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Erschienen in: Surgical Endoscopy 2/2017

22.06.2016

Biologic mesh for repair of ventral hernias in contaminated fields: long-term clinical and patient-reported outcomes

verfasst von: Amin Madani, Petru Niculiseanu, Wanda Marini, Pepa A. Kaneva, Benjamin Mappin-Kasirer, Melina C. Vassiliou, Kosar Khwaja, Paola Fata, Gerald M. Fried, Liane S. Feldman

Erschienen in: Surgical Endoscopy | Ausgabe 2/2017

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Abstract

Background

Guidelines recommend biologic prosthetics for ventral hernia repair (VHR) in contaminated fields, yet long-term and patient-reported data are limited. We aimed to determine the long-term rate of hernia recurrence, and other clinical and patient-reported outcomes following the use of porcine small intestine submucosa (PSIS) for VHR in a contaminated field.

Methods

Consecutive patients undergoing open VHR with PSIS mesh in a contaminated field from 2004 to 2014 were prospectively evaluated for hernia recurrence and other post-operative complications. Multivariate logistic and Cox regression analyses identified predictors of hernia recurrence and surgical site infection. Patient-reported outcomes were evaluated using SF-36, Hernia-Related Quality-of-Life Survey (HerQLes) and Body Image Questionnaire instruments.

Results

Forty-six hernias were repaired in clean-contaminated [16 (35 %)], contaminated [11 (24 %)] and dirty [19 (41 %)] fields. Median follow-up was 47 months [interquartile range: 31–79] and all patients had greater than 12-month follow-up. Sixteen patients (35 %) were not re-examined. Incidence of surgical site events and surgical site infection were 43 % (n = 20) and 56 % (n = 25), respectively. American Society of Anesthesiologists score 3 or greater was an independent predictor of surgical site infection (odds ratio 5.34 [95 % confidence interval 1.01–41.80], p = 0.04). Hernia recurrence occurred in 61 % (n = 28) with a median time to diagnosis of 16 months [interquartile range 8–26]. After bridged repair, 16 of 18 patients (89 %) recurred, compared to 12 of 28 (43 %) when fascia was approximated (p < 0.01). Bridged repair was an independent predictor of recurrence (odds ratio 10.67 [95 % confidence interval 2.42–76.08], p < 0.01). Patients with recurrences had significantly worse scores on the SF-36 mental health component and self-perceived body image, whereas HerQLes scores were similar.

