Tackling the issue of surgical mesh infection and a background on surgical implants.

There has recently been some media attention surrounding the use of surgical meshes, not only for hernia repair but also the TVT (transvaginal tape) and other meshes used for prolapse surgery and stress incontinence.  In the UK a ban on implantation of vaginal mesh has been called for.  See the following links- https://www.theguardian.com/society/2017/aug/31/vaginal-pelvic-mesh-explainer  and http://www.independent.co.uk/news/uk/vaginal-mesh-scandal-transvaginal-procedure-mps-debate-parliament-tvt-thalidomide-emma-hardy-a8006101.htmland   Also closer to home in Canada-  http://www.ctvnews.ca/health/growing-concerns-in-canada-over-surgical-mesh-usage-recalls-1.3372733

Surgical mesh for hernia repairs came into common use over two decades ago.  There are now a wide variety of meshes available on the market. It is recognised that use of mesh decreases the risk of hernia recurrence, particularly for large hernias and in overweight or obese patients.  I do use mesh for my hernia surgeries, but not all the time.  The basis for deciding to use mesh or not is based on a lot of different factors (is the hernia large? recurrent? for example)  but also on a discussion with the patient.  It must be stated that the consequences of a mesh infection (which are rare) are often devastating for the patient and a very expensive strain on the health care system.

But implanting foreign materials for long term use into the human body surgically has been around for a long time.  Ever increasing numbers and types of devices have been put into increasing numbers of patients since the implantation of the first pacemaker in 1958.  We now use metallic heart valves, cataract lenses, surgical clips, staples and sutures, artificial blood vessels (grafts), prosthetic (artificial) joints, orthopaedic hardware such as plates and screws to fix fractures, pacemakers, dialysis lines, and artificial sphincters- the list goes on and on.  The development of these medical devices has allowed people to live longer, happier, and healthier lives for those vast majority of patients where the operation goes well.  But every surgeon knows that infection of an implantable device usually means a long and difficult journey ahead for the patient.  As an aside- the surgeon usually has a pretty tough time with it too, just not nearly as tough as the patient.  While the recent focus has been on TVT and hernia mesh infection there are lots of examples of infection causing severe disability in other implantables.  Infection after cataract lens implantation can result in permanent blindness in that eye- see here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377381/.  Prosthetic joint infections (hip and knee replacements which become infected) are a devastating and costly complication- see here- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3993098/.   The list goes on, the point being, infection (usually bacterial) in implantable devices is a rare but very serious risk in modern surgical care, and that risk should never be taken lightly by surgeons, patients, or the public. Infection of an implantable device can be heralded by pain and fever- other symptoms depend on where the device is implanted and for what reason. These implantable devices themselves such as pacemakers, and artificial joints do not have any blood supply.  Blood supply is crucial to healing and once an infection has set in to an implantable device, there is little or no blood supply to bring in cells from the immune system to fight the infection.  Often treatment with antibiotics alone is a losing battle for these infections.  The infection can usually be brought under control by removing the device, but sometimes that is a difficult process in itself.

What do patients and the public need to know about not just surgical mesh, but all of these devices?  Firstly to ask questions, lots of them, BEFORE having surgery if there is a chance they may need to be used in a procedure.  Often there are few or no alternatives to using a prosthetic but occasionally there are.  Patients should ask what the risks are?  And what they can do to minimise those risks before, during and after the procedure? Patients should ask what happens if I choose not to have this procedure done?  Infection is more common in smokers, diabetics or those with immune system problems.  Also, even without infection, symptoms such as chronic disabling pain or other complications can occur without an implant infection. Quitting smoking and having good sugar control (if you are diabetic) are two obvious things patients can do around the time of surgery to decrease the risk of an implant infection and infection more generally as well. Ask the surgeon or other clinician what precautions will be taken to minimise infection and what signs and symptoms to look out for post op that may indicate an infection is developing and what steps to take if that happens.

Banning the use of implants of whatever type will decrease if not eradicate all cases of implant infection.  But it would also prevent thousands, if not millions, of patients from accessing life altering, and in some cases lifesaving surgery.  I have mesh in a couple of different places and I’m delighted by the results of my surgeries. And while anecdote does not equal data, hopefully the fact that a surgeon willingly asked for mesh to be put in her body is somewhat reassuring to those who may have to weigh the option of mesh or another implant in the future.

And so for medical regulators, the tricky balance of risk and benefit must be weighed when deciding to licence different products for various purposes. Mostly in Canada the bar for allowing medical devices to be implanted is very high- Health Canada has a comprehensive list of all devices and any recalls which have happened. We must do all we can to prevent implant infections from occurring, and continue to study and try and improve outcomes for our patients.  A good outcome will never be guaranteed as no surgery is risk free but it should certainly be strived for.

 

2 thoughts on “Tackling the issue of surgical mesh infection and a background on surgical implants.

  1. Do you have any view on other possible problems with mesh? For instance mesh folding and migration? Heat degradation resulting in shrinkage, the mesh then being less effective as a patch as well as now being rigid/stiff, which could be painful? It has been said this can cause lasting inflammation and therefore increased cell turnover which could open the door to cancers.
    The argument that without mesh vast numbers of people would have to suffer with their conditions is compelling, and even the tacit implication that if 10 in 90 have problems that is a vast improvement on 97 out of 100. Our NHS system in England surely cannot afford to see it any other way, for so many reasons, despite the current anti-mesh campaigns from the BBC, among others.

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    1. Yes those are problems with mesh- migration (moving around once put in), erosion (into other organs such as the bowel), and shrinkage (most mesh will shrink somewhat as it is being incorporated into tissues). There has been no reports of cancerous tumours forming due to mesh insertion that I am aware of. Mesh can be painful after being inserted, even without infection, and sometimes this can be a chronic or long term problem. There should be no long lasting inflammation once the mesh is incorporated. Also you are correct, to ban the use of mesh for the TVT procedure would result, for example, in the UK alone, thousands of women not being allowed to have surgery for stress incontinence (leaking urine with coughing, sneezing, activity etc). Stress incontinence is common after childbirth and while not life threatening it is an embarrassing problem which can result in women having to restrict their activities significantly.

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