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Dilek ÖF, Sevim KZ, Dilek ON. Acellular dermal matrices in reconstructive surgery; history, current implications and future perspectives for surgeons. World J Clin Cases 2024; 12:6791-6807. [PMID: 39687641 PMCID: PMC11525903 DOI: 10.12998/wjcc.v12.i35.6791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 10/03/2024] [Accepted: 10/15/2024] [Indexed: 10/24/2024] Open
Abstract
Large-scale defects of body in the reconstructive surgical practice, and the helplessness of their repair with autologous tissues, have been an important factor in the development of artificial biological products for the temporary, definitive, or staged repair of these defects. A major advance in the field of plastic and other reconstructive surgery in this regard has been the introduction and successful use of acellular dermal matrices (ADMs). In recent years, not only the type of tissue from which ADMs are produced, product range, diversity and areas of use have increased, but their use in reconstructive fields, especially in post oncologic breast surgery, has become highly regarded and this has favored ADMs to be a potential cornerstone in specific and well-defined surgical fields in future. It is essential that reconstructive surgeons become familiar with some of the ADM's as well as the advantages and limitations to their use. This review not only provides basic science and clinical evidence of the current use of ADMs in wide range of surgical fields but also targets to keep them as an important backdrop in the armamentarium of reconstructive surgeons. Brief considerations of possible future directions for ADMs are also conducted in the end.
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Affiliation(s)
- Ömer F Dilek
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul 34396, Türkiye
| | - Kamuran Z Sevim
- Department of Plastic and Reconstructive Surgery, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul 34396, Türkiye
| | - Osman N Dilek
- Department of Surgery, İzmir Katip Celebi University, School of Medicine, İzmir 35150, Türkiye
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Clarke N, Bhanot P, Alimi Y. Continuing the Dialogue: A Response to a Commentary on "Outcomes of Immediate Multistage Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence". Ann Plast Surg 2024; 93:402. [PMID: 39158340 DOI: 10.1097/sap.0000000000004042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
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DeLong CG, Crowell KT, Liu AT, Deutsch MJ, Scow JS, Pauli EM, Horne CM. Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction. Hernia 2024; 28:97-107. [PMID: 37648895 DOI: 10.1007/s10029-023-02856-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages. METHODS A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy. RESULTS Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05). CONCLUSION Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.
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Affiliation(s)
- C G DeLong
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - K T Crowell
- Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A T Liu
- Department of Surgery, Penn State University College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| | - M J Deutsch
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - J S Scow
- Division of Colon and Rectal Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - E M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA
| | - C M Horne
- Division of Minimally Invasive and Bariatric Surgery, Penn State University College of Medicine, Hershey, PA, USA.
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Xu Y, Shao S, Gong Z, Ri H, Xu Z, Kang H, Shan Y, Amadou BH, Ren Y, Zhang F, Chen X. Efficacy of prophylactic negative pressure wound therapy after open ventral hernia repair: a systematic review meta-analysis. BMC Surg 2023; 23:374. [PMID: 38082353 PMCID: PMC10712064 DOI: 10.1186/s12893-023-02280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION The susceptibility to surgical site occurrence (SSO) is high following ventral hernia repair (VHR) surgery. SSO severely increases the physical and mental burden on patients. The main purpose of this review was to analyze the efficacy of negative pressure wound therapy (NPWT) after open VHR(OVHR) and explore benefits to patients. METHODS The Cochrane Library, PubMed, and Embase databases were searched from the date of establishment to 15 October 2022. All randomized controlled trials and retrospective cohort studies comparing NPWT with standard dressings after OVHR were included. The Revman 5.4 software recommended by Cochrane and the STATA16 software were used in this meta-analysis. RESULTS Fifteen studies (involving 1666 patients) were identified and included in the meta-analysis, with 821 patients receiving NPWT. Overall, the incidence rate of SSO in the NPWT group was lower compared to the control group (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.21-0.93; I2 = 86%; P = 0.03). The occurrence rate of surgical site infection (SSI; OR = 0.51; 95% CI = 0.38-0.68, P < 0.001), wound dehiscence (OR = 0.64; 95% CI = 0. 43-0.96; P = 0.03), and hernia recurrence (OR = 0.51; 95% CI = 0.28-0.91, P = 0.02) was also lowered. There was no significant difference in seroma (OR = 0.76; 95% CI = 0.54-1.06; P = 0.11), hematoma (OR = 0.53; 95% CI = 0.25-1.11; P = 0.09), or skin necrosis (OR = 0.83; 95% CI = 0.47-1.46; P = 0.52). CONCLUSION NPWT can effectively decrease the occurrence of SSO, SSI wound dehiscence and hernia recurrence and should be considered following OVHR.
