550687
research-article2014
IJLXXX10.1177/1534734614550687The International Journal of Lower Extremity WoundsHansen and Gottrup
Case Report
Chronic Ulceration and Sinus Formation due to Foreign Body: An Often-Forgotten Problem
The International Journal of Lower Extremity Wounds 1–3 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614550687 ijl.sagepub.com
Karin Birgitte Hansen, MD1 and Finn Gottrup, MD, MDSci2
Abstract Foreign bodies like residues of suture or mesh may lead to a foreign body reaction, cavity formation and continuous secretion and perhaps ulceration. We present a more than 9 years long medical record of a 49 year old man after a simple surgical procedure. The background was a sinus formation generated from a foreign body reaction. The case report shows that this condition is often overlooked and even using advanced equipment, it is difficult to diagnose. The only solution is to diagnose and remove the triggering cause. Fistulography and ultrasound scanning seem to be the optimal diagnostic tool in these cases. The knowledge of the foreign body reaction in tissue continuously needs to be reestablished in the health care system especially in areas, where implantation of foreign material is used. Keywords foreign bodies, foreign body reaction, cavity formation, sinus, fistula Implantation of foreign materials leads to a tissue reaction in the host organism. The foreign body reaction composed of macrophages and foreign body giant cells is the endstage response of the inflammatory and wound healing responses following implantation of a medical device, prosthesis, or biomaterial. This reaction contains the following a sequence of events: injury, blood–material interactions, provisional matrix formation, acute inflammation, chronic inflammation, granulation tissue development, foreign body reaction, and fibrosis/fibrous capsule development.1 The consequences of the reaction to the material surface can be devastating. An implanted mesh represents a foreign body that induces a foreign body reaction. This reaction has been histologically described as a foreign body granuloma adjacent to the mesh fiber and a surrounding collagen capsule that shields the host from the foreign material.2 Several attempts have been conducted to improve biocompatibility of meshes and reduce the foreign body reaction. However, the local inflammatory event after mesh implantation cannot be influenced by, for instance, prior plasma coating and does not depend on the localization of implantation.2 Sinus and fistulas are usually secondary to the presence of foreign body, necrotic tissue in the affected tissue, or from certain types of microbial infection.3 These conditions may be asymptomatic, but most often they are prone to infection, which may manifest in recurrent or persistent discharge and pain if there is swelling. It might also cause formation of a
chronic ulceration. We report a patient presenting a more than 9-year long medical record with continued symptom and ulcerations after a simple surgical procedure. The background was an overlooked sinus formation generated from a foreign body reaction.
Case Report A 49-year-old man underwent laparoscopic inguinal herniotomy in 2002. This event resulted in a hematoma and superficial wound infection, which started a number of complications, including the appearance of an umbilical hernia. This condition led to a second surgery with enhancement of the fascia with Prolene mesh and suture. Because of sustained secretion, the patient underwent 2 other operative procedures within the first year—the first with revision of the soft tissue and the second with removal of the mesh and closing of the fascia with Nylon sutures. At the end of year 2003, the secretion diminished, but painful subcutaneous lymph nodes enlargement remained. Ultrasound scanning could not detect defects in the anterior 1
Hvidovre University Hospital, Copenhagen, Denmark Bispebjerg University Hospital, Copenhagen, Denmark
2
Corresponding Author: Finn Gottrup, Department of Dermatology, Copenhagen Wound Healing Center, D42, Bispebjerg University Hospital, DK-2400 Copenhagen NV, Denmark. Email: [email protected]
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
2
The International Journal of Lower Extremity Wounds
Figure 1. Abdominal wall of the presented patient with continuous secretion from foreign body sinus. A probe is placed in the sinus.
abdominal wall and the patient was not offered additional surgery. The following 7 years, the patient continuously suffered from pain from the subcutaneously lymph nodes on the belly. This situation resulted in a new surgical intervention in 2010, where the mesh, suture and fibrotic tissue were removed. Because of suspected formation of a fistula the patient was referred to the Copenhagen Wound Healing Center (CWHC) 9 months after his last surgery (Figure 1). At CWHC, the background diagnosis for the patient’s suffering was directed toward formation of a sinus due to foreign body reaction. Magnetic resonance scanning, however, could not identify this, but the following fistulography revealed an 8-cm deep duct. Ultrasound scanning furthermore showed remains of mesh at the end of the duct. The remaining mesh and sutures were then surgically removed and a Permacol mesh fixed with PDS thread was used to cover the defect, which was still remaining in the fascia. Subsequently, the wound healed and has been healed without any problems since 2011.
