Hernia DOI 10.

1007/s10029-013-1083-x

Hernia

Case reports CASE REPORT Case 1 Case 1 is a 59-year-old white male, with a 24 years history of mesh infection. In 19 88, he suffered multiple

laparotomies due to biliary pancreatitis. He was left with a perito neostomy and exposed mesh. In 2003, he was submitted to an unsuccessful attempt to close the abdominal defect, and from 2003 until 2007, he went through several interv entions to remove exposed pieces of mesh. After

Mesh cancer: long-term mesh infection leading to squamous-cell carcinoma of the abdominal wall

C. Birolini

J. G. Minossi

C. F. Lima

E. M. Utiyama

S. Rasslan

Received: 24 January 2013 / Accepted: 23 March 2013 Springer-Verlag France 2013

Abstract Purpose It is recognized that chronic in ammation can cause cancer. Even though most of the available synthetic meshes are considered non-carcinogenic, the in ammatory response to an infected mesh plays a constant aggression to the skin. Chronic mesh infection is frequently the result of misuse of mesh, and due to the challenging nature of this condition, patients usually suffer for years until the infected mesh is removed by surgical excision. Methods We report two cases of squamous-cell carcinoma (SCC) of the abdominal wall, arising in patients with
Fig. 1 Enteric fistula and SCC long-term mesh infection.

He is now under adjuvant chemotherapy. The big gap in the midline after tumor resection in case 2 required mesh bridging to close the defect. The poor prognosis of case 2 who died months after the operation, and the involvement of the armpit, groin and mesenteric nodes in case 1 shows how aggressive this disease can be. Conclusion Infected mesh must be treated early, by complete excision of the mesh. Long-standing mesh infection can degenerate into aggressive squamous-cell carcinoma of the skin.
Fig. 3 Follow-up atinfection 120 days Squamous-cell carcinoma Keywords Mesh

Results In both patients, the degeneration of mesh infection into SCC was presumably caused by the longterm in ammation secondary to infection. Patients presented with advanced SCC behaving just like the Marjolins ulcers of burns. Radical surgical excision was the treatment of choice. The involv ement of the bowel played an additional challenge in case 1, but it was possible to resect the tumor and the involved bowel and reconstruct the abdominal wall using polypropylene mesh as onlay reinforcement, in a single stage operation.

Synthetic mesh Enterocutaneous fistula

Introduction It is recognized that chronic in ammation plays a role in the development of cancer [ 1]. Even though most of the available synthetic meshes are considered non-carcinogenic, infected or extruded meshes cause constant in ammation of the surrounding skin. Chronic mesh infection (CMI) is frequently a result of the misuse of mesh; choosing the wrong material and malpositioning or mal-fixation of the mesh are among the commonest causes that prevent mesh incorporation into host tissues. An unincorporated mesh will act as a foreign body and will likely be expelled through the skin or digestive tract.

C. Birolini (&) C. F. Lima E. M. Utiyama S. Rasslan Abdominal Wall and Hernia Surgery, USPUniversity of Sa o Paulo, Sao Paulo, Brazil e-mail: cacobirolini@hotmail.com J. G. Minossi UNESPUniversity Fig. 2 Pre-operative of CT the scan. State Note of Sao the sinus Paulo, onBotucatu, the upperBrazil left

Due to the challenging nature of this condition, patients usually suffer for years until the infected mesh is finally removed by surgical excision. We report two cases of squamous-cell carcino ma (SCC) of the abdominal wall, arising in patients presenting with long-term mesh infection. Fig. 4 Post-operative CT scan at 120 days

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2007, he develop ed an intermittent enteric fistula. In 2012, there was a significant increase in the output of the fistula. Upon presentation in August 2012, he had palpable lymph nodes in his left armpit and in both groins. In the abdominal wall, there was a high output enteric fistula in the middle of an ulcer, alon g with exposed pieces of polyester mesh. There was a lateral sinus with discharge of noisome uids (Fig. 1). An excisional biopsy of the armpit node was positive for SCC. An abdominal CT scan revealed increased lymph nodes in the mesentery and in the groin and a destruction of his anterior abdominal wall (Fig. There was methicillin-resistant Staphylococcus aureus growth in the uids taken from the sinus. Before operation, he was put in parenteral nutrition and v ancomycin for a period of 2 weeks. The operation included a R0 resection of the tumor involving two segments of the small bowel and part of the transverse colon and the removal of the infected mesh. The abdominal wall was reconstructed 2).

anatomically and reinforced with an onlay polypropylene mesh. The skin was closed primarily. Except for the occurrence of a minor skin breakdown, the post-operative was uneventful (Figs. 3, 4). Pathology was positive for SCC (Figs. 5, 6). In September 2012, he was referred for adjuvant treatment, with Carboplatin AUC 5 and Paclitaxel 175 mg/m 2 , with a good oncological preliminary outcome up to 6 months after surgery. Case 2 Case 2 is a 46-year-old white male, with a 6 years history of mesh infection. In 2001, he suffered a closed abdominal trauma and was submitted to a laparotomy and splenectomy. He developed an incisional hernia that was treated with polyester mesh reinforcement. One year later, the mesh got infected and became partially exposed. In 2007, he presented with an ulcerated lesion of the skin around the extruded mesh (Figs. 7, 8). A biopsy of the ulcer was