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Affiliation(s)
- Yang Xu
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Shuai Shao
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - ZeZhong Gong
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - HyokJu Ri
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
- Department of Colorectal Surgery, the Hospital of Pyongyang Medical College, Pyongyang, 999093, Democratic People's Republic of Korea
| | - ZhaoHui Xu
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - HaoNan Kang
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Yan Shan
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Boureima Hamidou Amadou
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - YanYing Ren
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Fan Zhang
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China
| | - Xin Chen
- Department of Hernia and Colorectal Surgery, The Second Hospital of Dalian Medical University, Dalian, 116023, People's Republic of China.
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Alimi Y, Deldar R, Sosin M, Lofthus A, Nijhar K, Bartholomew AJ, Fan KL, Bhanot P. Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence. Ann Plast Surg 2023; 91:473-478. [PMID: 37713152 DOI: 10.1097/sap.0000000000003641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection. METHODS We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma. RESULTS Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence. CONCLUSION Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.
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Affiliation(s)
| | | | - Michael Sosin
- Plastic Surgery Arts of New Jersey, New Brunswick, NJ
| | | | | | | | - Kenneth L Fan
- Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
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Negative Pressure Wound Therapy Prevents Hernia Recurrence in Simultaneous Ventral Hernia Repair and Panniculectomy. Plast Reconstr Surg Glob Open 2022; 10:e4171. [PMID: 35265446 PMCID: PMC8901215 DOI: 10.1097/gox.0000000000004171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
Simultaneous ventral hernia repair with panniculectomy (VHR-PAN) is associated with a high rate of wound complications. Closed incision negative pressure wound therapy (ciNPWT) has been shown to lower complications in high-risk wounds. There is a debate in the literature as to whether ciNPWT is effective at preventing complications in VHR-PAN. The aim of our study was to evaluate if ciNPWT improves outcomes of VHR-PAN.
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Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review. J Gastrointest Surg 2022; 26:235-244. [PMID: 34590215 DOI: 10.1007/s11605-021-05155-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/17/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations. METHODS We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis. RESULTS Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial. CONCLUSION A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.