Discussion The 9-year-long history of wound problems reduced the quality of life for the patient in addition to being very costly to the society. The background for the extended suffering history of the patient is that the foreign body problem is very often ignored and not taken into consideration as the cause. To improve the knowledge of this problem, it is necessary to focus on 2 issues: First, the material inserted and second, the optimal way to diagnose this condition. Placement of foreign bodies in living tissue normally will lead to an inflammation reaction, whose intensity depends on the material inserted.1-5 The inflammation may result in formation of different cavity structures in the tissue, based on production of additional tissue fluid.
A complete fistula is the formation of an abnormal connection with 2 outputs either between 2 cavities of the viscera or between a cavity of the viscera and the outer surface of epithelium. A sinus consists of either a cavity or a duct leading to a single output on surface of epithelial.3 Formation of a sinus is not to be confused with formation of an abscess, which is pus in a not-preformed cavity. The foreign bodies in this case report are suture and synthetic net. Nylon suture is a synthetic nonresorbable thread, which is available as monofilament and as a twisted multifilament. Monofilament suture has the property of lesser affinity for bacteria than polyfilament suture.3 This suture generates minimal tissue reaction by percutaneous use, but is most often encapsulated in fibrous connective tissue when placed under the skin.4 On the other hand, PDS is a polydioxanone thread, which is a synthetic absorbable monofilament type. It is suitable for placing under the skin as it has a long period of about 60 days before it breaks or loses most of it tensile strength—prior to finally solution. The more thread there is absorbed the lesser inflammation reaction remains. Prolene mesh is a synthetic net made of monofilaments, which unlike the nets made of polyfilaments, does not attracts bacteria significantly. Yet it is purely synthetic and is nonresorbable causing a lifelong inflammation reaction in contradiction to the cross-linked mesh, which has an absorbable part and a lesser nonresorbable part. Permacol is a crosslinked biological mesh consisting of an acellular biological part obtained from the skin by a chemical process—together with a synthetically produced noncalcifying part hexamethlylene diisocyanate (HMDI). The purpose of this mesh is to combine the biological feeding of collagen with the synthetic strength and durability.5 The response to all meshes depends on the surgical placement, pH, and the surgeon.6,7 The second problem of such a case of foreign body reaction and resulting inflammatory process is to diagnose the foreign bodies. It is an imaging challenge to visualize foreign bodies. The mesh will appear as densified spots unilaterally or bilaterally on computed tomography and magnetic resonance imaging. Fistulogram investigation using contrast is used to reveal cavities, but it rarely shows the foreign bodies. The mesh will appear hyperechoic on ultrasound and should therefore be possible to visualize by ultrasonography. In our case, magnetic resonance scanning did not show any sinus duct, but the following fistulography did. Finally, the ultrasound scanning demonstrated remains of mesh at the end of the duct. The combination of fistulography and ultrasound scanning scanning for visualizing foreign bodies8 seems to be the optimal way to demonstrate a sinus formation based on a foreign body.
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
3
Hansen and Gottrup Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to research, authorship and/or publication of the article.
Funding The author(s) received no financial support for the research, authorship and/or publication of the article.
References 1. Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol. 2008;20:86-100. 2. Gerullis H, Georgas E, Borós M, et al. Inflammatory reaction as determinant of foreign body reaction is an early and susceptible event after mesh implantation. Biomed Res Int. 2014;2014:510807.
3. Bailey H. Bailey & Love’s Short Practice of Surgery. 14th ed. London, England: H.K. Lewis; 1968. 4. Bennet RG. Selection of wound closure materials. Dermatology. 1988;16:619-637. 5. Montgomery A. The battle between biological and synthetic meshes in ventral hernia repair. Hernia. 2013;17: 3-11. 6. Cronin C, Harisinghani M, Onofrio C et al. Multitechnique Imaging Findings and Prolene Plug Hernia Repair. AJR 2010; 195: 701-6. 7. Pascual G, Sotomayor S, Pérez-López P, Buján J, Bellón JM. Long term behavior of biological prostheses as abdominal wall substitutes. Histol Histopathol. 2014;29:139-149. 8. Borgohain B, Borgohain N, Handique A, Gogoi PJ. Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus. Crit Ultrasound J. 2012;4:10-13.
