Not all biologics are equal!

Background: Although the efficacy of various biologic meshes in the abdominal reconstruction of complex ventral hernia has been shown, the performance profile of various biologic mesh scaffolds in terms of hernia-specific outcomes such as recurrence, mesh explantation, and mesh infections has not been examined. Aim: To evaluate the clinical outcomes of patients who underwent complex ventral hernia repair with bioprosthetic material. Methods: This study is a retrospective analysis of the use of bioprosthetic material in complex ventral hernia at an academic institution from January 2002 to December 2007. Results: A total of 58 patients with a mean age of 57.2 years and mean body mass index (BMI) of 33.8 who underwent reconstruction of ventral abdominal defects with a bioprosthetic from January 2002 to February 2009 were included in the study. The study patients had about 4.8 previous surgeries and 43.1% of patients had reconstruction in a setting of enterocutaneous fistula, while 46.6% had a previous mesh infection. Complex ventral hernia was seen in 50 patients, while eight patients had ventral and parastomal hernia. The type of biologic used for reconstruction was human-derived (AlloDerm, 29), porcine cross-linked (CollaMend, 3; Permacol, 2), and non-cross-linked porcine (Surgisis, 16; Strattice, 8). At least one complication was seen in 72.4% of patients. Major complications noted were surgical wound infections (19.0%), seroma (8.6%), and abscess formation (5.2%). The one-year hernia recurrence rate was 27.9% and mesh explantation was needed in 17.2% of patients. AlloDerm was less likely to be explanted (13.8%) or become infected (37.9%) but more likely to recur (28.6%) compared to porcine cross-linked bioprosthesis. Porcine cross-linked biologics were more likely to become infected (60%) and explanted (40%) but less likely to recur (20%) compared to AlloDerm. Non-cross-linked porcine biologics were less likely to be explanted (16.7%) but had higher recurrence (29.4%) compared to cross-linked porcine biologics and a higher infection rate (54.2%) compared to AlloDerm. Conclusions: The results from this study underscore the difficulty of repairing complex abdominal wall defects in contaminated fields. Cross-linked porcine biologics showed relatively higher infection and explantation rates. Equivalent recurrence and explantation rates were observed for the non-cross-linked porcine biologics and AlloDerm. These data indicate that there is currently no ideal biologic for complex ventral hernia repair.