Fig. 5 Invasion of the skin by SCC. HE 109 Fig. 7 Ventral hernia and SCC

Fig. 6 Invasion of the bowel by SCC. HE 109

Fig. 8 Extrusion of polyester mesh

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Fig. 9 Immediate PO

positive for SCC. He was submitted to R0 resection of the tumor and reconstruction of the abdominal wall with a bridged Proceed mesh and primary closure of the skin (Fig. 9). Six months later, there was local recurrence with invasion of the transverse colon and splenic hilum (Fig. He was submitted to an un successful attempt of surgical resection (R2) and then was referred for adjuvant chemotherapy and radiotherapy. There was no response and he died 4 months later due to the progression of the disease. 10 ).

Fig. 10 Local recurrence after 6 months

used to reinforce a primary closure of the midline in this patient. The big gap after tumor resection in case 2 required the use of Proceed mesh to bridge the resu lting defect. In our point of view, the treatment of chronic mesh infection must include the complete removal of the mesh as well as the in ammatory tissues, fibrosis and foreign body granulomas, followed by the reconstruction of the abdominal wall. Most authors recommend staged operations, component separation techn iques or the use of bio-

Discussion The degeneration of mesh infection into SCC was presumably caused by the long-term aggression to the skin secondary to infection . In both patients, the infection took place over a bridged polyester mesh that got infected and unincorporated. It is our impression that the mesh itself did clearly not cause it. So far carcinogenesis by mesh has not been reported [ 2, 3]. From the patients history, it was not possible to determine other risk factors or when the degeneration into malignancy occurred, but both patients had an ongoing infection for years. This condition looks similar to the development of SCC in burn scars, a condition known as Marjolins ulcer [ 4]. Abou t the development of chronic infection in multifilament meshes, there is experimental data suggesting that multifilament polyester promotes an increase in bacterial adherence and is not cleared from bacterial contamination, when compared to monofilament meshes [ 5, 6]. The radical surgical excision of the tumor was the treatment of choice due to the precarious local conditions, demanding an urgent hygienic operation. The involvement of the bowel played an additional challenge in case 1, but it was possible to resect the tumor and the involved bowel and reconstruct the abdominal wall in a single stage operation. A heavy weight, large pore onlay polypropylene mesh was

logical mesh [ 7, 8], contraindicating the use of synthetic mesh in the setting of contaminated or infected surgical fields [ 9, 10 ]. We strongly recommend a single stage operation, with removal of the infected mesh, primary restoration of the midline and onlay reinforcement with polypropylene mesh in such patients [ 11 ]. The poor prognosis of case 2 and the involvement of the armpit, groin and mesenteric nodes and the bowel in patient 1 showed the aggressiveness of the disease. Despite the complexity of these cases, infected mesh must be treated early, in order to prevent mesh extrusion, mesh migration into the bowels and the other complications of this undesirable condition.

Conclusion Long-standing mesh infection can degenerate into aggressive squamous-cell carcinoma of the skin.
Con ict of interest None.

References
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Hernia 2. Klosterhalfen B, Klinge U, Schumpelick V (2001) Carcinogenicity of implantable biomaterials. In: Bendavid R (ed) Abdominal Wall Hernias: principles and management. Springer, New York, pp 235236 3. Ghadimi BM, Langer C, Becker H (2002) The carcinogenic potential of biomaterials in hernia surgery. Chirurg 73(8):833837 4. Copcu E (2009) Marjolins ulcer: a preventable complication of burns? Plast Reconstr Surg 124(1):156e164e 5. Klinge U, Junge K, Spellerberg B, Piroth C, Klosterhalfen B, Schumpelick V (2002) Do multifilament alloplastic meshes increase the infection rate? Analysis of the polymeric surface, the bacteria adherence, and the in vivo consequences in a rat model. J Biomed Mater Res 63(6):765771 6. Blatnik JA, Krpata DM, Jacobs MR, Gao Y, Novitsky YW, Rosen MJ (2012) In vivo analysis of the morphologic characteristics of synthetic mesh to resist MRSA adherence. J Gastrointest Surg 16(11):21392144 7. Johnson EK, Tushoski P (2010) Abdominal wall reconstruction in patients presenting with digestive tract fistulas. Clin Colon Rectal Surg 23(3):195208 8. Alaedeen DI, Lipman J, Medalie D, Rosen MJ (2007) The singlestaged approach to the surgical management of abdominal wall hernias in contaminated fields. Hernia 11(1):435440 9. Montgomery A (2013) The battle between biological and synthetic meshes in ventral hernia repair. Hernia 17(1):311 10. Choi JJ, Palaniappa NC, Dallas KB, Rudich TB, Colon MJ, Divino CM (2012) Use of mesh during ventral hernia repair in clean-contaminated and contaminated cases: outcomes of 33,832 cases. Ann Surg 255(1):176180 11. Birolini C, Utiyama EM, Rodrigues AJ, Birolini D (2000) Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 191(4):366372

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