Infection susceptibility of crosslinked and non-crosslinked biological meshes in an experimental contaminated environment

doi:10.1016/j.amjsurg.2014.06.025

The American Journal of Surgery

Volume 210, Issue 1, July 2015, Pages 159-166

Presented an oral summary at the 5th Congress of the American Hernia Society in New York, March 28–31, 2012 and the annual meeting of the Dutch Society of Surgery 2012, Veldhoven, May 10–11, 2012.

https://doi.org/10.1016/j.amjsurg.2014.06.025 Get rights and content

Abstract

Background

This experimental study investigates infectious complications and functional outcome of biological meshes in a contaminated environment.

Methods

In 90 rats peritonitis was induced, and after 24 hours, a biological mesh was implanted intraperitoneally including 2 non-crosslinked mesh groups (Strattice and Surgisis) and 2 crosslinked mesh groups (CollaMendFM and Permacol). Sacrifice was after 90 and 180 days.

Results

More mesh infections occurred in crosslinked meshes compared with non-crosslinked meshes (70% vs 4%; P < .001). Mesh infection was the highest in crosslinked CollaMendFM (81.2%) and lowest in non-crosslinked Strattice groups (0%). Incorporation into the abdominal wall was poor in all meshes (0% to 39%). After 180 days no residue of non-crosslinked Surgisis mesh was found. After 180 days, shrinkage was .8% in crosslinked Permacol and 20% in Strattice groups. Strattice showed the least adhesion formation (median 5%).

Conclusions

Infection rate of biological meshes in a contaminated field was the highest in crosslinked meshes. All biological meshes showed poor incorporation, which makes long-term abdominal wall repair questionable.

Section snippets

Animals

Experimental protocols were approved by the Ethical Committee on Animal Experimentation of the Erasmus University Rotterdam. Ninety male rats of the outbred Wistar strain were obtained from a licensed breeder (Harlan, the Netherlands) and accustomed to laboratory conditions 2 weeks before the start of the experiment. The animals were bred under specific pathogen-free conditions, were kept under standard laboratory conditions in individually ventilated cages in pairs, and had free access to

Results

During the 2 days after implantation of the mesh, 18 of the 90 rats (20%) were prematurely taken out of the experiment because of a low wellness score. Postoperative mortality was not statistically different between the groups. In all rats necropsy was performed and septicemia was found to be the cause of death. Abdominal cultures at day 1 confirmed bacterial contamination in all animals with gram-positive (Enterococcus, Staphylococcus, Streptococcus) and gram-negative microorganisms (

Comments

Crosslinked biological meshes were found to have a significantly higher percentage of mesh infection (70% vs 4%; P < .001) and intra-abdominal abscesses (P = .011) than non-crosslinked biological meshes. Infectious complications required euthanasia before the intended time point in almost half of animals in the crosslinked CollaMendFM group, as described in previous animal experiments.23, 24, 25, 26, 27 These results are in accordance with clinical reports of infectious complications of

Conclusions

In conclusion, this experiment demonstrates a high infection rate and increased adhesion formation of crosslinked biological meshes (Permacol and CollaMendFM). Resistance to infection of non-crosslinked Strattice could allow implantation in the contaminated environment. However, the poor incorporation of all biological meshes and complete degradation of Surgisis makes long-term biomechanical strength of hernia repair questionable. Implantation of biological prostheses could be a valid choice in

References (55)