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Klifto KM, Othman S, Messa CA, Piwnica-Worms W, Fischer JP, Kovach SJ. Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction. Hernia 2021; 25:1537-1548. [PMID: 33538927 DOI: 10.1007/s10029-021-02371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare two cohorts of patients; those with isolated ventral hernias (VH) and those with VH and enterocutaneous fistulas (ECF). Risk factors for surgical complications (including recurrent ECF) and outcomes during single-stage VH with ECF surgical reconstruction were analyzed. METHODS A retrospective review was performed from 2008 to 2019. We compared two cohorts of patients with single-stage VH repairs: (1) ventral hernia repair alone (hernia alone), and (2) combined VH repair and ECF repair (hernia plus ECF). Inclusion criteria were patients ≥ 18 years of age with pre-operative VH either with or without an ECF, who underwent open hernia repair and ECF repair in a single-stage operation, with a minimum follow-up of 12 months. Patient risk factors, operative characteristics, outcomes and surgical-site complications were compared using univariate and multivariate analyses. RESULTS We included 442 patients (hernia alone = 401; hernia plus ECF = 41) with a median follow-up of 22 months (12-96). Hernia plus ECF patients were more likely to have inflammatory bowel disease (IBD)(OR 4.4, 95% CI 1.1-17.5, p = 0.037), a history of abdominal wound infections (OR 3.4, 95% CI 1.5-7.9, p = 0.004), reoperations (OR 4.9, 95% CI 1.6-15.4, p = 0.006), superficial soft tissue infections (OR 2.5, 95% CI 1.1-6.1, p = 0.044) and hematomas (OR 8.4, 95% CI 1.2-58.8, p = 0.031), compared to hernia alone patients. ECF recurrence was associated with diabetes mellitus (DM) (n = 8, 73% vs. n = 6, 20%; p = 0.003) and surgical-site complications (n = 10, 91% vs. n = 16, 53%; p = 0.048), compared to ECF resolution. CONCLUSION Risk factors for developing ECF were IBD and history of abdominal wound infections. Single-staged combined ECF reconstruction was associated with reoperations, soft tissue infections and hematomas. DM and surgical-site complications were associated with ECF recurrence.
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Affiliation(s)
- K M Klifto
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S Othman
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - C A Messa
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - W Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA
| | - S J Kovach
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Boulevard, Philadelphia, PA, 19104, USA.
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Ober I, Nickerson D, Caragea M, Ball CG, Kirkpatrick AW. Invasive Candida albicans fungal infection requiring explantation of a noncrosslinked porcine derived biologic mesh: a rare but catastrophic complication in abdominal wall reconstruction. Can J Surg 2020. [PMID: 33211643 DOI: 10.1503/cjs.015619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
SUMMARY Biologic mesh is preferred over synthetic mesh for complex and contaminated abdominal wall repairs; however, there are very little data on the risks and complications associated with its use. We report the case of a 67-year-old man with failed synthetic mesh repair for recurrent ventral hernia, who subsequently required an abdominal wall reconstruction (AWR), including the intraperitoneal sublay of noncrosslinked biologic mesh. His postoperative course was complicated with catastrophic sepsis and sustained hemodynamic instability, responding only to mesh explantation. The biologic mesh was subsequently noted to be histologically infected with invasive Candida albicans. Although noncrosslinked biologic mesh is a valuable adjunct to AWR, it is not infection-resistant. Although it is rare, infection of any foreign tissue, including biologic mesh, can occur in the setting of complex ventral abdominal wall repairs. Clinicians should be watchful for such infections in complex repairs as they may require biologic mesh explantation for clinical recovery.
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Affiliation(s)
- Isha Ober
- From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick)
| | - Duncan Nickerson
- From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick)
| | - Mara Caragea
- From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick)
| | - Chad G Ball
- From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick)
| | - Andrew W Kirkpatrick
- From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick)
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Minor S, Brown CJ, Rooney PS, Hodde JP, Julien L, Scott TM, Karimuddin AA, Raval MJ, Phang PT. Single-stage repair of contaminated hernias using a novel antibiotic-impregnated biologic porcine submucosa tissue matrix. BMC Surg 2020; 20:58. [PMID: 32228664 PMCID: PMC7106678 DOI: 10.1186/s12893-020-00715-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 03/13/2020] [Indexed: 12/12/2022] Open
Abstract
Background Single-stage repair of incisional hernias in contaminated fields has a high rate of surgical site infection (30–42%) when biologic grafts are used for repair. In an attempt to decrease this risk, a novel graft incorporating gentamicin into a biologic extracellular matrix derived from porcine small intestine submucosa was developed. Methods This prospective, multicenter, single-arm observational study was designed to determine the incidence of surgical site infection following implantation of the device into surgical fields characterized as CDC Class II, III, or IV. Results Twenty-four patients were enrolled, with 42% contaminated and 25% dirty surgical fields. After 12 months, 5 patients experienced 6 surgical site infections (21%) with infection involving the graft in 2 patients (8%). No grafts were explanted. Conclusions The incorporation of gentamicin into a porcine-derived biologic graft can be achieved with no noted gentamicin toxicity and a low rate of device infection for patients undergoing single-stage repair of ventral hernia in contaminated settings. Trial registration The study was registered March 27, 2015 at www.clinicaltrials.gov as NCT02401334.
