Enterocutaneous fistula 14 years after prosthetic mesh repair of a ventral incisional hernia: A life-long risk?

Abstract

THE PATIENT was an 82-year-old woman with Munchausen syndrome who had undergone multiple abdominal operations, including appendectomy, cholecystectomy, hysterectomy, bilateral salpingooophorectomy, splenectomy, adhesiolysis, and right hemicolectomy. She also had undergone three operations to repair a recurrent ventral incisional hernia. The last repair, in which Marlex mesh was used, had been performed 14 years before. In that procedure a subfascial technique was used, with the mesh being secured to the edges of the fascial defect. Tissue interposition between small-bowel loops and mesh was not possible because of a lack of omentum as a result of the prior operations. The patient had been in relatively good health for the last 14 years until she experienced spontaneous drainage of enteric contents from the midabdominal wall. She had no signs of sepsis, although she was malnourished. A fistulogram confirmed communication with the midjejunum. No mucosal irregularities were seen on the small-bowel series. A CT scan of the abdomen did not reveal any intraperitoneal collections. An 8-week trial of bowel rest, total parenteral nutrition, and somatostatin failed to spontaneously close the fistula. After the patient was nutritionally repleted, an exploratory laparotomy to resect the enterocutaneous fistula was performed. At the time of surgery, multiple adhesions were present between bowel loops . A loop of jejunum was densely adherent to the mesh, which had eroded into the bowel wall in one area (Figure). We resected this segment of jejunum, as well as all of the involved mesh, and performed a primary stapled anastomosis. The patient’s abdominal fascia was severely attenuated and, after excision of the remaining mesh, a 4 × 6-cm defect was present. The wound was closed with retention sutures, and the area of the fascial defect was allowed to heal by secondary intention. The postoperative course was complicated only by delayed return of bowel function, and the patient was discharged on postoperative day 13, tolerating a regular diet.