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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 1
| Issue : 2 | Page : 42-49 |
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Optimal management of mesh infection: Evidence and treatment options
Michael R Arnold1, Angela M Kao1, Korene K Gbozah2, B Todd Heniford1, Vedra A Augenstein1
1 Department of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA
2 Department of General Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| Date of Submission | 17-Jul-2018 |
| Date of Acceptance | 25-Jul-2018 |
| Date of Web Publication | 16-Aug-2018 |
Correspondence Address:
Dr. Vedra A Augenstein
Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28204
USA
 Source of Support: None, Conflict of Interest: None  | 19 |
DOI: 10.4103/ijawhs.ijawhs_16_18
Mesh reinforcement is generally considered the standard of care in ventral hernia repair. Infection is a common complication following ventral hernia repair. Infection extending to the mesh is a complex problem. Knowledge of current treatment strategies is necessary for surgeons performing abdominal wall reconstruction. A comprehensive literature review was performed of current literature to assess risk factors and treatment options for mesh infection. Modifiable risk factors for mesh infections include active smoking, poorly controlled diabetes mellitus, abdominal skin or wound issues, and obesity. Operative factors that increase the risk of mesh infection include prior hernia repair, enterotomy and contamination of the surgical field. Of the synthetic meshes, lightweight polypropylene has the highest likelihood of salvage. Patients that are current smokers, those with other synthetic mesh types, and those infected with MRSA are rarely salvaged. Following excision of infected mesh, multi-staged abdominal wall reconstruction can be considered. Biologic or biosynthetic mesh is recommended when repairing incisional hernias following excision of infected mesh and likely represent the patient's best chance at a definitive hernia repair. Wound VAC-assisted delayed primary closure should be considered in higher-risk patients. Mesh infection is a complex complication that is commonly encountered by surgeons performing hernia repair. Prevention through patient optimization should be performed whenever appropriate. However, when patients develop a mesh infection, most will require complete mesh excision and recurrent hernia repair.
Keywords: Hernia, infection, management, mesh, treatment
How to cite this article:
Arnold MR, Kao AM, Gbozah KK, Heniford B T, Augenstein VA. Optimal management of mesh infection: Evidence and treatment options. Int J Abdom Wall Hernia Surg 2018;1:42-9 |
| Introduction | |  |
Ventral hernial repair (VHR) is one of the most common operations performed in the United States. Approximately 350,000 cases are performed each year, and the number is increasing by 1%–2% annually.[1] Mesh prosthesis has demonstrated a clear benefit in reducing hernial recurrence compared to suture repair alone due to reinforcement of native tissue, allowing for tissue ingrowth and lateralization of force across the entire abdominal wall.[2] Numerous studies have demonstrated that mesh is the most cost-effective method to prevent hernial recurrence during abdominal wall reconstruction (AWR).[3],[4] Thus, mesh reinforcement is considered the standard method of hernial repair. Unfortunately, the implantation of foreign bodies can be associated with postoperative complications including seroma, mesh migration, mesh infection, or mesh fistula.[4],[5] Mesh infection can occur between 1% and 8% of VHRs and remains a challenging postoperative complication.[6],[7],[8] Mesh infections are the third leading cause of reoperation following VHR and can result in significant patient morbidity, prolonged hospitalization, and increased costs to the patient and health-care system.[7],[9] In addition to the clinical consequences, the economic impact of mesh infections is substantial. Darouiche estimated that the annual cost of infections secondary to implantable devices reached 3 billion dollars in a study that is nearly 15 years old.[10],[11] Given the cost and potential re-operation, prevention and treatment of mesh infections are an important focus of AWR.
