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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 158-161

Recurrent and late esophageal mesh extrusion after paraesophageal hiatoplasty: A case report and review of the literature

1 Department of General and Digestive Surgery, Unit of Gastrointestinal and Hematological Surgery, Medical School, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
2 Department of Gastroenterology and Hepatology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Medical School, Barcelona, Spain

Date of Submission01-Jun-2020
Date of Decision23-Jun-2020
Date of Acceptance03-Jul-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Sonia Fernandez.Ananin
Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Sant Quintí 89, 08041 Barcelona
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_21_20

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The most accepted management for symptomatic paraesophageal hernias (PEHs) is the closure of the hiatal gap associated with an antireflux procedure. When the defect of the hiatus is particularly wide or the consistency of the pillars is weak, a prosthetic mesh may be used to cover the suture cruroplasty. Nevertheless, the use of mesh in PEHs repair is a subject of ongoing debate, due to the local risk of complications that a foreign body located in this area can lead. We present the case of a 77-year-old female who underwent PEH surgery with placement of polypropylene mesh twice. On both occasions, the prosthesis migrated late through the wall of the esophagus and could be removed by endoscopy. We consider that this case is exceptional, not only due to the multiple and late extrusion of the mesh in the lumen of the esophagus but also due to the absence of symptoms that this event caused to the patient.

Keywords: Complications, mesh, paraesophageal hernia, surgical treatment

How to cite this article:
Fernandez.Ananin S, Sacoto D, Balagué C, Guarner C, Targarona EM. Recurrent and late esophageal mesh extrusion after paraesophageal hiatoplasty: A case report and review of the literature. Int J Abdom Wall Hernia Surg 2020;3:158-61

How to cite this URL:
Fernandez.Ananin S, Sacoto D, Balagué C, Guarner C, Targarona EM. Recurrent and late esophageal mesh extrusion after paraesophageal hiatoplasty: A case report and review of the literature. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2021 Apr 23];3:158-61. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/4/158/302021

  Introduction Top

The use of mesh paraesophageal hernia (PEH) repair is a recurrent theme in debate. Even though the medical literature evidences that mesh hiatoplasty is a good maneuver to prevent recurrences and to decrease the rate of revisional surgery for a failed primary hiatoplasty,[1] serious complications question its routine use.[2],[3],[4]

The incidence related to the complications after mesh placement is not exactly known,it is estimated around 1%–2% in short-term studies.[5] Despite these low rates, complications can be so feared that they condition surgical challenging situations even in the hands of the most experienced surgeons.

Although several complications have been described related to mesh hiatoplasty for PEH (erosion, bleeding, inflammation, and stricture), the most serious is the prosthesis migration into the esophagus lumen or other neighboring organs.

Even though the mechanism responsible for the mesh erosion to the surrounding organs is unknown, the most accepted hypothesis is the reaction generated between the esophageal peristalsis with the friction with the foreign body. The continuous hiatal movements during the breathing in intimate contact with the prosthetic material lead to chronic inflammation of the esophageal wall, that might cause a subsequent later erosion ulcer with perforation and migration of the mesh into its lumen.[6] Consequences due to this complication generate greater morbidity and mortality, longer hospital stay, and consequent increment of economic cost.

In this regard, several studies have attempted to explore if the type of prosthetic material, its shape, or the way to fix it in the hiatus, may be determining factors for the complications described.

  Case Report Top

A 77-year-old female with gastroesophageal reflux disease underwent in 2009, prior signing of consent form, in another cente, a laparoscopic surgical treatment. Preoperative esophageal manometry ruled out motility disorders, and 24-h pH-metry reported a severe distal gastroesophageal reflux. Surgery revealed a PEH, and cruroplasty was reinforced with a polypropylene mesh around the esophagus followed by a Nissen antireflux fundoplication.

Four months later, reflux symptoms recurred. Gastroscopy and barium swallow showed a recurrent PHE. Revisional surgery was proposed. The prior wrap was migrated into the thorax. Complete reduction of the mediastinal sac, taked down the previous fundoplication into the abdominal cavity, closure of the hiatal defect, and new reinforcement of the cruroplasty with another polypropylene mesh over the previous were the technical steps performed in the redo surgery.

Postoperative course was uneventful, and the patient was discharged on the 3rd day after the surgery. Routine gastroscopies at 6 and 12 months showed no abnormalities.

