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Clinical Value of Hernia Mesh Pathology Evaluation – what’s next?
I see some level of detail about the patients that the explanted mesh came from, and their symptoms, in the recent JACS article, in the tweet from May 7th. There must have been some discussion, even if informal, about the types of mesh – the polymers used to make the fibers, the brand names, “light weight” vs normal weight, etc.
Was any of this detail discussed in the article? (It’s a pay-per-view article, I only read the abstract and conclusions and saw the illustration from your tweet.) Even though the goal was to show a way to reduce costs for mesh explantations, the fact that they all showed similarities must mean something.
Are there any plans to go deeper, possibly discovering or exposing which of the materials or devices are the bad ones? Or are they all equally bad? It seems like the opportunity is right there and more could be learned. If not people like the authors of the article, then who? Obviously the materials and patient details can be gathered and correlated. More work like this needs to be done.
https://www.sciencedirect.com/science/article/abs/pii/S1072751519301334
https://twitter.com/JAmCollSurg/status/1125762839149469696
[USER=”935″]drtowfigh[/USER]
Clinical Value of Hernia Mesh Pathology Evaluation. https://t.co/sUZZkoftZx #VisualAbstract @Herniadoc pic.twitter.com/9EV77vf1ch
— Journal of the American College of Surgeons (JACS) (@acsJACS) May 7, 2019
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7 Replies
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Here is a link to Hernia’s order form. Maybe I missed a link again.
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Thank you Dr. Twofigh. Unfortunately, that article really is a “pay-per-view” article so I am unable to see the results.
My point, as it usually is, is that the means exist to identify and call out the bad materials, methods, and devices. So many people would benefit, even the device makers, in the long-term. Stop selling the bad materials today and there will be fewer lawsuits tomorrow. Their reasons for staying quiet are so short-sighted.
If they won’t do it, that leaves the marketplace. Let us know what the bad materials are so that we can refuse them when they’re offered.
I forgot to mention one more possible correlation – laparoscopy. I don’t think that anyone who has been involved in the filed for 10 years or more can not see the correlation with the increase in laparoscopic methods and the increase in mesh problems. Regardless of the specifics, the broad trends seem to match. More lap = more problems. More lap also means more mesh, they use more and cover more area.
Until somebody shows what, specifically, is going wrong, all mesh will be considered bad, and to be avoided. It’s rational.
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Thanks for the comments about our paper.
Our purpose was not to look at specific mesh. That was already done in a prior publication “Why We Remove Mesh.”
our purpose was to standardize handling on mesh explants in an evidence based manner. We recommend the mesh be sent to pathology for gross identification. Further studies on the explanation, such as microscopic evaluation, sounds like a good idea but in fact provides to additional information of any clinical value. All explants, whether done for pain or not, for mesh reaction or not, will show similar microscopic pathology. What happens at the tissue level does not represent what the patient is experiencing clinically.
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There is also no breakout of the symptoms shown correlated with type of mesh. Even though the type of mesh is known. They are grouped in to the reaction and nonreaction groups. That would be the start of valuable information for patients. It’s the only way to make things better, identify the bad and get it out of the market.
Also interesting that the trade names and/or manufacturers of the biologic and hybrid mesh are shown but not the polypropylene and polypropylene with PTFE. Don’t know why that would not be disclosed too. Expanded PTFE is most likely a Gore product, but the polypropylene could be many different manufacturers. If the cause of chronic pain is unknown then it can’t be assumed that all polypropylene or all expanded PTFE is the same. Assumptions can waste a lot of time and effort.
It’s a great start, thank you to the authors, whether they meant us, the patients, as the audience or not.
“In the mesh reaction group, 17 (17%) patients had 27 (23%) mesh specimens removed (Table 1). The specimens included polypropylene (17 of 27 [63%]), polypropylene with expanded polytetrafluoroethylene (3 of 27 [11%]), biologic mesh (Strattice; Lifecell) (2 of 27 [7%]), and hybrid mesh (Zenapro; Cook Medical) (1 of 27 [4%]).
In the mesh nonreaction group, 84 (82%) patients had 88 (77%) mesh specimens removed for a variety of other indications not related to the mesh material itself. These other indications included pain (n = 57 [65%]), infection (n = 17 [19%]), hernia recurrence (n = 32 [36%]), neuropathy (n = 16 [18%]), and/or meshoma (n = 13 [15%]). Some patients had more than one indication for mesh removal, for example, meshoma-related pain and hernia recurrence. The specimens in this group included polypropylene (70 of 88 [80%]), polypropylene with expanded polytetrafluoroethylene (9 of 88 [9%]), expanded polytetrafluoroethylene (3 of 88 [3%]), polyester (4 of 88 [5%]), and biologic mesh (Strattice) (1 of 88 [1%]).”
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Thank you for that link. I wrote something about the paper itself but it is Unapproved. Hopefully it will be released and the following will make more sense.
Here is the image from the Twitter slide, which does not seem to be in the paper, showing the definitions of “mesh reaction” and “mesh nonreaction”. Basically, in conjunction with the Discussion from the paper, it shows that there is no predictive tool apparent for chronic pain. So, it’s still just a gamble, based on whatever information you can find out there.
From the Twitter slide –
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Thank you. I misread the “Recommended Article” fees in the sidebar as fees for this one.
I’ve read the article and don’t see a description of who explanted the mesh and/or who characterized the patients’ conditions, as “mesh reaction” or “mesh nonreaction”. It also seems that “chronic pain” is in the “nonreaction” group. Regardless, it’s a nice and simple study.
The Discussion seems to confirm even more though, that it’s just a straight-up gamble to get a mesh implantation. No way to predict if you’ll have chronic pain, according to its categorization in the “nonreaction” group. No preemptive allergy tests or similar that will show a predisposition to chronic pain. It seems to confirm how hopeless things are. Even indirectly, the fact that this study was necessary, shows that the problem is real and significant, enough so that it needs to be included in the financial planning of the medical industry. It all seems sort of crazy, like “how did we get to this point?” Putting mesh in, even though there are alternatives, and now planning how to reduce the cost of taking it out. Maybe, after the math becomes more clear, financial incentives will drive a solution for the patients.
From the paper –
“In summary, we confirm that findings of foreign-body reaction, fibrosis, and chronic inflammation are ubiquitous to explanted mesh and do not correlate with patients’ clinical symptoms. No clinical deductions can be made from the pathology findings and pathology findings would not change clinical management of the patient.”
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After clicking on https://www.sciencedirect.com/scienc…72751519301334 listed above,
I saw under the list of authors the following line https://doi.org/10.1016/j.jamcollsurg.2019.02.038That sent me to full article.
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