| Risk Factors for Mesh Infection | | |
Surgeons performing AWR should recognize the potential for any mesh to become infected and understand the risks and management strategies for mesh infection. Preoperative comorbidities such as active smoking, poorly controlled diabetes mellitus, skin or wound issues, and obesity have been shown to increase the risk of mesh infections. Operative and technical factors that have been previously identified as risk factors for mesh infection include surgical approach, prolonged operative time, emergency operations, wound classification, concomitant gastrointestinal (GI) surgery, and inadvertent enterotomies.[6],[9],[12]
Numerous strategies exist to reduce the incidence of wound complications which yield a 3-fold increase in mesh infection. These factors include the preoperative mitigation of modifiable comorbidities, as well as appropriate antibiotic prophylaxis according to the Surgical Care Improvement Program.[13] Despite this, VHR is the second most common operation leading to hospital readmission according to an American College of Surgeons National Surgical Quality Improvement Program study.[14] One of the most common reasons for readmission is the high rate of wound complications, occurring in 29%–66% of patients.[15],[16],[17],[18],[19],[20],[21] One meta-analysis evaluated 2418 mesh hernioplasties and found a combined mesh infection rate of 7.2% after AWR.[5] The same analysis also identified patient factors of advanced age, American Society of Anesthesiologists score ≥3, and tobacco smoking as significant risk factors for the development of mesh infection.[5] Smoking has been further demonstrated to increase the incidence of wound infections and 30-day readmissions in open VHR. This likely occurs due to decreased tissue oxygenation which negatively affects wound healing.[22] A trend toward higher mesh infection rates was also noted in patients with uncontrolled diabetes mellitus, obesity, and chronic obstructive pulmonary disease, prompting many surgeons to encourage weight loss, smoking cessation, and glycemic control to medically optimize patients preoperatively and mitigate wound complications.[5],[23] In addition, many have adopted more stringent patient selection criteria for elective VHRs following evidence supporting a direct correlation between preventable risk factors and wound complications.[24] Such efforts to modify patient comorbidities have been shown to significantly impact the hospital charges associated with surgery, in addition to the improvement in patient outcomes.[25] Carolinas equation for the determination of associated risks (CeDAR) is a smartphone application used worldwide to assisting providers with preoperative risk factor identification and stratification. Factors most significantly associated with wound complications are preoperative HbA1c >7.2 with an odds ratio (OR) of 2.01, prior hernial repair (OR: 2.64), enterotomy (OR: 2.65), or an infected surgical field (OR: 2.07). Use of the CeDAR app enables surgeons to counsel patients appropriately and institute preoperative interventions such as assistance with weight loss, diabetes management, and smoking cessation. With the implementation of such preoperative interventions, post-app patients had a significant decrease in wound-related complications including subsequent decrease in mesh infection and a dramatic decrease in cost of patient care.[26],[27]
Mesh infections can result from both open and minimally invasive surgical (MIS) approaches, although the incidence following minimally invasive VHR is lower.[8] MIS rates may reach 3.6%, while the mesh infection rate following open VHR can be as high as 10%.[28] Such infections usually present with the classic signs of erythema, tenderness, warmth, fluctuance, or drainage. There may also be generalized symptoms such as malaise, fever, chills, and pain. Mesh infections may also present as a poorly healing incision or a small, intermittently draining sinus [Figure 1]. A fluid collection on the mesh is often present on ultrasound or computed tomography (CT) imaging; however, infection scintigraphy can also be used as is done in orthopedic and vascular patients to evaluate for infection when a fluid collection is absent. This technique may also be used to differentiate between normal postoperative inflammation and infection following VHR with mesh.[29] Despite good outcomes, MIS hernial repair is not frequently utilized in the United States, with only 30% VHR being done laparoscopically.[30] | Figure 1: Preoperative image of patient with chronically draining sinus and poorly healing abdominal wounds
Click here to view |
| Limited Data on Treatment | | |
Despite its impact and magnitude, little data exist regarding the management of mesh infections, and there are certainly no guidelines. Our practice was initially to follow treatment methods established by orthopedic guidelines for infected prosthesis, i.e., expedient fluid aspiration and microbiological workup, with target antibiotics. The duration of such therapy was then determined by following erythrocyte sedimentation rate and C-reactive protein levels with or without the assistance of infectious disease consultants.[31] The lack of data and consensus on management is multifactorial. There is no dedicated database which follows each patient with implanted mesh. Often, patients who have a postoperative complication do not follow up with their original surgeon but seek help elsewhere. In a survey of 284 patients, all of which had recurrent hernias, 57% reported having a postoperative complication following their hernial repair. Of these patients, only 44% had informed their primary surgeon of the complications or hernial recurrence.[32] Furthermore, mesh infections are poorly studied and they often present remotely from the initial operation. Although one might assume that mesh infections would manifest in the early perioperative period like other surgical-site infections, a large series of over 160 mesh infections found that the signs, symptoms, and subsequent patient presentation are frequently remote from the original operation.[33] Only 57% of patients presented by 6 months and more than one-third of the patients presented a year or more from the time of hernial repair. This delayed presentation is consistent with the indolent nature of many mesh infections, likely due to the time taken from contamination to the development of biofilm which allows bacterial proliferation due to suppressed immune function and antibiotic penetration. Further adding to difficulty of tracking patients with infected mesh is the relatively low frequency of this complication and surgeons who do not perform high volume of hernial repairs or who do not follow their patients' term; therefore, it is difficult to establish patterns in infection, treatment, and salvage.