K.G. Cornwell et al.
Extracellular matrix biomaterials for soft tissue repair
Clin Podiatr Med Surg
(2009)
S.F. Badylak
The extracellular matrix as a biologic scaffold material
Biomaterials
(2007)
H.C. Liang et al.
Effects of crosslinking degree of an acellular biological tissue on its tissue regeneration pattern
Biomaterials
(2004)
B. Pomahac et al.
Use of a non-cross-linked porcine dermal scaffold in abdominal wall reconstruction
Am J Surg
(2010)
T. Ueno et al.
Clinical application of porcine small intestinal submucosa in the management of infected or potentially contaminated abdominal defects
J Gastrointest Surg
(2004)
N. Komen et al.
Colorectal anastomotic leakage: a new experimental model
J Surg Res
(2009)
K.E. Rodgers et al.
Effect of oxiplex* films (PEO/CMC) on adhesion formation and reformation in rabbit models and on peritoneal infection in a rat model
Fertil Steril
(2000)
W.B. Gaertner et al.
Experimental evaluation of four biologic prostheses for ventral hernia repair
J Gastrointest Surg
(2007)
T.M. Macleod et al.
Histological evaluation of Permacol as a subcutaneous implant over a 20-week period in the rat model
Br J Plast Surg
(2005)
A.H. Petter-Puchner et al.
Adverse effects associated with the use of porcine cross-linked collagen implants in an experimental model of incisional hernia repair
J Surg Res
(2008)

K.M. Itani et al.

Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH Study

Surgery

(2012)

S. Gandhi et al.

Histopathologic changes of porcine dermis xenografts for transvaginal suburethral slings

Am J Obstet Gynecol

(2005)

E. Peeters et al.

One-year outcome of biological and synthetic bioabsorbable meshes for augmentation of large abdominal wall defects in a rabbit model

J Surg Res

(2013)

K.A. Wichterman et al.

Sepsis and septic shock—a review of laboratory models and a proposal

J Surg Res

(1980)

C.R. Deeken et al.

Histologic and biomechanical evaluation of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral incisional hernia repair

J Am Coll Surg

(2011)

J.W. Burger et al.

Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia

Ann Surg

(2004)

R.W. Luijendijk et al.

A comparison of suture repair with mesh repair for incisional hernia

N Engl J Med

(2000)

J.J. Choi et al.

Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases

Ann Surg

(2012)

D. Xourafas et al.

Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection

Arch Surg

(2010)

Ventral Hernia Working Group et al.

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair

Surgery

(2010)

M.L. Jarman-Smith et al.

Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation

J Mater Sci Mater Med

(2004)

L.H. Olde Damink et al.

In vitro degradation of dermal sheep collagen cross-linked using a water-soluble carbodiimide

Biomaterials

(1996)

M. Hiles et al.

Are biologic grafts effective for hernia repair?: A systematic review of the literature

Surg Innov

(2009)

B.C. Shah et al.

Not all biologics are equal!

Hernia

(2011)

L.F. Chavarriaga et al.

Management of complex abdominal wall defects using acellular porcine dermal collagen

Am Surg

(2010)

K.C. Harth et al.

Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction

Surg Innov

(2009)

W.S. Helton et al.

Short-term outcomes with small intestinal submucosa for ventral abdominal hernia

Arch Surg

(2005)