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Affiliation(s)
- Samuel Minor
- QE2 Hospital, QEII Health Sciences Centre Dalhousie University, 1278 Tower Road, Halifax, NS, B3H 2Y9, Canada.
| | - Carl J Brown
- St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Paul S Rooney
- Royal Liverpool Hospital, Prescot Street, Merseyside, Liverpool, L7 8XP, UK
| | - Jason P Hodde
- Cook Biotech Incorporated, 1425 Innovation Place, West Lafayette, IN, 47906, USA
| | - Lisa Julien
- QE2 Hospital, QEII Health Sciences Centre Dalhousie University, 1278 Tower Road, Halifax, NS, B3H 2Y9, Canada
| | - Tracy M Scott
- St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Ahmer A Karimuddin
- St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Manoj J Raval
- St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - P Terry Phang
- St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Tork S, Jefferson RC, Janis JE. Acellular Dermal Matrices: Applications in Plastic Surgery. Semin Plast Surg 2019; 33:173-184. [PMID: 31384233 DOI: 10.1055/s-0039-1693019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Modern advances in tissue engineering have transformed the plastic surgeon's management strategies across a wide variety of applications. Comprehension of the fundamentals of biologic constructs is critical to navigating the available armamentarium. It is essential that plastic surgeons become familiar with some of the existing methods for utilizing biologics as well as the advantages and limitations to their use. In this article, the authors describe the basic science of biologics with a focus on acellular dermal matrices (ADMs), and review the recent evidence behind their use for a variety of reconstructive and aesthetic purposes. The review is organized by system and examines the common indications, techniques, and outcomes pertaining to the application of ADMs in select anatomic areas. The final section briefly considers possible future directions for using biologics in plastic and reconstructive surgery.
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Affiliation(s)
- Shahryar Tork
- Department of Plastic and Reconstructive Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Ryan C Jefferson
- Department of Plastic and Reconstructive Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Jeffrey E Janis
- Department of Plastic Surgery, University Hospitals, Wexner Medical Center, Ohio State University, Columbus, Ohio
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Shubinets V, Carney MJ, Colen DL, Mirzabeigi MN, Weissler JM, Lanni MA, Braslow BM, Fischer JP, Kovach SJ. Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience. Ann Plast Surg 2018; 80:145-153. [PMID: 28671890 DOI: 10.1097/sap.0000000000001189] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. METHODS Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. RESULTS A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. CONCLUSIONS This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.
