Abdominal wall mesh infection: a diagnostic and therapeutic flowchart proposal

Since there is still no univocal codified treatment for mesh infection or fistulization following abdominal wall repair, the aim of this study is to propose a diagnostic and therapeutic flowchart based on personal experience and literature review. We retrospectively evaluated 12 patients who developed mesh infection or enterocutaneous fistulas after mesh implantation for abdominal wall hernias. Patients had had different types of mesh implanted: 6 polypropylene meshes, 3 expanded polytetrafluoroethylene (ePTFE) meshes, 2 dual mesh, and 1 polyester mesh. Based on our experience and literature review, we extrapolated a diagnostic and therapeutic flowchart. The clinical course and results of treatment were heterogeneous in this group of patients. Four patients (33%) underwent fistulectomy with excision of the fistulous canal in association with removal of the infected mesh. One patient (9%) underwent fistulectomy with partial removal of the polypropylene mesh and resection of the affected tract of the ileum. Five patients (42%) underwent excision of the infected mesh. Conservative treatment was resolutive in two cases (16%). Of the 10 cases with a surgical procedure, in two cases a conservative approach with total parenteral nutrition (TPN) was initially adopted; this approach may have reduced the invasiveness of the surgical procedure. Three patients (25%) experienced a chronic fistula, nine patients (75%) healed and showed no recurrence after a mean follow-up of 18 months. The approach to mesh fistulization should be tailored to every single patient. In the majority of cases, a multistep approach seems to be necessary.