| Mesh Salvage | | |
Given the expected hernial recurrence that follows debridement of infected tissue and mesh removal where defects are sometimes larger than the original hernia, explantation of mesh is an unfortunate but often unavoidable consequence of mesh infection. Surgical-site complications have been identified as the primary predictor for mesh explantation.[10] There are advocates for medical management of mesh infections with antibiotics and local wound therapy, their intent being mesh salvage and prevention of a subsequent operation. This strategy typically involves percutaneous drainage or local debridement with VAC systems combined with prolonged antibiotic regimens.[34],[35],[36],[37] However, the data to support mesh salvage or partial mesh excision are limited to case reports and case series. Stremitzer et al. demonstrated a 55% salvage rate in a series of 31 patients with a mesh infection.[38] Berrevoet et al. reported a series of patients with mesh salvage using negative pressure therapy and demonstrated that the only meshes consistently requiring explantation due to ongoing infection and lack of granulation tissue covering the mesh were multifilament polyester meshes. This is likely due to the increased biofilm present on multifilamented polyester mesh compared to polypropylene mesh.[37],[39]
Other series have demonstrated higher failure rates even with short-term follow-up.[40] Long-term studies have shown poor results with mesh salvage, and recent data suggest that patients have worse outcomes with partial mesh excision.[41],[42] Our previously described series of over 160 patients with nearly 3 years of follow-up also demonstrated that mesh salvage is unlikely. This is particularly true when certain patient factors are present, such as current smoking or methicillin-resistant Staphylococcus aureus colonization.[33] In this study, only 32 patients were successful in attempting mesh salvage, with half of the patients requiring chronic or intermittent suppressive antibiotics. Therefore, it could be argued that only 16 patients (10%) truly had their mesh salvaged at an average of 33.9-month follow-up from the time of diagnosed infection. In this series, no patients presented with sepsis during the study period, implying that while less efficacious, it is likely safe to attempt mesh salvage in appropriate patients. However, there are further health concerns when patients are on chronic suppressive antibiotics because of complications associated with chronic indolent infection including poorly controlled diabetes, atherosclerosis, and cardiovascular disease.[43],[44]
This study further demonstrated that the successful mesh salvage was highly dependent on mesh type. The salvage rate of polypropylene mesh was higher than polytetrafluoroethylene (PTFE) mesh (19.6% vs. 4.5%), with lightweight polypropylene having a higher salvage rate than mid- or heavyweight mesh (62.5% vs. 12.5%). No patients with polyester or composite mesh were successfully salvaged.[33] Hawn et al. demonstrated even higher rates of mesh explantation with PTFE. However, there are over 200 types of mesh available in the United States, and no synthetic mesh has demonstrated superiority.[45],[46] Furthermore, placing synthetic mesh into a contaminated field is controversial. For example, lightweight polypropylene has been shown to have the greatest likelihood of clearance of mesh infection and has been used in contaminated fields with good short-term results, but the long-term data have shown high hernial recurrence rates due to central fracture of the mesh.[23],[47],[48]
With caution, it should be noted that, at the time of operation for mesh excision, 17% of patients were found to have a quiescent mesh-enteric fistula. In a previously reported series of 78 patients with mesh fistula, no patient had resolution of their mesh fistula without surgical intervention.[41] Similar features associated with the failure of nonoperative management of mesh infection have been demonstrated by other groups.[38]
| Mesh Excision – complete Versus Partial | | |