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
research-article2014
IJLXXX10.1177/1534734614550687The International Journal of Lower Extremity WoundsHansen and Gottrup
Case Report
Chronic Ulceration and Sinus Formation due to Foreign Body: An Often-Forgotten Problem
The International Journal of Lower Extremity Wounds 1–3 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614550687 ijl.sagepub.com
Karin Birgitte Hansen, MD1 and Finn Gottrup, MD, MDSci2
Abstract Foreign bodies like residues of suture or mesh may lead to a foreign body reaction, cavity formation and continuous secretion and perhaps ulceration. We present a more than 9 years long medical record of a 49 year old man after a simple surgical procedure. The background was a sinus formation generated from a foreign body reaction. The case report shows that this condition is often overlooked and even using advanced equipment, it is difficult to diagnose. The only solution is to diagnose and remove the triggering cause. Fistulography and ultrasound scanning seem to be the optimal diagnostic tool in these cases. The knowledge of the foreign body reaction in tissue continuously needs to be reestablished in the health care system especially in areas, where implantation of foreign material is used. Keywords foreign bodies, foreign body reaction, cavity formation, sinus, fistula Implantation of foreign materials leads to a tissue reaction in the host organism. The foreign body reaction composed of macrophages and foreign body giant cells is the endstage response of the inflammatory and wound healing responses following implantation of a medical device, prosthesis, or biomaterial. This reaction contains the following a sequence of events: injury, blood–material interactions, provisional matrix formation, acute inflammation, chronic inflammation, granulation tissue development, foreign body reaction, and fibrosis/fibrous capsule development.1 The consequences of the reaction to the material surface can be devastating. An implanted mesh represents a foreign body that induces a foreign body reaction. This reaction has been histologically described as a foreign body granuloma adjacent to the mesh fiber and a surrounding collagen capsule that shields the host from the foreign material.2 Several attempts have been conducted to improve biocompatibility of meshes and reduce the foreign body reaction. However, the local inflammatory event after mesh implantation cannot be influenced by, for instance, prior plasma coating and does not depend on the localization of implantation.2 Sinus and fistulas are usually secondary to the presence of foreign body, necrotic tissue in the affected tissue, or from certain types of microbial infection.3 These conditions may be asymptomatic, but most often they are prone to infection, which may manifest in recurrent or persistent discharge and pain if there is swelling. It might also cause formation of a
chronic ulceration. We report a patient presenting a more than 9-year long medical record with continued symptom and ulcerations after a simple surgical procedure. The background was an overlooked sinus formation generated from a foreign body reaction.
Case Report A 49-year-old man underwent laparoscopic inguinal herniotomy in 2002. This event resulted in a hematoma and superficial wound infection, which started a number of complications, including the appearance of an umbilical hernia. This condition led to a second surgery with enhancement of the fascia with Prolene mesh and suture. Because of sustained secretion, the patient underwent 2 other operative procedures within the first year—the first with revision of the soft tissue and the second with removal of the mesh and closing of the fascia with Nylon sutures. At the end of year 2003, the secretion diminished, but painful subcutaneous lymph nodes enlargement remained. Ultrasound scanning could not detect defects in the anterior 1
Hvidovre University Hospital, Copenhagen, Denmark Bispebjerg University Hospital, Copenhagen, Denmark
2
Corresponding Author: Finn Gottrup, Department of Dermatology, Copenhagen Wound Healing Center, D42, Bispebjerg University Hospital, DK-2400 Copenhagen NV, Denmark. Email: [email protected]
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
2
The International Journal of Lower Extremity Wounds
Figure 1. Abdominal wall of the presented patient with continuous secretion from foreign body sinus. A probe is placed in the sinus.
abdominal wall and the patient was not offered additional surgery. The following 7 years, the patient continuously suffered from pain from the subcutaneously lymph nodes on the belly. This situation resulted in a new surgical intervention in 2010, where the mesh, suture and fibrotic tissue were removed. Because of suspected formation of a fistula the patient was referred to the Copenhagen Wound Healing Center (CWHC) 9 months after his last surgery (Figure 1). At CWHC, the background diagnosis for the patient’s suffering was directed toward formation of a sinus due to foreign body reaction. Magnetic resonance scanning, however, could not identify this, but the following fistulography revealed an 8-cm deep duct. Ultrasound scanning furthermore showed remains of mesh at the end of the duct. The remaining mesh and sutures were then surgically removed and a Permacol mesh fixed with PDS thread was used to cover the defect, which was still remaining in the fascia. Subsequently, the wound healed and has been healed without any problems since 2011.
