Endoscopic Removal of Eroded Esophageal Mesh

Abstract

Purpose: Background: Erosion of prosthetic mesh is a rare but significant complication of paraesophageal hernia repair. We present a case of endoscopic removal of eroded mesh after open repair of a recurrent paraesophageal hernia. Case: A 49-year-old female underwent laparoscopic Nissen fundoplication and posterior cruroplasty in April 2004 for paraesophageal hernia. In August 2006, she underwent open redo Nissen fundoplication and posterior cruroplasty with polytetrafluoroethylene (PTFE) onlay to repair a recurrent paraesophageal hernia. The patient developed nausea, dysphagia, iron-deficiency anemia, and weight loss within six months of the second surgery. In June 2007 at endoscopy, the mesh was seen at the GE junction protruding into the stomach with granulation tissue around it. The gastroscope was retroflexed in the stomach and a suture eroding on the left side was released using rat-tooth forceps. With traction, the mesh could not be pulled completely into the stomach. The gastroscope was withdrawn into the esophagus and the mesh was tackled end on, slowly mobilizing it. The proximal end of the mesh was grasped with the forceps and further mobilized by carefully applying torque. Another suture was found on the right side and was released allowing easy mesh removal. On retrieval, the mesh was found to be intact without any tears. There was a significant amount of edema and granulation tissue noted in the distal esophagus. A temporary wall stent was placed due to the concern for esophageal stricture formation and leak. At follow up in November of 2007, the patient was asymptomatic after stent removal. Discussion: This experience confirms that an eroded esophageal mesh from paraesophageal hernia repair can be safely removed endoscopically as demonstrated in a previous case report. It may not be possible in all cases and is ideal for mesh that is completely or mostly within the lumen of the gastrointestinal tract. Careful coordination with a surgeon is necessary in the case that the mesh cannot be removed endoscopically. Optimal surgical management for paraesophageal hernia remains controversial. Some authors suggest that biomesh or newer synthetic meshes may be better alternatives to synthetic mesh repair with PTFE or polypropylene.Figure: Eroded mesh from paraesophageal hernia repair removed intact endoscopically.