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Cost-effectiveness analysis of resorbable biosynthetic mesh in contaminated ventral hernia repair
2022, Journal de Chirurgie Viscerale
Le but de l’étude était de comparer, en termes de coûts et de complications postopératoires graves, l’utilisation d’une prothèse biosynthétique résorbable avec des prothèses biologiques, lors d’une cure d’éventration contaminée (modified Ventral Hernia Working Group grade 3). La prothèse Phasix® a peu fait l’objet d’études comparative en milieu contaminé, et des données supplémentaires sont requises pour confirmer un changement d’utilisation de prothèses en milieu contaminé.
Une analyse coût–efficacité a été conduite. Elle était basée sur un modèle d’analyse décisionnelle, construit avec des données cliniques et économiques issues d’une étude avant–après, qui incluait 94 patients opérés d’une cure d’éventration à l’hôpital universitaire de Strasbourg (France) entre juin 2011 et février 2018. Le critère d’efficacité était le nombre de patient présentant une complication grave générale ou spécifique à 6 mois postopératoire. La durée d’hospitalisation à l’hôpital, à domicile et les soins ont été pris en compte dans les coûts.
Nos résultats montrent moins de complications avec la prothèse biosynthétique comparativement aux prothèses biologiques : 21 % versus 33 %. Nous avons déterminé une épargne de US $5146. L’analyse de sensibilité déterministe et l’analyse probabiliste ont confirmé nos résultats et la robustesse de notre modèle.
La prothèse biosynthétique P4HB apparaît comme étant la solution la plus efficiente et la moins chère. Des données supplémentaires doivent par la suite confirmer la supériorité de prothèse biosynthétique en termes de récidive à long terme.
NCT03590184.
The aim of this study was to compare, in terms of cost and serious complications, the use of biosynthetic resorbable parietal mesh with biologic mesh in patients undergoing contaminated ventral hernia repair (modified Ventral Hernia Working Group grade 3). Poly-4-hydroxy-butyrate (P4HB) biosynthetic mesh has rarely been the subject of comparative studies in the context of contamination. Data are required to confirm the effects of a transition from biological mesh to biosynthetic resorbable mesh.
A cost-effectiveness analysis was conducted. It was based on a decision analysis model built with clinical and economic data issued from a before–after study that included 94 patients hospitalized for ventral hernia repair at the university hospital of Strasbourg (France) from June 2011 to February 2018. The effectiveness endpoint was the number of patients presenting with a serious specific complication or a general complication at 6 months. Data for surgical hospitalization stays, home hospitalizations and ambulatory care costs were included.
We found fewer serious complications with biosynthetic mesh: 21 % versus 33 % with biologic mesh. A cost savings of US $5146 was determined. Deterministic sensitivity analyses and a probabilistic analysis confirmed our findings and the robustness of the model.
P4HB biosynthetic resorbable mesh appeared to be the most effective and the least costly option. Additional data will be needed to confirm the superiority of biosynthetic mesh in terms of the recurrence risk reduction over a longer period.
NCT03590184.
Cost-effectiveness analysis of resorbable biosynthetic mesh in contaminated ventral hernia repair
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Citation Excerpt :
Therefore, it could represent an inherent bias for the use of biologics. The biologic mesh group was implanted with non-reticulated mesh, which is known to be more resistant to infection [33,34] and to have an increased mechanical strength [35]. Three different biologic meshes (XenMatrix®, Cellis® and Strattice®) were used in our study.
The aim of this study was to compare, in terms of cost and serious complications, the use of biosynthetic resorbable parietal mesh with biologic mesh in patients undergoing contaminated ventral hernia repair (modified Ventral Hernia Working Group grade 3). Poly-4-hydroxy-butyrate (P4HB) biosynthetic mesh has rarely been the subject of comparative studies in the context of contamination. Data are required to confirm the effects of a transition from biological mesh to biosynthetic resorbable mesh.
A cost-effectiveness analysis was conducted. It was based on a decision analysis model built with clinical and economic data issued from a before-after study that included 94 patients hospitalized for ventral hernia repair at the University Hospital of Strasbourg (France) from June 2011 to February 2018. The effectiveness endpoint was the number of patients presenting with a serious specific complication or a general complication at 6 months. Data for surgical hospitalization stays, home hospitalizations and ambulatory care costs were included.
We found fewer serious complications with biosynthetic mesh: 21% versus 33% with biologic mesh. A cost savings of US $5146 was determined. Deterministic sensitivity analyses and a probabilistic analysis confirmed our findings and the robustness of the model.
P4HB biosynthetic resorbable mesh appeared to be the most effective and the least costly option. Additional data will be needed to confirm the superiority of biosynthetic mesh in terms of the recurrence risk reduction over a longer period.
Bogotà bag for pediatric Open Abdomen
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Out of them all the absorbablemesh has a higher resistance to infections, though it is encumbered by a high risk of fistula formation and is always related to a large ventral hernia; for these reasons, in addition to the high cost and the difficulty in finding biological material, the biological mesh should be implanted only in contaminated or potentially contaminated (presence of stoma, gastro-intestinal perforation, history of mesh infection) surgical fields or in fascial bridge techniques. Given the lack of experience on the use of biological patches in pediatric age in OA techniques, further randomized studies are necessary to evaluate the long-term results and the right indication for the use of biological prosthesis rather than a synthetic one [24–34]. In the Bogota bag technique, the use of an almost inert and non-adhesive material minimizes fluid and heat loss, reduces trauma on the viscera and permits an easy control of the IAP with a very low rate of entero-cutaneous fistula.
