Factors affecting salvage rate of infected prosthetic mesh.
Enteroprosthetic fistula
Mesh infection
Mesh salvage
Subsequent abdominal operations
Journal
American journal of surgery
ISSN: 1879-1883
Titre abrégé: Am J Surg
Pays: United States
ID NLM: 0370473
Informations de publication
Date de publication:
09 2020
09 2020
Historique:
received:
07
01
2020
revised:
16
01
2020
accepted:
18
01
2020
pubmed:
10
2
2020
medline:
26
11
2020
entrez:
10
2
2020
Statut:
ppublish
Résumé
Prosthetic mesh infection (PMI) is a challenging complication of ventral hernia repair (VHR). The sparsity of data leaves only experience and judgment to guide surgical decision-making. Retrospective review of patients diagnosed with PMI. Subsequent abdominal operation (SAO) constitutes any intraabdominal operation occurring after the index hernia repair prior to PMI presentation. Any mesh removal was considered salvage failure. Analysis was performed using Chi-square test, Fishers Exact, or Mann-Whitney U test. Analyses completed using R Version 3.0.2. We identified 213 instances of PMI. Most cases (58.7%) involved intraperitoneal mesh. Thirty-seven percent of patients had an SAO, only 25.3% of which were clean cases. Enteroprosthetic fistula occurred in 38 patients (17.8%). Mean time to presentation was 19.9 mos after index hernia repair or SAO for infection alone, and 48.1 mos when a fistula was present (p < 0.001). Percutaneous drainage was used to treat 29 cases, successfully in 10 (34.5%), 8 of which were macroporous polypropylene and 2 biologic mesh. Negative pressure wound therapy (NPWT) was used in 46 patients, but successful in only 16 (34.8%), all of which were macroporous polypropylene. Local wound care alone successfully salvaged only 16 of 85 meshes (18.8%), 13 of which were macroporous polypropylene. Macroporous polypropylene mesh was salvaged in 65% of cases overall, and 72.2% when in an extraperitoneal position. Mesh salvage was not possible in any case involving composite or PTFE mesh, and rarely for microporous polypropylene (7.7%) multifilament polyester (4.2%), or intraperitoneal mesh (2.4%). Closure of the defect after mesh removal significantly lowers recurrence rate (p < 0.001). PMI involving composite, PTFE, multifilament polyester, or microporous polypropylene mesh requires explantation in nearly all cases. Infected macroporous polypropylene mesh in an extraperitoneal position is salvageable in most cases. Furthermore, the risk of secondary mesh infection after SAO, particularly with intraperitoneal mesh, should be considered during index VHR.
Sections du résumé
BACKGROUND
Prosthetic mesh infection (PMI) is a challenging complication of ventral hernia repair (VHR). The sparsity of data leaves only experience and judgment to guide surgical decision-making.
METHODS
Retrospective review of patients diagnosed with PMI. Subsequent abdominal operation (SAO) constitutes any intraabdominal operation occurring after the index hernia repair prior to PMI presentation. Any mesh removal was considered salvage failure. Analysis was performed using Chi-square test, Fishers Exact, or Mann-Whitney U test. Analyses completed using R Version 3.0.2.
RESULTS
We identified 213 instances of PMI. Most cases (58.7%) involved intraperitoneal mesh. Thirty-seven percent of patients had an SAO, only 25.3% of which were clean cases. Enteroprosthetic fistula occurred in 38 patients (17.8%). Mean time to presentation was 19.9 mos after index hernia repair or SAO for infection alone, and 48.1 mos when a fistula was present (p < 0.001). Percutaneous drainage was used to treat 29 cases, successfully in 10 (34.5%), 8 of which were macroporous polypropylene and 2 biologic mesh. Negative pressure wound therapy (NPWT) was used in 46 patients, but successful in only 16 (34.8%), all of which were macroporous polypropylene. Local wound care alone successfully salvaged only 16 of 85 meshes (18.8%), 13 of which were macroporous polypropylene. Macroporous polypropylene mesh was salvaged in 65% of cases overall, and 72.2% when in an extraperitoneal position. Mesh salvage was not possible in any case involving composite or PTFE mesh, and rarely for microporous polypropylene (7.7%) multifilament polyester (4.2%), or intraperitoneal mesh (2.4%). Closure of the defect after mesh removal significantly lowers recurrence rate (p < 0.001).
CONCLUSION
PMI involving composite, PTFE, multifilament polyester, or microporous polypropylene mesh requires explantation in nearly all cases. Infected macroporous polypropylene mesh in an extraperitoneal position is salvageable in most cases. Furthermore, the risk of secondary mesh infection after SAO, particularly with intraperitoneal mesh, should be considered during index VHR.
Identifiants
pubmed: 32035628
pii: S0002-9610(20)30039-8
doi: 10.1016/j.amjsurg.2020.01.028
pii:
doi:
Substances chimiques
Polyesters
0
Polypropylenes
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
751-756Informations de copyright
Copyright © 2020 Elsevier Inc. All rights reserved.
Déclaration de conflit d'intérêts
Declaration of competing interest Author Warren JA receives honoraria for teaching from Intuitive Surgical, Ethicon, CMR Surgical. Author Cobb WS receives honoraria for teaching from W.L. Gore, Maquet/Getinge, Lifecell/Allergan, and Ethicon. Author Carbonell AM receives honoraria for teaching from W.L. Gore and Intuitive Surgical.