Three years later, patient-reported heartburn without other symptoms. On this occasion, an upper gastrointestinal endoscopy found a foreign body into the esophageal wall, 1 cm above the cardia, compatible with a. transmural migration of prosthetic mesh.

The patient was referenced to our unit for a second opinion. In our hospital, a thoracoabdominal computed tomography scan and a barium test were performed, which did not show any foreign body or other alterations. Gastroscopy revealed remnants of mesh in the distal esophagus and the cardia. It was removed slight erosions in the mucosa of the esophagus with minimal bleeding that stopped spontaneously.

From the clinical point of view, the patient has remained asymptomatic with proton pump inhibitors therapy. Over the next 4 years, annual routine gastroscopy did not show anomalies. Until the last endoscopy, performed 9 years after the redo surgery. It evidenced new fragments of migrated polypropylene mesh into the esophageal lumen. Again these remains were extracted by the endoscopic approach without incidents. Currently, the patient remains asymptomatic and she continues with her routine annual examinations.

  Discussion Top

Laparoscopic crural closure combined with an antireflux technique is considered the treatment of choice for PEHs. However, it is well known that simple cruroplasty is associated with a high recurrence rate, which can reach 42% in the midterm follow-up.

Recurrence has been associated with different factors, mainly with the presence of tension in the closure of hiatal gap. To prevent failures and avoid relapses, some authors recommend the use of prosthetic mesh to reinforce the hiatal suture.[7]

There is still no consensus about the indication of mesh placement, type of material (absorbable vs. nonabsorbable), prosthesis shape, or way to fix it to the hiatus. What seems clear is that meshes should not be used routinely in all PEH defects, being used only in selected cases. If we review surveys of panels of experts in esophagogastric surgery and the published guidelines, only <10% of surgeons place reinforcement meshes in the standard laparoscopic hiatal hernia repair.[8],[9]

Most surgeons limit their use to large defects, the weak structure of the pillars, and revisional surgeries. The complex anatomical location, the continuous and dynamic contact of a strange body with the esophagus and the stomach, and the permanent movements of diaphragmatic muscles would cause intraluminal erosion, fibrotic stenosis, adhesions, perforation, and its migration into the lumen.

Throughout these years, several articles have focused on determining if the different prosthetic materials, shape and its fixation to the crura could be responsible for these disorders. However, the reflected results are not clarified, and even in some issues, they are disagreeing and contradictory.[10],[11]

In the last decades, five randomized controlled trials [Table 1].[12],[13],[14],[15],[16] lead to explore clinical outcomes, safety and effectiveness, complications, and recurrence rates comparing the use of prostheses versus simple suture. Frantzides et al., Granderath et al. and Oelschlager et al. demonstrated in their trials a lower incidence of recurrence after mesh placement. However, the heterogenity of the studies about the mesh material, the desing, the indication for use, the recurrent definition do not allow reliable conclusions to be drawn. Even Oelschlager et al., in a later article, after analyzing the same cohort during a median follow-up of 58 months, obtained not so optimistic results with a recurrence after biological mesh placement of 9% to 54%.
Table 1: Prospective randomized studies on the use of meses in hiatus hernia

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However, Watson, in his recent study, concluded the absence of advantages after mesh placement in PEH surgical procedure after a 5-year follow-up. It also showed more later symptoms, such as chest pain, diarrhea, and bloating, in those patients who had had prosthesis placement.

However, the use of reinforcing mesh in the hiatus is not exempt from complications, and although the incidence of these is <1%–2% in reported series[17] and it is probably underestimated, sometimes can be so severe as to need major surgical procedures (distal esophageal resection, partial, or total gastrectomy) or lifelong tube feeding requirements.

Cases of mesh erosion and migration have been described with different prosthetic materials. Although polypropylene and polytetrafluoroethylene PTFE/expanded (PTFE) have a great capacity to form adhesions and therefore to erode neighboring organs, this type of complications also been described with other types of materials [Figure 1].
Figure 1: (a) Upper gastrointestinal endoscopy showed a foreign body inside the distal esophagus and cardia, suggestive of externalized hernioplasty mesh. (b) The mesh was removed using endoscopic crocodile forceps

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Endoscopic extraction is the first choice treatment with a successful rate of 15.7%, sometimes needing to be supervised by laparoscopy. Surgery is reserved when endoscopic treatment is not feasible or there is the symptomatic recurrence of the hernia.