The management of a “Complex Abdomen” (CA) and the choice of the best way or technique to deal with it is still a challenge for surgeons. When there are the criteria to define an abdomen as a complex one, whether in emergency or elective surgery, the abdomen may need to remain open to allow access for re-operation and time for decompression. The use of an “Open Abdomen” (OA) as a surgical option permits an easy re-exploration, the control of the abdominal contents, the reduction of the risk of intra-abdominal hypertension (IAH) and consequent Abdominal Compartment Syndrome (ACS) and the preservation of the fascia for closure of the abdominal wall [1–4]. Many different techniques have been described to manage the OA and the Temporary Abdominal Closure (TAC) [5–7]. This kind of approach to the CA, well known by pediatric surgeons and widely used in the management of large gastroschisis, is now used also in other situations. We describe our experience with the Bogotà bag in one young man and three children affected by different pathologies, in the first and third one the OA was necessary because of a massive peritonitis due to acute appendicitis while in the last two cases a congenital digestive malformation was present at birth. The Bogotà bag technique is safe, easily managed and less expensive than other techniques and can be safely used in children and young adults.
Commentary on ‘Perioperative complications of complex abdominal wall reconstruction with biologic mesh: A pooled retrospective cohort analysis of cohort of 220 patients from two academic centers’
2020, International Journal of Surgery
Zinc-Impregnated Mesh for Abdominal Wall Repair Reduces Infection in a Rat Model of Peritonitis
2020, Journal of Surgical Research
Citation Excerpt :
The histological parameters including inflammatory cell reaction, mesh-specific parameters, and collagen deposition were not significantly different between the two groups after 30 and 90 d. However, the power calculation was not based on these secondary outcomes and might therefore lack enough power to detect a difference. The mortality after peritonitis induction was 32%, which is slightly higher when compared with previous literature using this cecal ligation puncture model (10%-28%)13,16,17,22,23 A notable high mortality rate was seen in the ZnMesh group (nine ZnMesh animals versus three control animals). However, two of these nine rats never received a ZnMesh.
The objective of this study was to assess whether a zinc-impregnated polypropylene mesh (ZnMesh) has better antibacterial properties in a contaminated environment compared with a regular polypropylene mesh.
Thirty-eight Wistar Han rats underwent cecal ligation and puncture to induce peritonitis 24 h before implantation of an intraperitoneal ZnMesh or a regular polypropylene mesh. Primary outcome was the number of colony forming units (CFU) per sample (mesh and abdominal wall). Secondary outcomes were macroscopic (incorporation of mesh, abscesses, and adhesions on mesh surface) and histological (inflammatory cell reaction, mesh-specific parameters, and collagen deposition) parameters. All outcomes were evaluated after 30 and 90 d.
After 30 d, no significant difference in CFU per sample was present between the ZnMesh and control groups. After 90 d, a lower number of CFU per sample was present in the ZnMesh group compared with the control group (trypticase soy agar with 5% sheep blood: 0 log₁₀ CFU/sample IQR: 0-1.40 versus 1.58 log₁₀ CFU/sample IQR: 0-4.30, P = 0.012; MacConkey: 0 log₁₀ CFU/sample IQR: 0-2.65 versus 1.18 log₁₀ CFU/sample IQR: 0-4.04, P = 0.438). After 90 d, the percentage of adhesions on mesh surface was significantly higher in the ZnMesh group (95% IQR: 60%-100% versus 50% IQR: 23%-75%, P = 0.029). No differences were seen in other macroscopic outcomes or histology.
A significantly lower number of CFU per sample was found in the ZnMesh group after 90 d. After 30 d, no statistically significant differences in CFU per sample were seen. This result suggests that the ZnMesh group has better antibacterial properties in a contaminated environment. However, this is at the cost of a significantly higher percentage of adhesions.
Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects
2016, American Journal of Surgery
Repair of contaminated abdominal wall defects entails the dilemma of choosing between synthetic material, with its presumed risk of surgical site complications, and biologic material, a costly alternative with questionable durability.
Thirty-two studies published between January 1990 and June 2015 on repair of (potentially) contaminated hernias with ≥25 patients were reviewed. Fifteen studies solely described hernia repair with biologic mesh, 6 nonabsorbable synthetic meshes, and 11 described various techniques. Surgical site complications and hernia recurrence rates were evaluated per degree of contamination and mesh type by calculating pooled proportions.
Analysis showed no benefit of biologic over synthetic mesh for repair of potentially contaminated hernias with comparable surgical site complication rates and a hernia recurrence rate of 9% for biologic and 9% for synthetic repair. Biologic mesh repair of contaminated defects showed considerable higher rates of surgical site complications and a hernia recurrence rate of 30%. As only 1 study on synthetic repair of contaminated hernias was available, surgical decision making in the approach of contaminated abdominal wall defects is hampered.