With data showing poor rates of mesh salvage, most patients with mesh infection will eventually require excision of their infected mesh.[40] Complete excision is often difficult due to the chronic inflammation and an already compromised abdominal wall. Some argue that aggressively attempting complete mesh excision can lead to enterotomies or injury of the abdominal wall vasculature leading to ischemia and fascial injury, further complicating hernial repair.[38],[49] However, retained foreign body following partial mesh excision predisposes the patient to persistent infection, and the foreign body reaction from material as small as suture has long been known to potentiate infectious complications.[6],[50] These opposing arguments are reflected in the literature, with some studies demonstrating fewer complications when removing only infected portions of mesh, while leaving well-incorporated mesh behind.[34],[51] However, this has been shown to have a high rate of failure in patients with 20%–50% or more requiring some type of subsequent procedural intervention.[42],[52] In a recent study of 1904 patients from the American Hernia Society Quality Collaborative, Kao et al. performed a propensity-matched analysis that demonstrated a substantially higher rate of postoperative morbidity, notably surgical-site occurrence requiring procedural intervention and reoperation with partial mesh excision as compared to complete mesh excision. These differences were most impressive in patients with mesh infection and mesh fistula.[53] The findings from this large multicentric hernia database were further established by preliminary results from our own institution which studied outcomes in 263 patients with mesh infections or fistulas. Following surgical treatment for excision of prior mesh, those who underwent partial excision had significantly increased wound complications and abscesses. In 78 patients with mesh fistula, those undergoing partial mesh excision had a 4.5-fold increase in the rate of fistula recurrence and a 4-fold increase in the rate of hernia recurrence.[41] These data would suggest that, whenever safe, the entire mesh, all sutures, tacks, and other foreign material should be removed in the setting of mesh infection.
| Mesh Excision – technique | | |
When undertaking mesh excision for patients with a mesh infection, the importance of preoperative optimization remains significant. Patients can generally be managed medically with drainage and deep culture-guided appropriate antibiotic coverage with little risk for septic complications. Consultation with infectious disease specialists may be obtained, but is not mandatory. During this time, their medical comorbidities and nutritional status should be optimized if possible. This period also allows for patient counseling and informed consent, including the extent of surgery, the risk of complications, and possible future interventions. Most patients will have a preoperative CT scan to evaluate the intra-abdominal anatomy, identify mesh fistulae if possible, and a bowel prep may be considered if bowel resection is anticipated.
Intraoperatively, an elliptical laparotomy incision is made to include any cicatrix and fistula that may be present. The peritoneal cavity is entered remotely from expected adhesions. Intestinal adhesions are meticulously taken down from the abdominal wall and continued circumferentially around the infected mesh, and if a fistula is present, it is pedicalized [Figure 2]. In essence, the area of the fistula is approached last due to this area, often requiring the most difficult dissection. Once the entire mesh, all suture material, and possibly bowel are excised [Figure 3], the hernial defect may be closed primarily or reinforced with a nonpermanent mesh [Figure 4]. | Figure 2: Pedicalized mesh fistula with mesh eroded into the small bowel
Click here to view |
 | Figure 4: Preperitoneal placement of biologic mesh prior to fascial closure
Click here to view |
As previously discussed, avoidance of wound complications is important. In these high-risk patients, our institutional data have shown that, in addition to preoperative optimization, wound closure is an important aspect in the prevention of wound complications and subsequent hernial failure. In this regard, delayed primary closure (DPC) has been shown to be a significant adjunct to the prevention of wound closure complications. In our experience, patients with DPC aided by a vacuum-assisted closure (VAC) had an 83.4% success rate when their predicted wound-related complication rate was 69.7% using the CeDAR app.[54]
| Suture Versus Mesh Repair | | |
There is debate regarding staging hernial repairs for patients with contaminated wounds, with advocates for both multi-stage[55],[56] and single-stage repairs.[57],[58],[59] In either case, most authors agree that the basic operative goals in patients with mesh infection include infection control, restoration of GI continuity when necessary, and stable AWR. Multistaged hernial repair is an option with excision of the infected mesh and suture repair of the fascial defect performed at the first operation, followed by a definitive repair with synthetic mesh at a planned second operation once the infection has cleared and healing has been completed. The excision of infected mesh with suture repair of the fascia is considered a multistaged repair due to the almost universal hernial recurrence after the first operation. Even in clean cases, with small defects, suture repair results in a very high rate of hernial recurrence.