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Prevention and Treatment Strategies for Mesh Infection in Abdominal Wall Reconstruction. Plast Reconstr Surg 2018; 142:149S-155S. [DOI: 10.1097/prs.0000000000004871] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study. Plast Reconstr Surg 2017; 139:1234-1244. [PMID: 28445378 DOI: 10.1097/prs.0000000000003264] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients. METHODS The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups. RESULTS Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients. CONCLUSION Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Hodgkinson JD, Maeda Y, Leo CA, Warusavitarne J, Vaizey CJ. Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates. Colorectal Dis 2017; 19:319-330. [PMID: 28102927 DOI: 10.1111/codi.13609] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/28/2016] [Indexed: 02/08/2023]
Abstract
AIM Minimal evidence exists to guide surgeons on the risk of complications when performing abdominal wall reconstruction (AWR) in the presence of active infection, contamination or enterocutaneous fistula. This study aims to establish the outcomes of contaminated complex AWR. METHOD Analysis was conducted according to PRISMA guidelines. Systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on single-staged repair of contaminated complex AWR were included. Pooled data were analysed to establish rates of complications. RESULTS Sixteen studies were included, consisting of 601 contaminated complex AWRs, of which 233 included concurrent enterocutaneous fistula repair. The average follow-up period was 26.7 months. There were 146 (24.3%) reported hernia recurrences. When stratified by repair method, suture repair alone had the lowest rate of recurrence (14.2%), followed by nonabsorbable synthetic mesh reinforcement (21.2%), biological mesh (25.8%) and absorbable synthetic mesh (53.1%). Hernia recurrence was higher when fascial closure was not achieved. Of the 233 enterocutaneous fistula repairs, fistula recurrence was seen in 24 patients (10.3%). Suture repair alone had the lowest rate of recurrence (1.6%), followed by nonbiological mesh (10.3%) and biological mesh reinforcement (12%). Forty-six per cent of patients were reported as having a wound-related complication and the mortality rate was 2.5%. CONCLUSION It is feasible to perform simultaneous enterocutaneous fistula repair and AWR as rates of recurrent fistula are comparable with series describing enterocutaneous fistula repair alone. Hernias recurred in nearly a quarter of cases. This analysis is limited by a lack of comparative data and variability of outcome reporting.
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Affiliation(s)
| | - Y Maeda
- St Mark's Hospital and Academic Institute, London, UK
| | - C A Leo
- St Mark's Hospital and Academic Institute, London, UK
| | | | - C J Vaizey
- St Mark's Hospital and Academic Institute, London, UK
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Abdominal Wall Allograft: Preclinical Biomechanical Investigation of a Novel Reconstructive Adjunct. Ann Plast Surg 2017; 78:S315-S321. [PMID: 28296717 DOI: 10.1097/sap.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acellular dermal matrices have revolutionized abdominal wall reconstruction; however, device failure and hernia recurrence remain significant problems. Fascia grafts are a reconstructive adjunct with increased tensile strength compared with acellular dermal matrices; however, clinical use is limited by insufficient donor material and donor site morbidity. To this end, we investigate the biomechanical properties of human abdominal wall allografts (AWAs) consisting of the anterior rectus sheath from xiphoid to pubis. METHODS After cadaveric procurement of 6 human AWAs, the tissue was divided horizontally and a matched-sample study was performed with specimens randomized to 2 groups: fresh, unprocessed versus processed with gamma irradiation and decellularization. Specimens were evaluated for physical properties, DNA content, tensile strength, and electron microscopy. RESULTS All AWA donors were male, with a mean age of 55.2 years (range, 35-74 years). Procured AWAs had a mean length of 21.70 ± 1.8 cm, width of 14.30 ± 1.32 cm, and area of 318.50 cm, and processing resulted in a 98.3% reduction in DNA content. Ultimate tensile strength was significantly increased after tissue processing, and after subcutaneous implantation, processed AWA demonstrated 4-fold increased tensile strength compared with unprocessed AWAs. CONCLUSIONS Acellular AWAs represent a novel reconstructive adjunct for abdominal wall reconstruction with the potential of replacing "like with like" without additional donor site morbidity or antigenicity.
