The Elusive Erosion: Mesh Migration into the Colon

Abstract

Tension-free mesh has been applied in abdominal hernia repairs as the gold-standard for repair to decrease hernia recurrence and post-operative pain. Common complications include infection, mesh rejection, and fistula formation. Mesh migration and erosion are uncommon, late-onset complications that can occur months to years after initial mesh placement. Clinical presentation depends on the organ into which the mesh erodes. While mesh fixation has been investigated recently, patients with historical repair are still at risk for this rare complication. We present an unusual case of a patient with mesh erosion into the sigmoid colon diagnosed on colonoscopy. Our patient is a 72-year-old male with history of double-hernia repair in the 1990s. He had recently presented to his primary care doctor for abdominal pain and a CT Abdomen was ordered, which noted postoperative changes of hernia repair. Patient was referred for EGD for nausea and abdominal pain and was already scheduled for a follow-up screening colonoscopy. EGD showed mild gastritis. Colonoscopy showed a foreign body in the mid-sigmoid colon that appeared to be mesh with spiral fasteners noted within the foreign body and appeared to be eroding through the wall of the sigmoid colon causing some luminal narrowing. Colonoscope was removed and patient was referred to general surgery. Patient was taken for surgery. The left inguinal region was attached to the sigmoid colon via the surgical mesh requiring complex dissection and removal of pus and infected material noted in this region. The mesh was removed, and patient's abdominal pain, nausea, and discomfort had resolved as noted on follow-up 2 weeks after. Mesh erosion and migration are late-complications of hernia repair that can cause severe symptoms for patients. D'Amore et al. identified seven previous cases (2 cecum and 5 left colon) of mesh erosion into the colon since 1997. There was one additional case report noting erosion of mesh into the sigmoid colon. There has been on-going discussion if fixation of hernias during mesh repair is required for prevention of erosion; however, our case had evidence of spiral fasteners that eroded along with the mesh. This is unusual as fixation is theorized to prevent this complication, and studies are ongoing to determine the outcomes comparing fixation to no fixation. Our case is important as it defines a case where fixation did not prevent mesh erosion and resulted in an infected mesh erosion.1474_A Figure 1. Colonoscopy showing evidence of fastener with mesh in colon1474_B Figure 2. Colonoscopy showing luminal narrowing in the sigmoid colon with mesh in place1474_C Figure 3. Colonoscopy again showing luminal narrowing with fastener once again seen