Our case is exceptional for several reasons. The most remarkable is the recurrence of the mesh intrusion into the lumen of the esophagus. Both prostheses migrated years later and were successfully retrieved by the endoscopic approach. Another exceptional feature is that the patient did not show clinical symptoms related to this complication, despite 95% of patients present symptomatology of dysphagia or weight loss when mesh migration occurs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fuchs KH, Babic B, Breithaupt W, Dallemagne B, Fingerhut A, Furnee E, et al. EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 2014;28:1753-73.  Back to cited text no. 1
Shrestha AK, Joshi M, DeBono L, Naeem K, Basu S. Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: A single centre experience. Hernia 2019;23:387-96.  Back to cited text no. 2
Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr., Michael Brunt L, Hunter JG, et al. Mesh complications after prosthetic reinforcement of hiatal closure: A 28-case series. Surg Endosc 2009;23:1219-26.  Back to cited text no. 3
Carpelan-Holmström M, Kruuna O, Salo J, Kylänpää L, Scheinin T. Late mesh migration through the stomach wall after laparoscopic refundoplication using a dual-sided PTFE/ePTFE mesh. Hernia 2011;15:217-20.  Back to cited text no. 4
Müller-Stich BP, Kenngott HG, Gondan M, Stock C, Linke GR, Fritz F, et al. Use of mesh in laparoscopic paraesophageal hernia repair: A meta-analysis and risk-benefit analysis. PLoS One 2015;10:e0139547.  Back to cited text no. 5
Li J, Cheng T. Mesh erosion after hiatal hernia repair: The tip of the iceberg? Hernia 2019;23:1243-52.  Back to cited text no. 6
Balagué C, Fdez-Ananín S, Sacoto D, Targarona EM. Paraesophageal hernia: To mesh or not to mesh? The controversy continues. J Laparoendosc Adv Surg Tech A 2020;30:140-6.  Back to cited text no. 7
Bonrath EM, Grantcharov TP. Contemporary management of paraesophaegeal hernias: Establishing a European expert consensus. Surg Endosc 2015;29:2180-95.  Back to cited text no. 8
Pfluke JM, Parker M, Bowers SP, Asbun HJ, Daniel Smith C. Use of mesh for hiatal hernia repair: A survey of SAGES members. Surg Endosc 2012;26:1843-8.  Back to cited text no. 9
Memon MA, Siddaiah-Subramanya M, Yunus RM, Memon B, Khan S. Suture cruroplasty versus mesh hiatal herniorrhaphy for large hiatal hernias (HHs): An updated meta-analysis and systematic review of randomized controlled trials. Surg Laparosc Endosc Percutan Tech 2019;29:221-32.  Back to cited text no. 10
Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, et al. Guidelines for the management of hiatal hernia. Surg Endosc 2013;27:4409-28.  Back to cited text no. 11
Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs. simple cruroplasty for large hiatal hernia. Arch Surg 2002;137:649-52.  Back to cited text no. 12
Granderath FA, Schweiger UM, Kamolz T, Asche KU, Pointner R. Laparoscopic nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: Preliminary results of a prospective randomized functional and clinical study. Arch Surg 2005;140:40-8.  Back to cited text no. 13
Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: Long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg 2011;213:461-8.  Back to cited text no. 14
Oor JE, Roks DJ, Koetje JH, Broeders JA, van Westreenen HL, Nieuwenhuijs VB, et al. Randomized clinical trial comparing laparoscopic hiatal hernia repair using sutures versus sutures reinforced with non-absorbable mesh. Surg Endosc 2018;32:4579-89.  Back to cited text no. 15
Watson DI, Thompson SK, Devitt PG, Aly A, Irvine T, Woods SD, et al. Five year follow-up of a randomized controlled trial of laparoscopic repair of very large hiatus hernia with sutures versus absorbable versus nonabsorbable mesh. Ann Surg 2020 72(2):241-7.  Back to cited text no. 16
Targarona EM, Balagué C, Martinez C, Garriga J, Trias M. The massive hiatal hernia: Dealing with the defect. Semin Laparosc Surg 2004;11:161-9.  Back to cited text no. 17


  [Figure 1]

  [Table 1]


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