The early outcomes of complex abdominal wall reconstruction with polyvinylidene (PVDF) mesh in the setting of active infection:a prospective series
应用聚偏二氟乙烯（PVDF）网片治疗活动性感染复杂腹壁疝的早期结果：一项前瞻性研究
Claudio Birolini1 · Eduardo Yassushi Tanaka1 · Jocielle Santos de Miranda1 · Abel Hiroshi Murakami1 ·Sergio Henrique Bastos Damous1 · Edivaldo Massazo Utiyama1
Received: 10 February 2022 / Accepted: 22 July 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022
Abstract
Purpose The use of synthetic mesh to repair infected abdominal wall defects remains controversial. Polyvinylidene fluoride(PVDF) mesh was introduced in 2002 as an alternativeto polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDFmesh to treat infected abdominal wall defects in the elective setting.
Methods This prospective clinical trial started in 2016 and was designed to evaluate the short- and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh (DynaMesh®—CICAT) reinforcement to treat their defects. Results Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and required a longer operative and anesthesia time. At 30 days, surgical site occurrences were observed in 16 (42.1%) AI vs. 17 (44.7%) CC,p = 0.817; surgical site infection occurred in 4 (10.5%) AI vs. 6 (15.8%) CC, p = 0.497; and a higher number of procedural interventions were required in the CC group, 15.8 AI vs. 28.9% CC, p = 0.169. Both groups did not have chronic infections at 1 year of follow-up, and one hernia recurrence was observed in the AI group. Conclusions The use of PVDF mesh in the infected setting presented favorable results with a low incidence of wound infection.
Keywords Ventral hernia · Incisional hernia · Mesh infection · Enteric fistula · Polyvinylidene mesh · DynaMesh® · CICAT mesh
Introduction
The use of mesh in repairing contaminated and infected abdominal wall defects remains controversial. The main aspects under discussion include mesh vs. suture repairs, single-stage vs. staged repairs, and the choice of biologic vs. synthetic vs. bio-absorbable mesh [1]. In previous reports, authors advocated using polypropylene mesh as a reliable alternative in elective repairs in the setting of contamination and active infection [2, 3]. Despite good outcomes, including low hernia recurrence rates and the cure of mesh infection following mesh replacement, polyvinylidene fluoride (PVDF) mesh is a newer generation material and a possible substitute for polypropylene in this scenario.
PVDF mesh was introduced in 2002, as an alternative to polypropylene, with the alleged advantages of an improved biostability, lowered bending stiffness, and a minimum tissue response [4, 5]. Ever since, it has been used in many clinical settings for the prevention of parastomal hernias [6],ventral hernias [7], cystocele [8], rectopexy [9], and emergency hernia repair [10].
This study aimed to evaluate the short- and mid-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting and compare it with the results of clean repairs.
Methods
From May 2016 to February 2021, 38 consecutive patients admitted with chronic mesh infection and/or enteric fistulas were enrolled in this prospective study. The active infection group (AI) was compared to a cohort of 38 patients submitted to clean ventral hernia repairs (CC) during the same period. The inclusion criteria in the AI group were the presence of active chronic mesh infection (non-healing sinus, exposed mesh, or mesh-related enteric fistulas) resulting from a previous repair, or the presence of an enteric/enteroatmospheric fistula, with or without an associated abdominal wall defect. The patients invited to participate
as controls had a primary or recurrent ventral hernia without previous history of infection and were eligible for clean operations. The operations in the AI group were classified as class IV (dirty-infected), according to the CDC Wound Classifications [11], as adopted by the European registry for abdominal wall hernias [12]. All operations in both groups were elective.
The exclusion criteria were giant ventral hernias with a Tanaka index [13] higher than 25%, patients on immunosuppressive or corticosteroid therapy, patients with portal hypertension, Crohn’s disease, acute postoperative mesh infection, chronic infections following inguinal hernia repair, a septic open-abdomen condition, and emergency operations.
Demographic data included age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), comorbidities, smoking status, cancer history, and the number of previous abdominal operations. Perioperative details included the list of associated procedures, the defect width, the extension of the pre-aponeurotic dissection, operative time, and anesthesia time. Further analysis in the AI group included the clinical presentation, the onset of symptoms, the type and position of the infected mesh, the possible causes for mesh infection, and the microbiology of mesh explants.
Patients were followed and operated on at a tertiary referral university center for abdominal wall and hernia surgery. Six surgeons on the team conducted the operations in both groups. The local ethics committee approved the study. Informed consent was obtained from all individual participants.
The manufacturer provided all the DynaMesh®- CICAT mesh samples (FEG Textiltechnik, Aachen, Germany) through their local dealer (BMR Medical, www. bmrme dical.com. br) at no cost. None of the authors or our institution received any financial support to undertake the study.
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