Conclusions

Hernia recurrences and wound infections are high with the use of biologic PSIS mesh in contaminated surgical fields. Careful consideration is warranted using this approach.
Literatur
1.
Zurück zum Zitat Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–583 discussion 583–575 PubMedPubMedCentral Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–583 discussion 583–575 PubMedPubMedCentral
2.
Zurück zum Zitat Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J (2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343:392–398CrossRefPubMed Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J (2000) A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343:392–398CrossRefPubMed
3.
Zurück zum Zitat Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LM, Polk HC Jr (1981) Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 194:219–223CrossRefPubMedPubMedCentral Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LM, Polk HC Jr (1981) Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 194:219–223CrossRefPubMedPubMedCentral
4.
Zurück zum Zitat Jones JW, Jurkovich GJ (1989) Polypropylene mesh closure of infected abdominal wounds. Am Surg 55:73–76PubMed Jones JW, Jurkovich GJ (1989) Polypropylene mesh closure of infected abdominal wounds. Am Surg 55:73–76PubMed
5.
Zurück zum Zitat Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ (2013) Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg 217:991–998CrossRefPubMed Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ (2013) Outcomes of synthetic mesh in contaminated ventral hernia repairs. J Am Coll Surg 217:991–998CrossRefPubMed
6.
Zurück zum Zitat Ventral Hernia Working G, Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, Rosen M, Silverman RP, Vargo D (2010) Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558CrossRef Ventral Hernia Working G, Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF, Rosen M, Silverman RP, Vargo D (2010) Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 148:544–558CrossRef
7.
Zurück zum Zitat Shankaran V, Weber DJ, Reed RL 2nd, Luchette FA (2011) A review of available prosthetics for ventral hernia repair. Ann Surg 253:16–26CrossRefPubMed Shankaran V, Weber DJ, Reed RL 2nd, Luchette FA (2011) A review of available prosthetics for ventral hernia repair. Ann Surg 253:16–26CrossRefPubMed
8.
Zurück zum Zitat Hiles M, Record Ritchie RD, Altizer AM (2009) Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 16:26–37CrossRefPubMed Hiles M, Record Ritchie RD, Altizer AM (2009) Are biologic grafts effective for hernia repair?: a systematic review of the literature. Surg Innov 16:26–37CrossRefPubMed
9.
Zurück zum Zitat Bachman S, Ramshaw B (2008) Prosthetic material in ventral hernia repair: how do I choose? Surg Clin N Am 88:101–112CrossRefPubMed Bachman S, Ramshaw B (2008) Prosthetic material in ventral hernia repair: how do I choose? Surg Clin N Am 88:101–112CrossRefPubMed
10.
Zurück zum Zitat Beale EW, Hoxworth RE, Livingston EH, Trussler AP (2012) The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature. Am J Surg 204:510–517CrossRefPubMed Beale EW, Hoxworth RE, Livingston EH, Trussler AP (2012) The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature. Am J Surg 204:510–517CrossRefPubMed
11.
Zurück zum Zitat Mariette C, Wind P, Micelli Lupinacci R, Tresallet C, Adham M, Arvieux C, Benoist S, Berdah S, Berger A, Briez N, Brigand C, Caiazzo R, Carrere N, Casa C, Collet D, Deguelte S, Dousset B, Dubuisson V, Glehen O, Gineste JC, Hamy A, Lacaine F, Laurent C, Lehur PA, Mabrut JY, Mathieu P, Mathonnet M, Meunier B, Michot F, Ouaissi M, Palot JP, Parc Y, Pattou F, Paye F, Pezet D, Piessen G, Pocard M, Regenet N, Regimbeau JM, Sabbagh C, Zerbib P, Toussaint JM (2014) Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons. J Visc Surg 151:9–16CrossRefPubMed Mariette C, Wind P, Micelli Lupinacci R, Tresallet C, Adham M, Arvieux C, Benoist S, Berdah S, Berger A, Briez N, Brigand C, Caiazzo R, Carrere N, Casa C, Collet D, Deguelte S, Dousset B, Dubuisson V, Glehen O, Gineste JC, Hamy A, Lacaine F, Laurent C, Lehur PA, Mabrut JY, Mathieu P, Mathonnet M, Meunier B, Michot F, Ouaissi M, Palot JP, Parc Y, Pattou F, Paye F, Pezet D, Piessen G, Pocard M, Regenet N, Regimbeau JM, Sabbagh C, Zerbib P, Toussaint JM (2014) Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons. J Visc Surg 151:9–16CrossRefPubMed
12.
Zurück zum Zitat Harth KC, Krpata DM, Chawla A, Blatnik JA, Halaweish I, Rosen MJ (2013) Biologic mesh use practice patterns in abdominal wall reconstruction: a lack of consensus among surgeons. Hernia J Hernias Abdom Wall Surg 17:13–20CrossRef Harth KC, Krpata DM, Chawla A, Blatnik JA, Halaweish I, Rosen MJ (2013) Biologic mesh use practice patterns in abdominal wall reconstruction: a lack of consensus among surgeons. Hernia J Hernias Abdom Wall Surg 17:13–20CrossRef