[3] In our experience, patients undergoing suture repair in a contaminated setting have a nearly 80% hernial recurrence, with most of those without recurrence having very short follow-up.[60] Thus, patients undergoing suture repair alone after mesh excision are counseled on an essentially inevitable hernia recurrence with a plan for synthetic mesh repair in the future. Although advocates of the multistaged repair may argue that delaying the repair allows for clearance of the infection and placement of synthetic mesh, recent data have suggested that the definitive second-stage hernial repair often does not occur. In a series of 78 mesh fistula repairs, only 21% underwent repair of their recurrent hernia following suture repair alone.[41] Patients simply would prefer to live with a hernia as opposed to another operation. Thus, hernial repair at the time of mesh excision with a nonsynthetic material may be the patient's best chance for a durable AWR and consequent optimal value for the patient and health-care system.
Single-staged repairs with synthetic mesh are generally considered inappropriate due to the very high risk of re-infection regardless of mesh type.[61] Conversely, single-staged repairs with nonpermanent mesh are more common. In single-staged repair, biologic or biosynthetic meshes are used due to lower risk for infection because these are thought to support rapid neovascularization promoting bacterial clearance.[35] Critics of single-staged repairs cite higher expense and hernial recurrence compared to permanent mesh.[62] Among many others, the Ventral Hernia Working Group recommended against the use of permanent mesh in infected fields.[6] When looking at data from a single-institutional series of 136 patients undergoing hernial repair with acellular porcine dermal matrix, the recurrence rate was 9.5%.[63] This was comparable, if not lower, than previously published series ranging from 13% to 28%.[35],[64] Furthermore, the high recurrence attributed to biologic mesh may be in part due to its frequent use as a bridged repair in cases where fascial approximation is unable to be achieved. When Garvey et al. excluded bridged repairs from their analysis, the hernial recurrence was 6.4% with 3-year follow-up and 8.3% in patients with 5-years of follow-up. This effect may not be limited to biologic mesh. When eliminating parastomal hernias, Rosen et al. estimated a 14% hernial recurrence using a biosynthetic mesh (Gore Bio-A Tissue Reinforcement; Flagstaff, Arizona, USA) with 24 months of follow-up.[65]
Despite advances in surgical technique and materials, mesh infection remains one of the most difficult postoperative complications following hernial repair. Without guidelines and robust databases with long-term follow-up of mesh, management of infections remains complicated and is usually guided by surgeons' anecdotal experience. While VHR remains one of the most common surgical procedures performed worldwide, mesh infections will be encountered by nearly all general surgeons from time to time in their career. The best strategy is prevention: preoperative identification and optimization of modifiable risk factors specifically, tobacco cessation, diabetes management, and weight loss prior to elective hernial repairs. Considering minimally invasive techniques as well as abiding to the general principles of perforator-sparing skin and subcutaneous tissue mobilization and incisional wound management will decrease the risks of surgical-site complications and thereby mesh infection.[66] When mesh infection is present, initial attempts at medical management or surgical salvage with appropriate antibiotics and percutaneous or open drainage of fluid collections can be attempted. When conservative management fails and patients are suitable for surgery, complete excision of mesh and any foreign material should be the goal, but overall patient safety is foremost. Consideration should be given to abdominal wall reinforcement with nonsynthetic mesh and delayed primary wound closure. Management of patients with mesh infection is complex and may benefit from consultation with colleagues with high-volume hernial referral practices, possibly infectious disease specialists, radiologists, or plastic and reconstructive surgeons. Long-term follow-up of patients will elucidate the value of these interventions and facilitate future development of guidelines for management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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