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Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: A propensity score analysis. Surgery 2016; 161:499-508. [PMID: 27810091 DOI: 10.1016/j.surg.2016.08.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/04/2016] [Accepted: 08/10/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous studies suggest that bridged mesh repair for abdominal wall reconstruction may result in worse outcomes than mesh-reinforced, primary fascial closure, particularly when acellular dermal matrix is used. We compared our outcomes of bridged versus reinforced repair using ADM in abdominal wall reconstruction procedures. METHODS This retrospective study included 535 consecutive patients at our cancer center who underwent abdominal wall reconstruction either for an incisional hernia or for abdominal wall defects left after excision of malignancies involving the abdominal wall with underlay mesh. A total of 484 (90%) patients underwent mesh-reinforced abdominal wall reconstruction and 51 (10%) underwent bridged repair abdominal wall reconstruction. Acellular dermal matrix was used, respectively, in 98% of bridged and 96% of reinforced repairs. We compared outcomes between these 2 groups using propensity score analysis for risk-adjustment in multivariate analysis and for 1-to-1 matching. RESULTS Bridged repairs had a greater hernia recurrence rate (33.3% vs 6.2%, P < .001), a greater overall complication rate (59% vs 30%, P = .001), and worse freedom from hernia recurrence (log-rank P <.001) than reinforced repairs. Bridged repairs also had a greater rate of wound dehiscence (26% vs 14%, P = .034) and mesh exposure (10% vs 1%, P = .003) than mesh-reinforced abdominal wall reconstruction. When the treatment method was adjusted for propensity score in the propensity-score-matched pairs (n = 100), we found that the rates of hernia recurrence (32% vs 6%, P = .002), overall complications (32% vs 6%, P = .002), and freedom from hernia recurrence (68% vs 32%, P = .001) rates were worse after bridged repair. We did not observe differences in wound healing and mesh complications between the 2 groups. CONCLUSION In our population of primarily cancer patients at MD Anderson Cancer Center bridged repair for abdominal wall reconstruction is associated with worse outcomes than mesh-reinforced abdominal wall reconstruction. Particularly when employing acellular dermal matrix, reinforced repairs should be used for abdominal wall reconstruction whenever possible.
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In vitro assessment of an antibacterial quaternary ammonium-based polymer loaded with chlorhexidine for the coating of polypropylene prosthetic meshes. Hernia 2016; 20:869-878. [PMID: 27590327 DOI: 10.1007/s10029-016-1537-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE This study assesses the use of an absorbable polymer loaded with chlorhexidine (CHX) as an antibacterial coating for polypropylene (PP) meshes employed in hernia repair. METHODS The polymer N,N-dimethyl-N-benzyl-N-(2-methacryloyloxyethyl) ammonium bromide was loaded with CHX (1 % w/w). Fragments (1 cm2) of Optilene® Mesh Elastic were coated either with the unloaded (POL) or CHX-loaded polymer (POL-CHX). Uncoated fragments (PP) served as controls. The release kinetics of the POL-CHX coating was monitored by HPLC. Sterile fragments were placed on agar plates previously contaminated with 106 CFU of Staphylococcus aureus (Sa) ATCC25923, Staphylococcus epidermidis (Se) ATCC12228, or Escherichia coli (Ec) ATCC25922 and incubated at 37 °C for 1/2/7 days. At each time point, inhibition halos were measured and bacterial adhesion to the meshes quantified by sonication and scanning electron microscopy. Coating cytotoxic effects were examined on cultured fibroblasts. RESULTS The polymer coating gradually released CHX over 3 days. Inhibition halos were produced only around the POL-CHX-coated meshes and these were significantly smaller for Ec than Sa or Se (p < 0.01). While POL-CHX prevented bacterial adhesion to the mesh, the reduced bacterial yields over time were observed for the POL-coated versus control PP meshes (p < 0.001). By day 7, only Ec remained attached to the surface of control meshes. The POL coating was not cytotoxic, yet POL-CHX reduced the viability of cultured fibroblasts. CONCLUSIONS When loaded with the antiseptic CHX, this quaternary ammonium-based polymer coating released its contents in a controlled manner indicating its potential prophylactic use to reduce the risk of infection following PP mesh implantation.
