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Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials
BACKGROUND: Previous meta-analyses of randomised controlled trials (RCTs) have suggested a reduction in parastomal hernias (PSH) with prophylactic mesh. However, concerns persist regarding variably supportive evidence and cost. We performed an updated systematic review and meta-analysis to inform a...
Autores principales: | , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Springer International Publishing
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954076/ https://www.ncbi.nlm.nih.gov/pubmed/29732505 http://dx.doi.org/10.1007/s10151-018-1774-5 |
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author | Findlay, J. M. Wood, C. P. J. Cunningham, C. |
author_facet | Findlay, J. M. Wood, C. P. J. Cunningham, C. |
author_sort | Findlay, J. M. |
collection | PubMed |
description | BACKGROUND: Previous meta-analyses of randomised controlled trials (RCTs) have suggested a reduction in parastomal hernias (PSH) with prophylactic mesh. However, concerns persist regarding variably supportive evidence and cost. We performed an updated systematic review and meta-analysis to inform a novel cost-effectiveness analysis. METHODS: The PubMed, EMBASE and Cochrane Centre Register of Controlled Trials databases were searched (February 2018). We included RCTs assessing mesh reinforcement during stoma formation. We assessed PSH rates, subsequent repair, complications and operative time. Odds ratios (OR) and numbers needed to treat (NNT) were generated on intention to treat (ITT) and per protocol (PP) bases. These then informed cost analysis using 2017 UK/USA reimbursement rates and stoma care costs. RESULTS: Eleven RCTs were included. Four hundred fifty-three patients were randomised to mesh (PP 412), with 454 controls (PP 413). Six studies used synthetic meshes, three composite and two biological (91.7% colostomies; 3.64% ileostomies, 4.63% not specified). Reductions were seen in the number of hernias detected clinically and on computed tomography scan. For the former, ITT OR was 0.23 (95% confidence interval 0.11–0.51; p = 0.0003; n = 11); NNT 4.17 (2.56–10.0), with fewer subsequent repairs: OR 0.29 (0.13–0.64; p = 0.002; n = 7; NNT16.7 (10.0–33.3). Reductions persisted for synthetic and composite meshes. Operative time was similar, with zero incidence of mesh infection/fistulation, and fewer peristomal complications. Synthetic mesh demonstrated a favourable cost profile, with composite approximately cost neutral, and biological incurring net costs. CONCLUSIONS: Reinforcing elective stomas with mesh (primarily synthetic) reduces subsequent PSH rates, complications, repairs and saves money. We recommend that future RCTs compare mesh subtypes, techniques, and applicability to emergency stomas. |
format | Online Article Text |
id | pubmed-5954076 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | Springer International Publishing |
record_format | MEDLINE/PubMed |
spelling | pubmed-59540762018-05-18 Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials Findlay, J. M. Wood, C. P. J. Cunningham, C. Tech Coloproctol Short Communication BACKGROUND: Previous meta-analyses of randomised controlled trials (RCTs) have suggested a reduction in parastomal hernias (PSH) with prophylactic mesh. However, concerns persist regarding variably supportive evidence and cost. We performed an updated systematic review and meta-analysis to inform a novel cost-effectiveness analysis. METHODS: The PubMed, EMBASE and Cochrane Centre Register of Controlled Trials databases were searched (February 2018). We included RCTs assessing mesh reinforcement during stoma formation. We assessed PSH rates, subsequent repair, complications and operative time. Odds ratios (OR) and numbers needed to treat (NNT) were generated on intention to treat (ITT) and per protocol (PP) bases. These then informed cost analysis using 2017 UK/USA reimbursement rates and stoma care costs. RESULTS: Eleven RCTs were included. Four hundred fifty-three patients were randomised to mesh (PP 412), with 454 controls (PP 413). Six studies used synthetic meshes, three composite and two biological (91.7% colostomies; 3.64% ileostomies, 4.63% not specified). Reductions were seen in the number of hernias detected clinically and on computed tomography scan. For the former, ITT OR was 0.23 (95% confidence interval 0.11–0.51; p = 0.0003; n = 11); NNT 4.17 (2.56–10.0), with fewer subsequent repairs: OR 0.29 (0.13–0.64; p = 0.002; n = 7; NNT16.7 (10.0–33.3). Reductions persisted for synthetic and composite meshes. Operative time was similar, with zero incidence of mesh infection/fistulation, and fewer peristomal complications. Synthetic mesh demonstrated a favourable cost profile, with composite approximately cost neutral, and biological incurring net costs. CONCLUSIONS: Reinforcing elective stomas with mesh (primarily synthetic) reduces subsequent PSH rates, complications, repairs and saves money. We recommend that future RCTs compare mesh subtypes, techniques, and applicability to emergency stomas. Springer International Publishing 2018-05-07 2018 /pmc/articles/PMC5954076/ /pubmed/29732505 http://dx.doi.org/10.1007/s10151-018-1774-5 Text en © The Author(s) 2018 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. |
spellingShingle | Short Communication Findlay, J. M. Wood, C. P. J. Cunningham, C. Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title | Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title_full | Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title_fullStr | Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title_full_unstemmed | Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title_short | Prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
title_sort | prophylactic mesh reinforcement of stomas: a cost-effectiveness meta-analysis of randomised controlled trials |
topic | Short Communication |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954076/ https://www.ncbi.nlm.nih.gov/pubmed/29732505 http://dx.doi.org/10.1007/s10151-018-1774-5 |
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