13.
Zurück zum Zitat Primus FE, Harris HW (2013) A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions. Hernia J Hernias Abdom Wall Surg 17:21–30CrossRef Primus FE, Harris HW (2013) A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions. Hernia J Hernias Abdom Wall Surg 17:21–30CrossRef
14.
Zurück zum Zitat Lee L, Mata J, Landry T, Khwaja KA, Vassiliou MC, Fried GM, Feldman LS (2014) A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields. Surg Endosc 28:2531–2546CrossRefPubMed Lee L, Mata J, Landry T, Khwaja KA, Vassiliou MC, Fried GM, Feldman LS (2014) A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields. Surg Endosc 28:2531–2546CrossRefPubMed
15.
Zurück zum Zitat Slater NJ, van der Kolk M, Hendriks T, van Goor H, Bleichrodt RP (2013) Biologic grafts for ventral hernia repair: a systematic review. Am J Surg 205:220–230CrossRefPubMed Slater NJ, van der Kolk M, Hendriks T, van Goor H, Bleichrodt RP (2013) Biologic grafts for ventral hernia repair: a systematic review. Am J Surg 205:220–230CrossRefPubMed
16.
Zurück zum Zitat Rosen MJ, Krpata DM, Ermlich B, Blatnik JA (2013) A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 257:991–996CrossRefPubMed Rosen MJ, Krpata DM, Ermlich B, Blatnik JA (2013) A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh. Ann Surg 257:991–996CrossRefPubMed
17.
Zurück zum Zitat Diaz JJ Jr, Conquest AM, Ferzoco SJ, Vargo D, Miller P, Wu YC, Donahue R (2009) Multi-institutional experience using human acellular dermal matrix for ventral hernia repair in a compromised surgical field. Arch Surg 144:209–215CrossRefPubMed Diaz JJ Jr, Conquest AM, Ferzoco SJ, Vargo D, Miller P, Wu YC, Donahue R (2009) Multi-institutional experience using human acellular dermal matrix for ventral hernia repair in a compromised surgical field. Arch Surg 144:209–215CrossRefPubMed
18.
19.
Zurück zum Zitat Brenneman FD, Wright JG, Kennedy ED, McLeod RS (1999) Outcomes research in surgery. World J Surg 23:1220–1223CrossRefPubMed Brenneman FD, Wright JG, Kennedy ED, McLeod RS (1999) Outcomes research in surgery. World J Surg 23:1220–1223CrossRefPubMed
20.
Zurück zum Zitat Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 27:97–132; quiz 133–134; discussion 196CrossRefPubMed Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 27:97–132; quiz 133–134; discussion 196CrossRefPubMed
21.
Zurück zum Zitat (1999) Centers for Disease Control and Prevention Guideline for Prevention of Surgical Site Infection. Centers for Disease Control and Prevention (1999) Centers for Disease Control and Prevention Guideline for Prevention of Surgical Site Infection. Centers for Disease Control and Prevention
22.
Zurück zum Zitat Criss CN, Petro CC, Krpata DM, Seafler CM, Lai N, Fiutem J, Novitsky YW, Rosen MJ (2014) Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery 156:176–182CrossRefPubMed Criss CN, Petro CC, Krpata DM, Seafler CM, Lai N, Fiutem J, Novitsky YW, Rosen MJ (2014) Functional abdominal wall reconstruction improves core physiology and quality-of-life. Surgery 156:176–182CrossRefPubMed
23.
Zurück zum Zitat Hiatt EL, Collins RL, Pastorek NJ, Bellows CF (2009) Body image and health locus of control among male patients with incisional hernias. Body image 6:242–245CrossRefPubMed Hiatt EL, Collins RL, Pastorek NJ, Bellows CF (2009) Body image and health locus of control among male patients with incisional hernias. Body image 6:242–245CrossRefPubMed
24.
Zurück zum Zitat Sosin M, Patel KM, Albino FP, Nahabedian MY, Bhanot P (2014) A patient-centered appraisal of outcomes following abdominal wall reconstruction: a systematic review of the current literature. Plast Reconstr Surg 133:408–418CrossRefPubMed Sosin M, Patel KM, Albino FP, Nahabedian MY, Bhanot P (2014) A patient-centered appraisal of outcomes following abdominal wall reconstruction: a systematic review of the current literature. Plast Reconstr Surg 133:408–418CrossRefPubMed
25.
Zurück zum Zitat Poelman MM, Schellekens JF, Langenhorst BL, Schreurs WH (2010) Health-related quality of life in patients treated for incisional hernia with an onlay technique. Hernia J Hernias Abdom Wall Surg 14:237–242CrossRef Poelman MM, Schellekens JF, Langenhorst BL, Schreurs WH (2010) Health-related quality of life in patients treated for incisional hernia with an onlay technique. Hernia J Hernias Abdom Wall Surg 14:237–242CrossRef
26.
