John A. Brown, MD1, Houssam Mardini, MD, FACG2; 1University of Kentucky, Lexingtion, KY; 2University of Kentucky, Lexington, KY
Introduction: Hiatal hernia surgical repair may involve the use of biosynthetic absorbable (bioresorbable) mesh. This mesh can erode over time particularly following revisional surgery. Less invasive methods for management with the use of endoscopy should be considered when possible.
Methods: A 58 year old female with history of hiatal hernia status post remote Toupet fundoplication and subsequent revision with takedown and performance of Collis gastroplasty with Nissen fundoplication and use of biosynthetic absorbable mesh approximately ten months prior presented with epigastric abdominal pain, dysphagia, nausea and 10 pound weight loss over one month period. Patient underwent upper endoscopy at outside facility and was noted to have what appeared to be eroded mesh in the esophagus near the gastroesophageal junction. This could not be completely removed with biopsy forceps. CT scan showed evident surgical mesh with no obvious perforation or leak. Following transfer to our facility, upper endoscopy was repeated which was notable for penetrating mesh 36 cm from incisors. A fistula was noted at this site following removal of mesh with rat toothed forceps. A 20 mm x 12 cm Taewoong partially covered controlled-release stent with 25 mm flange was placed in the esophagus. A 12 French nasojejunal feeding tube was placed. The patient was made NPO for 48 hours with tube feeding as initial primary means of nutrition. Patient was then started on clear liquid diet and advanced to pureed diet with good tolerance. The nasojejunal tube was removed. A repeat EGD was performed four weeks following with removal of stent. The fistula had decreased in size, however further mesh erosion was noted. The decision was made to replace esophageal stent and patient was scheduled for outpatient follow up for consideration of additional intervention. Discussion: Endoscopic management of eroded bioresorbable mesh following hiatal hernia surgical repair should be considered prior to repeat surgical intervention when possible. However, conservative management may not always be successful and multi-disciplinary collaboration is needed from the time of presentation.
Erosion of biosynthetic absorbable mesh in the lower esophagus following revisional hiatal hernia surgery.
Biosynthetic absorbable mesh pictured after removal.
Placement of 20 mm x 12 cm Taewoong partially covered controlled-release stent with 25 mm flange following removal of eroded biosynthetic absorbable mesh in the esophagus with rat toothed forceps. A fistula is visualized near the gastroesophageal junction.
Disclosures: John Brown indicated no relevant financial relationships. Houssam Mardini indicated no relevant financial relationships.