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Kugler NW, Bobbs M, Webb T, Carver TW, Milia D, Paul JS. A dual-stage approach to contaminated, high-risk ventral hernia repairs. J Surg Res 2016; 204:200-4. [PMID: 27451887 DOI: 10.1016/j.jss.2016.04.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/21/2016] [Accepted: 04/28/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Modified Hernia Grading System (MHGS) was developed to risk stratify complex ventral hernia repairs (VHRs). MHGS grade 3 patients have mesh infections, dirty or contaminated fields, and/or violation of the alimentary tract. Reported surgical site infection (SSI) rates are over 40% after single-stage VHR in contaminated fields. In an attempt to decrease the SSI rate in MHGS grade 3 patients, we developed a dual-stage VHR (DSVHR) approach. METHODS We reviewed adult general surgery patients undergoing DSVHR between January 2010 and June 2014. All patients were MHGS grade 3. Primary end point was 30-d superficial and deep SSI. Secondary end points included other surgical site occurrences, 6-mo recurrence, and mesh excision rates. RESULTS Fifteen patients underwent DSVHR. Mean age was 56 y, and median body mass index was 38.3 kg/m(2). Operative indication included enterocutaneous fistulas (ECF; n = 6), ECF with infected mesh (n = 2), infected mesh (n = 2), and VHR requiring bowel resection (n = 5). Thirty-one operative procedures were performed with median of 2.5 d between procedures. Fascial closure was re-established in 12 patients; five patients had underlay biologic mesh placement; seven underwent component separation with retrorectus mesh placement (synthetic [n = 2], biologic [n = 5]). The remaining patients underwent bridging repair with biologic mesh. One patient developed a recurrence after 6 mo, whereas a single patient had a recurrence of their ECF. Four (27%) patients developed a SSI, with an additional four (27%) experiencing a surgical site occurrence. There were no postoperative mesh infections. CONCLUSIONS DSVHR in MHGS grade 3 patients is associated with a lower SSI rate than previously reported for those undergoing single-stage repairs.
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Affiliation(s)
- Nathan W Kugler
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Melanie Bobbs
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Travis Webb
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Thomas W Carver
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Milia
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jasmeet S Paul
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Zhu L, Mohan AT, Abdelsattar JM, Wang Z, Vijayasekaran A, Hwang SM, Tran NV, Saint-Cyr M. Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:e77-86. [PMID: 26922050 DOI: 10.1016/j.bjps.2016.01.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/14/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIM Tissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm. METHODS A retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups. RESULTS The study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (p < 0.001), high first postoperative expansion ratio (p < 0.001), shorter duration of expansion (p = 0.02), less number of expansion visits (p = 0.002), and less average pain during admission (p = 0.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p = 0.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups. CONCLUSION The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.
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Affiliation(s)
- Lin Zhu
- Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing, China; Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anita T Mohan
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA; Restoration of Appearance and Function charitable Trust (RAFT), UK
| | | | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Soyun M Hwang
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nho V Tran
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
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Montgomery A, Kallinowski F, Köckerling F. Evidence for Replacement of an Infected Synthetic by a Biological Mesh in Abdominal Wall Hernia Repair. Front Surg 2016; 2:67. [PMID: 26779487 PMCID: PMC4705815 DOI: 10.3389/fsurg.2015.00067] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/17/2015] [Indexed: 12/12/2022] Open
Abstract
Introduction The incidence of deep infection using a synthetic mesh in inguinal hernia repair is low and reported to be well below 1%. This is in contrast to incisional hernia surgery where the reported incidence is 3% respective 13% comparing laparoscopic to open mesh repair reported in a Cochrane review. Main risk factors were long operation time, surgical site contamination, and early wound complications. An infected mesh can be preserved using conservative treatment were negative pressure wound therapy (VAC®) could play an important role. If strategy fails, the mesh needs to be removed. This review aims to look at evidence for situations were a biological mesh would work as a replacement of a removed infected synthetic mesh. Materials and methods A literature search of the Medline database was performed using the PubMed search engine. Twenty publications were found relevant for this review. Results For studies reviewed three options are presented: removal of the infected synthetic mesh alone, replacement with either a new synthetic or a new biological mesh. Operations were all performed at specialist centers. Removal of the mesh alone was an option limited to inguinal hernias. In ventral/incisional hernias, the use of a biological mesh for replacement resulted in a very high recurrence rate, if bridging was required. Either a synthetic or a biological mesh seems to work as a replacement when fascial closure can be achieved. Evidence is though very low. Conclusion When required, either a synthetic or a biological mesh seems to work as a replacement for an infected synthetic mesh if the defect can be closed. It is, however, not recommended to use a biological mesh for bridging. Mesh replacement surgery is demanding and is recommended to be performed in a specialist center.
