Mesh – Is it the Cause of the Problem? SAGES 2019

Hernia Discussion Forums Hernia Discussion Mesh – Is it the Cause of the Problem? SAGES 2019

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    • #29131
      Good intentions
      Participant

      Here’s another presentation from the same meeting. Dr. Orenstein is a teacher at OHSU, one of the premier medical universities in the Pacific Northwest. So, the things he is presenting here are probably the things that he is teaching his medical students.

      I saw the title and the presenter and was really hoping for more objectivity. But, as you can see, he has hand-picked a few, a very sparse selection, of the many publications out there in the world, to support the use of mesh. But ignored the ones that show that mesh usage correlates with chronic pain. His final slides are really hard to watch.

      He also showed a slide with the legal issues that people find on the internet, implying that it’s the lawyers causing fear of mesh.

      People that use the legal profession as the reason for mesh fear never seem to ask why there are no large number of lawsuits for pure tissue repairs, or appendectomies, or gall bladder removals. Or the rods and screws used to repair broken bones. Hundreds of thousands of medical procedures performed with insignificant lawsuits. Yet, somehow, the lawyers have chosen mesh as a target. It’s not rational to assume that lawyers have created this issue. But it makes a good foil, I assume. I feel embarrassed for the professionals that do that. They must know better. But it’s normal to find a reason to keep doing what you’re invested so much time working on.

      Finally, he showed a plug removal slide, and said “plugs are bad” and should be avoided. but did not show any flat mesh removal work, at all, even though they do those at OHSU also. Just avoided that inconsistency entirely.

      This is from 2019 so you can see that mesh has very solid support behind it and will continue to be used at high volume, no matter what the data shows.

    • #29137
      Good intentions
      Participant

      Here is the abstract of the paper that seems to be the foundation for Dr. Orenstein’s conclusions. Dr. Orenstein is, apparently, a research scientist. This is a very shaky foundation for any conclusions. A single paper put together from databases which do not accurately define or quantify chronic pain.

      The work in the paper seems to have been done with a goal already defined. To imply that non-mesh repairs cause just as much chronic pain as mesh repairs. Dr. Andresen is the developer of the Onstep hernia repair system, which uses a mesh product sold by Bard. Dr. Rosen also consults for Bard.

      The major flaw in the paper is so obvious that it’s almost ludicrous. The pain has to be reported, and defined, as chronic pain.

      “The main outcome was chronic pain reported a minimum of six months after mesh and nonmesh repair in adult patients with a primary inguinal hernia. ”

      https://www.sciencedirect.com/science/article/abs/pii/S0039606017308905

      Background
      Chronic pain affects 10%–12% of patients after inguinal hernia repairs. Some have suggested that less foreign material may theoretically prevent pain. If the prevalence of chronic pain is less after nonmesh repairs, selected hernias might be repaired without mesh. Our aim was to clarify if nonmesh repairs are superior to mesh repairs regarding chronic pain.

      Methods
      For this systematic review, searches were conducted in five databases. The main outcome was chronic pain reported a minimum of six months after mesh and nonmesh repair in adult patients with a primary inguinal hernia. Only randomized controlled trials (RCTs) were included.

      Results
      A total of 23 RCTs with 5,444 patients were included. The median follow up was 1.4 years (range 0.5–10). Twenty-one studies reported crude chronic pain rates, and when considering moderate and severe pain, the prevalences of pain after nonmesh repairs and mesh repairs were similar: median 3.5% (0%–16.2%) versus median 2.9% (0%–27.6%), respectively. Both the meta-analyses and the network meta-analysis indicated no difference in chronic pain rates when comparing nonmesh repairs with open- and laparoscopic mesh repairs.

      Conclusion
      Mesh may be used without fear of causing a greater rate of chronic pain.

    • #29138
      Good intentions
      Participant

      Any surgeon who tries to justify the use of mesh based on equivalent chronic pain rates needs to also consider the damage done in relieving the patient of the chronic pain. The damage from mesh removal as compared to whatever methods are used to cure non-mesh repair chronic pain.

      Which hernia repair method gives the patient the best odds of a pain-free life, in the long-term, considering also the damage done in trying to cure the chronic pain, if it occurs.

      No matter how you talk around it, a non-mesh repair is the right first choice of repair. It is the best long-term potential solution for the patient.

    • #29172
      DrBrown
      Participant

      @good-intentions
      Dear Good Intentions.
      I agree. If you review the papers from the shouldice clinic, they do not report any chronic pain after hernia repair. In my experience, if the patient does not have chronic pain before surgery, then there is no chronic pain after a pure tissue repair. There are no articles in the literature that report chronic pain after hernia repair from the 1980’s (before mesh was introduced).
      Regards.
      Bill Brown MD

    • #29174
      Alephy
      Participant

      @DrBrown this is another interesting point. On the one hand there are no articles from the 1980s of chronic pain and hernia repairs, on the other some doctors (I think I also remember Dr. Towfigh mentioning this at one point) think that in the past chronic pain was assumed as normal, and this is why it was not reported/published. It is also mentioned in recent papers that compare mesh vs non mesh, that the rate of chronic pain is the same in both (with a few years follow up I guess), although I would expect a lower rate than in the 1980s because of better surgical procedures?

      So which is which?? I find it interesting that a patient cannot be given simple facts e.g.

      if you do mesh, you have ~x% chance of complications + possible problems in tot years

      if you do pure tissue repair, you have ~y% chance of complications + possible problems in tot years

      (as mentioned by many, recurrence should enter the discussion but not be the focus of it)

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