Experience of biological implants in thoracic surgery for soft tissue and chest wall reconstruction in clean and contaminated environments

Our plain-English summary of Experience of biological implants in thoracic surgery for soft tissue and chest wall reconstruction in clean and contaminated environments, by H. Jesani, V. Surendrakumar, H. Walji, et al (Journal of Thoracic Disease, 2026).

The study

• Authors: H. Jesani, V. Surendrakumar, H. Walji, M. Ahmed, L. Hernandez-Arenas, L. Socci, A. Martin-Ucar
• Journal: Journal of Thoracic Disease
• Published: 2026;18(8):931
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Biological mesh has become an integral tool in surgery for reconstructive procedures. Acellular dermal matrices derived from porcine or bovine collagen scaffolds provide a durable implant material for use in reconstruction of the chest wall, and soft tissues including the pericardium and diaphragm. We aimed to present our experience of biological meshes used for thoracic reconstructive procedures for a wide range of clinical indications by a single surgeon, comparing the effect of contaminated and clean surgical environments and implant materials.

Methods: We retrospectively reviewed all patients who had undergone thoracic surgery reconstructive procedures under a single surgical team with biological mesh material over a 16-year period from March 2009 to April 2025. Data included indication for surgery, operative procedure, surgical site, biological implant material (cross-linked or non-cross-linked), postoperative infection, in-hospital mortality and reoperation rate. We directly compared the results between patients undergoing the procedure in infected/contaminated versus clean cases.

Results: In total 152 consecutive procedures were performed utilising 212 patches. Median age was 65 years (range, 24-84 years) and majority treated were males 104/152 (68%). Indications for surgery included total pleurectomy for mesothelioma (38%), resection of extended thoracic malignancy (33%), surgery for trauma or related complications (19%), and benign conditions including adult congenital abnormalities (10%). Cross-linked biological mesh had a significantly reduced surgical site infection rate compared to non-cross-linked biological mesh (n=6; 7% vs. n=16; 23%, P=0.008). This remained significant following adjustment for key clinical confounding factors [adjusted odds ratio (OR) 0.289, 95% confidence interval (CI): 0.105-0.793, P=0.02]. Direct comparison of contaminated environments versus clean showed surgical site infections postoperatively were not significantly different (24% vs. 12% P=0.09). No biological patch necessitated explantation due to infection. In-hospital mortality and reoperation rates remained low at 4% and 9% respectively.

Conclusions: Our study evaluates and supports the continued use of biological patches for thoracic reconstruction of soft tissues and chest wall. Biological patches have a role in a diverse range of surgical indications including extended resection of malignancy and traumatic injuries and can be feasibly used in high risk contaminated surgical fields.

© AME Publishing Company.

In plain English

This retrospective cohort study reviewed 152 consecutive thoracic operations done by a single surgeon in 3 hospitals between March 2009 and April 2025. In these operations, 212 biological mesh patches made from pig (porcine) or cow (bovine) collagen were used to rebuild the diaphragm, pericardium or chest wall. The most common reason for surgery was total pleurectomy for mesothelioma (38% of procedures). Overall, 14% of patients had a surgical site infection. Infection occurred in 8 of 34 patients (24%) operated on in contaminated fields and in 14 of 118 (12%) in clean fields. This difference was not statistically significant. Infection occurred in 6 of 81 patients (7%) given cross-linked mesh and in 16 of 71 (23%) given non-cross-linked mesh. That association remained significant after adjustment for contamination and urgency, but not after further adjustment for surgical indication. In-hospital mortality was 4% and the reoperation rate was 9%. The authors concluded that biological patches were feasible, including in contaminated fields. They said the lower infection rate with cross-linked mesh should be interpreted cautiously because of the retrospective design, potential selection bias and incomplete adjustment for confounders.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective cohort analysis of consecutive patients from a single surgeon's practice
• Who was studied: 152 procedures using 212 biological patches, performed by one surgeon in 3 hospitals from March 2009 to April 2025 (author affiliations: Coventry and Bristol, UK). 104 patients were male and 48 female, median age 65 years (range 24 to 84).
• Exposure: Not an asbestos exposure study. The study compared biological mesh implants: cross-linked porcine mesh, non-cross-linked porcine mesh, and non-cross-linked bovine pericardium mesh. It also compared surgery in contaminated and clean surgical fields.
• Main results:
  • Total pleurectomy for mesothelioma was the indication in 38% of procedures (58 of 152). Extended thoracic malignancy was the indication in 33%, trauma or related complications in 19%, and benign conditions in 10%.
  • The surgical site infection rate for the whole cohort was 14%.
  • Surgical site infection occurred in 8 of 34 patients (24%) in contaminated fields and 14 of 118 patients (12%) in clean fields. This difference was not statistically significant (P=0.09; OR 2.29, 95% CI 0.87 to 6.02).
  • Surgical site infection occurred in 6 of 81 patients (7%) with cross-linked mesh and 16 of 71 patients (23%) with non-cross-linked mesh (P=0.008).
  • After adjustment for surgical field contamination and operative urgency, cross-linked mesh was associated with reduced odds of infection compared with non-cross-linked mesh (adjusted OR 0.289, 95% CI 0.105 to 0.793, P=0.02).
  • In a sensitivity analysis also adjusting for surgical indication, the cross-linked mesh association was no longer statistically significant (adjusted OR 0.376, 95% CI 0.126 to 1.126, P=0.08).
  • In-hospital deaths: 6 of 152 (4%). Reoperations: 14 of 152 (9%).
  • There were 6 (4%) patch-related complications: 2 patch disruptions, 1 patch release and 3 later hernia recurrences. No patch required removal because of infection.
  • Median hospital stay was longer in the contaminated group than in the clean group (13 vs 9 days, P=0.002).
• The authors' conclusion: The authors concluded that biological patches were feasible for thoracic reconstruction across a range of complex scenarios, including contaminated fields. They said the lower infection rate with cross-linked mesh should be interpreted cautiously, and that further prospective, multicentre studies are needed.
• Limitations the authors state:
  • The study was retrospective and not randomized.
  • The 16-year study period creates potential era bias.
  • Being a single-surgeon study may limit how far the results apply elsewhere.
  • The comparison of mesh types may be affected by temporal selection bias.
  • No analysis was done of individual manufacturers' products.
  • Some confounders were not included in the multivariate analysis.
  • Perioperative antibiotic use was not consistently recorded and could not be analysed.
  • The study may have been underpowered.

Topics

Medical terms in this study, explained in our Lexicon: Thoracic Surgery, Collagen, Pericardium, Diaphragm, Mesothelioma, Confounding, Odds Ratio, confidence interval.

Related studies

• Initial experience with the use of biological implants for soft tissue and chest wall reconstruction in thoracic surgery — A. Barua, J.A. Catton, et al. (2012)
• Surgical Management and Reconstruction of Diaphragm, Pericardium and Chest Wall in Mesothelioma Surgery: A Review — P. Bertoglio, E. Garelli, et al. (2021)
• Massive chest wall resection and reconstruction for malignant disease — C.N. Foroulis, A.D. Kleontas, et al. (2016)
• Long-term results of chest wall reconstruction with DualMesh — T. Nagayasu, N. Yamasaki, et al. (2010)
• En bloc resection of the recurrent pleural mesothelioma and reconstruction of the chest wall after immunotherapy: A case report — C. Qin, Q. Xia, et al. (2023)
• Chest Wall Reconstruction Using a Titanium Mesh Plate and an Expanded Polytetrafluoroethylene Sheet: A Case Report — T. Toyoda, T. Suzuki, et al. (2025)

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