Zurück zum Zitat Krpata DM, Schmotzer BJ, Flocke S, Jin J, Blatnik JA, Ermlich B, Novitsky YW, Rosen MJ (2012) Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 215:635–642CrossRefPubMed Krpata DM, Schmotzer BJ, Flocke S, Jin J, Blatnik JA, Ermlich B, Novitsky YW, Rosen MJ (2012) Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess abdominal wall function. J Am Coll Surg 215:635–642CrossRefPubMed
27.
Zurück zum Zitat Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA (1998) Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn’s disease. Surg Endosc 12:1334–1340CrossRefPubMed Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA (1998) Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn’s disease. Surg Endosc 12:1334–1340CrossRefPubMed
28.
Zurück zum Zitat van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF (2012) Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. Am J Surg 204:144–150CrossRefPubMed van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF (2012) Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. Am J Surg 204:144–150CrossRefPubMed
29.
Zurück zum Zitat Chavarriaga LF, Lin E, Losken A, Cook MW, Jeansonne LO, White BC, Sweeney JF, Galloway JR, Davis SS Jr (2010) Management of complex abdominal wall defects using acellular porcine dermal collagen. Am Surg 76:96–100PubMed Chavarriaga LF, Lin E, Losken A, Cook MW, Jeansonne LO, White BC, Sweeney JF, Galloway JR, Davis SS Jr (2010) Management of complex abdominal wall defects using acellular porcine dermal collagen. Am Surg 76:96–100PubMed
30.
Zurück zum Zitat Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H (2005) Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Archives of surgery 140:549–560; discussion 560–542CrossRefPubMed Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H (2005) Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Archives of surgery 140:549–560; discussion 560–542CrossRefPubMed
31.
Zurück zum Zitat Franklin ME Jr, Trevino JM, Portillo G, Vela I, Glass JL, Gonzalez JJ (2008) The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up. Surg Endosc 22:1941–1946CrossRefPubMed Franklin ME Jr, Trevino JM, Portillo G, Vela I, Glass JL, Gonzalez JJ (2008) The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up. Surg Endosc 22:1941–1946CrossRefPubMed
32.
Zurück zum Zitat Rogmark P, Petersson U, Bringman S, Ezra E, Osterberg J, Montgomery A (2015) Quality-of-life and Surgical Outcome 1 Year After Open and Laparoscopic Incisional Hernia Repair: PROLOVE: A Randomized Controlled Trial. Annals of surgery Rogmark P, Petersson U, Bringman S, Ezra E, Osterberg J, Montgomery A (2015) Quality-of-life and Surgical Outcome 1 Year After Open and Laparoscopic Incisional Hernia Repair: PROLOVE: A Randomized Controlled Trial. Annals of surgery
33.
Zurück zum Zitat Alaedeen DI, Lipman J, Medalie D, Rosen MJ (2007) The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields. Hernia J Hernias Abdom Wall Surg 11:41–45CrossRef Alaedeen DI, Lipman J, Medalie D, Rosen MJ (2007) The single-staged approach to the surgical management of abdominal wall hernias in contaminated fields. Hernia J Hernias Abdom Wall Surg 11:41–45CrossRef
34.
Zurück zum Zitat Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, Liu J, Butler CE (2013) Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 217:999–1009CrossRefPubMed Booth JH, Garvey PB, Baumann DP, Selber JC, Nguyen AT, Clemens MW, Liu J, Butler CE (2013) Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg 217:999–1009CrossRefPubMed
35.
Zurück zum Zitat Slater NJ, van Goor H, Bleichrodt RP (2015) Large and complex ventral hernia repair using “components separation technique” without mesh results in a high recurrence rate. Am J Surg 209:170–179CrossRefPubMed Slater NJ, van Goor H, Bleichrodt RP (2015) Large and complex ventral hernia repair using “components separation technique” without mesh results in a high recurrence rate. Am J Surg 209:170–179CrossRefPubMed
36.
Zurück zum Zitat Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS, Liang MK (2014) Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA surgery 149:415–421CrossRefPubMed Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT, Kao LS, Liang MK (2014) Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA surgery 149:415–421CrossRefPubMed
Metadaten
Titel
Biologic mesh for repair of ventral hernias in contaminated fields: long-term clinical and patient-reported outcomes
verfasst von
Amin Madani
Petru Niculiseanu
Wanda Marini
Pepa A. Kaneva
Benjamin Mappin-Kasirer
Melina C. Vassiliou
Kosar Khwaja
Paola Fata
Gerald M. Fried
Liane S. Feldman
Publikationsdatum
22.06.2016
Verlag
Springer US
Erschienen in
Surgical Endoscopy / Ausgabe 2/2017
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-016-5044-1

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