Explanted Mesh Doesn't Need Microscopic Assessment

By Marilynn Larkin

March 05, 2019

NEW YORK (Reuters Health) - There is no value to sending a mesh specimen for microscopic pathology evaluation, regardless of the reason for removal, nor can any clinical claims be made based on pathology findings from explanted mesh, researchers say.

"It used to be standard for me to send every mesh to the pathologist for both gross and microscopic pathology evaluation," Dr. Shirin Towfigh of the Beverly Hills Hernia Center in California said in an email to Reuters Health. "However, similar pathology findings were noted on every specimen, regardless of the indication for mesh removal. Also, the pathology findings did not provide me with any new insight into my patient's clinical situation and did not change how I managed the patient."

As reported online February 14 in the Journal of the American College of Surgeons, and presented in January at the Annual Scientific Meeting of the American College of Surgeons Southern California Chapter in Santa Barbara, Dr. Towfigh and colleagues analyzed 115 hernia mesh specimens gathered from 101 patients between 2013-2018.

Some of the patients - the "mesh reaction" group - had mesh removed because of a serious allergic, immunogenic, or inflammatory reaction to the mesh product itself.

The rest - the "mesh non-reaction" group - had mesh removed for reasons unrelated to the mesh material - e.g., infection, chronic pain (due to meshoma, nerve entrapment, mesh erosion).

Patients with mesh reaction were significantly younger (39 vs. 56) and more likely to be female (71% vs. 39%) than those without mesh reaction.

While patients' clinical symptoms before explant varied widely, their pathology findings were similar.

"We assumed that patients with systemic findings of mesh reaction would benefit from a microscopic pathology evaluation of their mesh," Dr. Towfigh said. "Our assumption was that if the patient is having systemic reactions, then findings at the tissue level will help confirm a hyper-immune or allergic response to the mesh material."

"Our research results do not support our original assumption," she acknowledged. "Thus, I have changed my practice: I send mesh specimens for gross examination only. This allows for documentation of the explantation, without incurring the additional costs and work of microscopic evaluation."

"I do recommend that other specimens be sent for microscopic pathology, such as in the case of neurectomy," she noted. "Also, if there is a suspicion of infection, the mesh should be swabbed or a piece sent for aerobic and anaerobic culture."

"Calls to our office are frequently made by patients seeking to have their mesh removed," she added. "Many are involved or plan to be involved in a lawsuit for their hernia and/or mesh-related problem."

"Lawsuits on behalf of patients who may have been injured by mesh are widely using mesh pathology findings to support their claims of mesh reaction," Dr. Towfigh said. "Our results do not support these claims."

Commenting by email, Dr. Mike Liang, Associate Professor of Surgery at the University of Texas Health Science Center at Houston, noted that most surgeons, similar to his own practice, do not send explanted mesh to pathology.

"I have not seen a surge in mesh explantations and it is uncommon for me to see a patient who requests that their mesh be removed," he told Reuters Health. "Reoperation and mesh explantation are a last resort. In our practice, we typically only explant mesh during a reoperation for hernia recurrence or recalcitrant mesh infection. We seek to utilize all reasonable non-operative interventions to treat symptoms of pain or discomfort following hernia repair."

"Patients often express concern with mesh and mesh placement," he said. "They cite advertisements from lawyers seeking patients who have complications and a history of mesh placement. However, this is a major disservice, as nearly every high quality study has shown that in elective, clean cases, mesh repair results in superior long-term outcomes compared to suture repair with groin/inguinal and ventral hernias."

"The article, while thought-provoking, (involves) cases seen by a single surgeon, which limits its generalizability, and the small number of patients makes the study underpowered to truly find no difference between groups," he noted. "However, the strength of the article is that it highlights the need to follow our patients long-term to assess the impact of implants and to include patient-reported outcomes."

SOURCE: http://bit.ly/2NICjdS

J Am Coll Surg 2019.

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