Discussion The 9-year-long history of wound problems reduced the quality of life for the patient in addition to being very costly to the society. The background for the extended suffering history of the patient is that the foreign body problem is very often ignored and not taken into consideration as the cause. To improve the knowledge of this problem, it is necessary to focus on 2 issues: First, the material inserted and second, the optimal way to diagnose this condition. Placement of foreign bodies in living tissue normally will lead to an inflammation reaction, whose intensity depends on the material inserted.1-5 The inflammation may result in formation of different cavity structures in the tissue, based on production of additional tissue fluid.
A complete fistula is the formation of an abnormal connection with 2 outputs either between 2 cavities of the viscera or between a cavity of the viscera and the outer surface of epithelium. A sinus consists of either a cavity or a duct leading to a single output on surface of epithelial.3 Formation of a sinus is not to be confused with formation of an abscess, which is pus in a not-preformed cavity. The foreign bodies in this case report are suture and synthetic net. Nylon suture is a synthetic nonresorbable thread, which is available as monofilament and as a twisted multifilament. Monofilament suture has the property of lesser affinity for bacteria than polyfilament suture.3 This suture generates minimal tissue reaction by percutaneous use, but is most often encapsulated in fibrous connective tissue when placed under the skin.4 On the other hand, PDS is a polydioxanone thread, which is a synthetic absorbable monofilament type. It is suitable for placing under the skin as it has a long period of about 60 days before it breaks or loses most of it tensile strength—prior to finally solution. The more thread there is absorbed the lesser inflammation reaction remains. Prolene mesh is a synthetic net made of monofilaments, which unlike the nets made of polyfilaments, does not attracts bacteria significantly. Yet it is purely synthetic and is nonresorbable causing a lifelong inflammation reaction in contradiction to the cross-linked mesh, which has an absorbable part and a lesser nonresorbable part. Permacol is a crosslinked biological mesh consisting of an acellular biological part obtained from the skin by a chemical process—together with a synthetically produced noncalcifying part hexamethlylene diisocyanate (HMDI). The purpose of this mesh is to combine the biological feeding of collagen with the synthetic strength and durability.5 The response to all meshes depends on the surgical placement, pH, and the surgeon.6,7 The second problem of such a case of foreign body reaction and resulting inflammatory process is to diagnose the foreign bodies. It is an imaging challenge to visualize foreign bodies. The mesh will appear as densified spots unilaterally or bilaterally on computed tomography and magnetic resonance imaging. Fistulogram investigation using contrast is used to reveal cavities, but it rarely shows the foreign bodies. The mesh will appear hyperechoic on ultrasound and should therefore be possible to visualize by ultrasonography. In our case, magnetic resonance scanning did not show any sinus duct, but the following fistulography did. Finally, the ultrasound scanning demonstrated remains of mesh at the end of the duct. The combination of fistulography and ultrasound scanning scanning for visualizing foreign bodies8 seems to be the optimal way to demonstrate a sinus formation based on a foreign body.
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
3
Hansen and Gottrup Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to research, authorship and/or publication of the article.
Funding The author(s) received no financial support for the research, authorship and/or publication of the article.
References 1. Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol. 2008;20:86-100. 2. Gerullis H, Georgas E, Borós M, et al. Inflammatory reaction as determinant of foreign body reaction is an early and susceptible event after mesh implantation. Biomed Res Int. 2014;2014:510807.
3. Bailey H. Bailey & Love’s Short Practice of Surgery. 14th ed. London, England: H.K. Lewis; 1968. 4. Bennet RG. Selection of wound closure materials. Dermatology. 1988;16:619-637. 5. Montgomery A. The battle between biological and synthetic meshes in ventral hernia repair. Hernia. 2013;17: 3-11. 6. Cronin C, Harisinghani M, Onofrio C et al. Multitechnique Imaging Findings and Prolene Plug Hernia Repair. AJR 2010; 195: 701-6. 7. Pascual G, Sotomayor S, Pérez-López P, Buján J, Bellón JM. Long term behavior of biological prostheses as abdominal wall substitutes. Histol Histopathol. 2014;29:139-149. 8. Borgohain B, Borgohain N, Handique A, Gogoi PJ. Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus. Crit Ultrasound J. 2012;4:10-13.
Downloaded from ijl.sagepub.com at CMU Libraries - library.cmich.edu on October 26, 2015
