EP.TU.734Rectal mesh erosion post pelvic gynaecological surgery: A literature review

Introduction Surgical mesh has long been used for the repair of pelvic organ prolapse. In recent years high rates of serious complications have been reported and the US has withdrawn it from use, while the UK advises extreme caution. Here, we present a review of the literature with a focus on causative factors. Methods Twenty-three articles were included in the review: 21 cases of rectal mesh erosion and three cases of sigmoid mesh erosion. Causative factors were subdivided into patient-related, mesh-related and procedure-related. Results Main patient related risk factors included pre-existing intestinal diseases (reported in 4 cases) and an older age (median 65.5). Risk factors that were mesh related included increased porosity. 11 cases were reported with a macroporous (>75µm) mesh, whereas only 1 case had used a microporous (<10µM) mesh. 9 cases with partial/ no details of the mesh. The main risk factor that was procedure related was concomitant hysterectomy with 7 cases of mesh erosion had concomitant hysterectomy, 11 cases without concomitant hysterectomy, with a further 5 being unclear. Conclusion Pre-existing bowel disease, mesh type and mechanical factors associated with surgical technique all influenced the risk of mesh erosion into the bowels. A lack of reported information regarding the original surgical mesh and operation hindered the ability to draw conclusions. A step into rectifying this in the future would be the provision of medical device cards directly to the patient detailing the mesh.

The long-term impact of vaginal surgical mesh devices in UK primary care: a cohort study in the CPRD

Objective: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are treated with surgical mesh devices; evidence of their long-term complications is lacking. To examine long-term complications in women with SUI and/or POP, with and without surgical mesh implants. Design: Longitudinal open cohort study from April 01 2006 to November 30 2018 Setting: The Clinical Practice Research Datalink (CPRD) Gold database, linked to Hospital Episodes Statistics (HES) inpatient data, Office for National Statistics mortality data, and Index of Multiple Deprivation socioeconomic status data. Participants: Women aged ≥18 years with a diagnostic SUI/POP code. Exposure: Mesh surgery coded in HES or CPRD data, compared to no mesh surgery. Main Outcomes measures: Rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, using Cox proportional hazards regression, and rates of prescriptions for antibiotics and opioids, using negative binomial regression. Results: There were 220,544 women eligible for inclusion; 74% (n=162,687) had SUI, 37% (n=82,123) had POP and 11% (n=24,266) had both. Women undergoing mesh surgery for SUI or POP had higher rates of antibiotic use (SUI: IRR 1.15 (95% CI 1.13 to 1.18; p<0.001); POP: IRR 1.09 (95% CI 1.04 to 1.14; p<0.001)). Women with no previous history of the outcome, who underwent mesh surgery for SUI or POP, had higher rates of depression, anxiety, or self-harm (SUI: HR 2.43 (95% CI 2.19 to 2.70; p<0.001; POP: HR 1.47 (95% CI 1.19 to 1.81; p<0.001)), sexual dysfunction (SUI: HR 1.88 (1.50 to 2.36; p<0.001); POP: HR 1.64 (95% CI 1.02 to 2.63; p=0.04)) and opioid use (SUI: IRR 1.40 (95% CI 1.26 to 1.56, p<0.001); POP: IRR 1.23 (95% CI 1.01 to 1.49; p=0.04)). Women with a history of depression, anxiety and self-harm had lower rates of these outcomes with SUI or POP mesh surgery (SUI: HR 0.70 (95% CI 0.67 to 0.73; p<0.001), POP: HR 0.72 (95% CI 0.65 to 0.79; p<0.001). Women with a history of opioid use who had POP mesh surgery had lower rates of prescriptions (IRR 0.91 95% CI (0.86 to 0.96); p=0.001). Conclusions: Mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. Careful consideration of the benefits and risk of mesh surgery for women with SUI or POP on an individual basis is required.

Hydrogel–mesh composite for wound closure

During operations, surgical mesh is commonly fixed on tissues through fasteners such as sutures and staples. Attributes of surgical mesh include biocompatibility, flexibility, strength, and permeability, but sutures and staples may cause stress concentration and tissue damage. Here, we show that the functions of surgical mesh can be significantly broadened by developing a family of materials called hydrogel–mesh composites (HMCs). The HMCs retain all the attributes of surgical mesh and add one more: adhesion to tissues. We fabricate an HMC by soaking a surgical mesh with a precursor, and upon cure, the precursor forms a polymer network of a hydrogel, in macrotopological entanglement with the fibers of the surgical mesh. In a surgery, the HMC is pressed onto a tissue, and the polymers in the hydrogel form covalent bonds with the tissue. To demonstrate the concept, we use a poly(N-isopropylacrylamide) (PNIPAAm)/chitosan hydrogel and a polyethylene terephthalate (PET) surgical mesh. In the presence a bioconjugation agent, the chitosan and the tissue form covalent bonds, and the adhesion energy reaches above 100 J⋅m−2. At body temperature, PNIPAAm becomes hydrophobic, so that the hydrogel does not swell and the adhesion is stable. Compared with sutured surgical mesh, the HMC distributes force over a large area. In vitro experiments are conducted to study the application of HMCs to wound closure, especially on tissues under high mechanical stress. The performance of HMCs on dynamic living tissues is further investigated in the surgery of a sheep.