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Affiliation(s)
| | | | - Ferdinand Köckerling
- Department of Surgery, Centre for Minimally Invasive Surgery, Vivantes Hospital Berlin, Academic Teaching Hospital of Charité Medical School , Berlin , Germany
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Khan SI, Blumrosen G, Vecchio D, Golberg A, McCormack MC, Yarmush ML, Hamblin MR, Austen WG. Eradication of multidrug-resistant pseudomonas biofilm with pulsed electric fields. Biotechnol Bioeng 2015; 113:643-650. [PMID: 26332437 DOI: 10.1002/bit.25818] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/10/2015] [Accepted: 08/23/2015] [Indexed: 01/09/2023]
Abstract
Biofilm formation is a significant problem, accounting for over eighty percent of microbial infections in the body. Biofilm eradication is problematic due to increased resistance to antibiotics and antimicrobials as compared to planktonic cells. The purpose of this study was to investigate the effect of Pulsed Electric Fields (PEF) on biofilm-infected mesh. Prolene mesh was infected with bioluminescent Pseudomonas aeruginosa and treated with PEF using a concentric electrode system to derive, in a single experiment, the critical electric field strength needed to kill bacteria. The effect of the electric field strength and the number of pulses (with a fixed pulse length duration and frequency) on bacterial eradication was investigated. For all experiments, biofilm formation and disruption were confirmed with bioluminescent imaging and Scanning Electron Microscopy (SEM). Computation and statistical methods were used to analyze treatment efficiency and to compare it to existing theoretical models. In all experiments 1500 V are applied through a central electrode, with pulse duration of 50 μs, and pulse delivery frequency of 2 Hz. We found that the critical electric field strength (Ecr) needed to eradicate 100-80% of bacteria in the treated area was 121 ± 14 V/mm when 300 pulses were applied, and 235 ± 6.1 V/mm when 150 pulses were applied. The area at which 100-80% of bacteria were eradicated was 50.5 ± 9.9 mm(2) for 300 pulses, and 13.4 ± 0.65 mm(2) for 150 pulses. 80% threshold eradication was not achieved with 100 pulses. The results indicate that increased efficacy of treatment is due to increased number of pulses delivered. In addition, we that showed the bacterial death rate as a function of the electrical field follows the statistical Weibull model for 150 and 300 pulses. We hypothesize that in the clinical setting, combining systemic antibacterial therapy with PEF will yield a synergistic effect leading to improved eradication of mesh infections.
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Affiliation(s)
- Saiqa I Khan
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114
| | - Gaddi Blumrosen
- Department of Computer Science, Tel Aviv University, Tel Aviv, Israel
| | - Daniela Vecchio
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts 02114.,Department of Dermatology, Harvard Medical School, Boston, Massachusetts 02115
| | - Alexander Golberg
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and the Shriners Burns Hospital, Boston, Massachusetts 02114.,Porter School of Environmental Studies, Tel Aviv University, Tel Aviv, Israel
| | - Michael C McCormack
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114
| | - Martin L Yarmush
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and the Shriners Burns Hospital, Boston, Massachusetts 02114.,Department of Biomedical Engineering, Rutgers University, Piscataway, New Jersey 08854
| | - Michael R Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts 02114.,Department of Dermatology, Harvard Medical School, Boston, Massachusetts 02115.,Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts 02139
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114
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