None Shall Pass: Migrated Surgical Mesh Causing Gastric Outlet Obstruction With Endoscopic Extraction

Abstract

Background: Surgical mesh migration is an uncommon and unpredictable complication which is rarely reported in the literature. Migration often presents with pain, but can be complicated by bleeding, fistula formation, or abscess. Case: A 77-year-old female with a history of a paraesophageal hernia repair initially presented to an outside hospital with a few months of nausea, vomiting, and regurgitation following both liquid and solid intake with a 10 pound weight loss. An EGD was performed at the outside hospital with a visualized foreign body in the stomach. Due to the size of the foreign body she was referred to General Surgery for further evaluation. Her initial hernia repair occurred 11 years prior to presentation, but required recurrent repair with Nissen fundoplication with mesh reinforcement three years prior. The surgeon felt that her foreign body was likely the surgical mesh which had migrated into the gastric lumen. She was subsequently admitted to the hospital and underwent CT scan which demonstrated the foreign body with multiple ring foci of metallic densities in the distal stomach. Gastroenterology was consulted and a repeat EGD was performed demonstrating a large mobile foreign body which appeared to be surgical mesh with multiple metallic rivets. The foreign body was too large to be fully encompassed with a net and was too stiff to be compressed enough with a snare to allow for extraction through the fundoplication. A double channel therapeutic upper endoscope was then inserted and nets were passed through both channels. Using both nets, the foreign body was able to be completely encompassed and gradually compressed to a diameter which allowed for successful extraction through the mouth. Reinsertion of the scope post-extraction revealed some mild oozing of blood in the distal esophagus, but no mucosal tear or perforation. Discussion: Surgical mesh migration is a rare complication of hernia repair with complete transmural migration even rarer. There are reports in the literature of mesh migration into the colon, small bowel, stomach, urinary bladder, and scrotum. Patients often require further surgery for extraction of the mesh and repair of complications, however transmural migration can allow for endoscopic removal such as in this case. Complications from surgical mesh tend to occur years after surgery and mesh migration should be considered in atypical presentations of abdominal pain in patients with a history of hernia repair with mesh.1898 Figure 1. Surgical mesh with metallic rivets freely mobile within the gastric lumen.