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: There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.

: The authors declare no conflicts of interest.

: I.M.M., E.B.D., J.J., and J.F.L. contributed to the study concept and design. I.M.M. and E.B.D. contributed to the acquisition of data. I.M.M., E.B.D., W.A.B., J.J., and J.F.L. contributed to the analysis and interpretation of data. I.M.M., E.B.D., and J.F.L. drafted the manuscript. I.M.M., E.B.D., W.A.B., J.J., and J.F.L. contributed to the critical revision of the manuscript for important intellectual content. I.M.M. and E.B.D. contributed to statistical analysis. J.J. and J.F.L. obtained funding for the study. J.J. provided administrative, technical, and material support. W.A.B., J.J., and J.F.L. supervised the study.

: For this experiment CollaMendFM meshes were provided by C.R. Bard [Davol], Warwick, RI, NJ and Permacol meshes by Sofradim, Trevoux, France, part of Covidien, North Haven, CT. The sponsors were not involved in design and conduct of the study, collection, management, analysis, and interpretation of the data and preparation, review, or approval of the manuscript.

: I.M.M. and E.B.D. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

¹: Both authors contributed equally to designing and performing the experiment, data-interpretation, and writing of the manuscript and both should be considered first authors.

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ResearchInfection susceptibility of crosslinked and non-crosslinked biological meshes in an experimental contaminated environment

Abstract

Background

Methods

Results

Conclusions

Section snippets

Animals

Results

Comments

Conclusions

Clin Podiatr Med Surg

Biomaterials

Biomaterials

Am J Surg

J Gastrointest Surg

J Surg Res

Fertil Steril

J Gastrointest Surg

Br J Plast Surg

J Surg Res

Surgery

Am J Obstet Gynecol

J Surg Res

J Surg Res

J Am Coll Surg

Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia

Ann Surg

A comparison of suture repair with mesh repair for incisional hernia

N Engl J Med

Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases

Ann Surg

Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection

Arch Surg

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair

Surgery

Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation

J Mater Sci Mater Med

In vitro degradation of dermal sheep collagen cross-linked using a water-soluble carbodiimide

Biomaterials

Are biologic grafts effective for hernia repair?: A systematic review of the literature

Surg Innov

Not all biologics are equal!

Hernia

Management of complex abdominal wall defects using acellular porcine dermal collagen

Am Surg

Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction

Surg Innov

Short-term outcomes with small intestinal submucosa for ventral abdominal hernia

Arch Surg

Research
Infection susceptibility of crosslinked and non-crosslinked biological meshes in an experimental contaminated environment