Strategies for Mesh Salvage after Skin and Soft Tissue Infection in a Cohort of 6,574 Ventral Hernia Repairs with Mesh
William J. O'Brien1, Radwan Dipp Ramos1, Kalpana Gupta2, Kamal M.F. Itani1
1VA Boston Dept. of Surgery, Boston MA 2VA Boston Dept. of Medicine, Boston MA
Background: Skin and soft tissue infection (SSTI) following ventral hernia surgery with mesh is a dreaded complication. In this study, we assess the 5-year incidence of SSTI, and the association of antibiotics and debridement with mesh salvage.
Methods: Veterans undergoing mesh repair of a ventral hernia between 2008-2015 were included. SSTI included all 30-day SSI and any SSTI beyond 30 days detected by a validated machine learning algorithm. Mesh explantation was identified using selected CPT codes and manual review. Baseline characteristics of SSTI vs. no-SSTI groups were balanced using a propensity score model with inverse probability of treatment weighting. A Cox proportional hazards model estimated hazard of mesh explantation as a function of SSTI, also controlling for number of debridement procedures and days supply of antibiotics after the onset of infection.
Results: There were 6,574 surgeries. Mean age was 60.5 and 92.5% were male. The incidence rate of SSTI was 7.7% (506/6,574), and the rate of 5-year mesh explantation was 2.2% (147/6,574). The hazard ratio of SSTI was 24.7 (95% CI 13.3-46.0). Longer courses of antibiotics were associated with lower explantation risk (e.g. the HR of 31-60 days compared with 3 or fewer was 0.22 [0.12-0.41]). Having 1 debridement procedure compared with no debridement was associated with higher explantation risk (HR 14.5 [8.3-25.5]).
Conclusion: Half of SSTI patients resolved the infection and did not undergo mesh explantation within 5 years. Antibiotic therapy is important in preventing progression to mesh explantation. Debridement associated with higher explantation might be a surrogate of infection severity.
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