Abdominal wall mesh infection: a diagnostic and therapeutic flowchart proposal

Background: 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. Methods: 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. Results: 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. Conclusion: The approach to mesh fistulization should be tailored to every single patient. In the majority of cases, a multistep approach seems to be necessary.