective study included patients with a concurrent stoma or enterocutaneous fistula and incisional ventral hernia who underwent ostomy reversal or fistula repair with abdominal wall reconstruction from January 2010 to January 2023. Cases were evaluated by expert plastic and colorectal surgery teams. Intestinal reconnection involved colonoscopy and contrast enema, and the abdominal wall was assessed via CT. Variables from CT scans were recorded using the Tanaka Index. Hernia repairs were retromuscular with posterior component separation, using biologic mesh when necessary.
Tanaka was used to obtain the ratio of the hernia sac volume divided by the residual abdominopelvic cavity, whereas Sabbagh was used to describe the proportion of total abdominopelvic cavity volume contained within the hernia.
Surgical procedures involved collaborative efforts from plastic and colorectal surgery teams, using retromuscular repair with posterior component separation and biologic mesh.
The primary outcome was the anastomotic leak rate and its association with abdominal defect size, followed by surgical site infection. Other complications included intestinal or cutaneous dehiscence and ventral defect recurrence.

Results/Outcomes: Patients were divided into Group 1 (5 patients with anastomotic leakage) and Group 2 (50 patients without leakage). No significant demographic differences were found. Univariate analysis identified the Tanaka Index (OR: 1.12, p=0.010) and Sabbagh Index (OR: 1.18, p=0.008) as significant risk factors, with a trend towards male gender (OR: 1.95, p=0.098). Logistic regression showed the Tanaka Index as the only significant independent variable (OR: 1.27, p=0.010). The leakage group had a median Tanaka Index of 19.2 vs. 3.9 in controls (p=0.008) and a Sabbagh Index of 16.1 vs. 3.7 (p=0.009). ROC analysis determined a Tanaka Index cutoff >8.455, with 100% sensitivity and 82% specificity for predicting leaks (AUC=0.91; p=0.002).

Conclusion/Discussion: There is a lack of prospective studies on the best treatment for patients with complex incisional hernias and enterocutaneous fistulas needing intestinal reconstruction. Anastomotic leak is the most severe complication after stoma reversal, increasing morbidity, hospital stay, intensive care needs, and thirty-day mortality. Our study reported a 9.09% leak rate, 25% morbidity, and 0% mortality. This is the first study to correlate hernia sac size with anastomotic leaks using the Sabbagh and Tanaka Indices. We established a Tanaka Index cutoff of >8.455 to predict leaks, aiding in deciding to perform procedures separately in high-risk patients. Protocols are needed to identify patients who could benefit from single-stage procedures, minimizing complications without increasing leak risks. The Tanaka Index cutoff can help exclude high-risk patients from single-stage procedures.