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| CASE REPORTS |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 48-52 |
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Enterocutaneous fistula from a mesh eroding the small bowel after incisional hernia repair: A case report
Michael L Lorentziadis, Moustafa Mahmoud Nafady Hego, Fatma Al Nasser
Imam Abdulrahman Bin Faisal Hospital, Department of General Surgery, Dammam, Saudi Arabia
| Date of Submission | 06-Jan-2023 |
| Date of Decision | 26-Jan-2023 |
| Date of Acceptance | 16-Feb-2023 |
| Date of Web Publication | 30-Mar-2023 |
Correspondence Address:
Michael L Lorentziadis
Imam Abdulrahman Bin Faisal Hospital, Department of General Surgery, P.O. Box 4616, Dammam 31412
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_2_23
Tension-free hernia repair with mesh reinforcement has become the standard of care in hernia surgery. Mesh eroding the bowel with enterocutaneous fistula is a rare and serious complication. We present a case of a 46-year-old obese man with abdominal wall abscess who developed enterocutaneous fistula due to the erosion of the small bowel from a bioabsorbable coated mesh after incisional hernia repair. We discuss the biological response to hernia repair meshes as well as this challenging to treat, early or late complication of hernia surgery. Keywords: Complication of hernia surgery, enterocutaneous fistula, hernia repair, mesh erosion of the bowel
How to cite this article:
Lorentziadis ML, Nafady Hego MM, Al Nasser F. Enterocutaneous fistula from a mesh eroding the small bowel after incisional hernia repair: A case report. Int J Abdom Wall Hernia Surg 2023;6:48-52 |
How to cite this URL:
Lorentziadis ML, Nafady Hego MM, Al Nasser F. Enterocutaneous fistula from a mesh eroding the small bowel after incisional hernia repair: A case report. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 9];6:48-52. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/48/372934 |
| Introduction | |  |
Francis Usher in 1955 used a polypropylene mesh to hernia treatment, applying in clinical practice the idea of Th. Billroth to use a prosthetic material to close a hernia defect.[1] Today hernia repair is one of the most common procedures and tension-free repair techniques with mesh, open or laparoscopic, have become the standard of care.[1],[2],[3]
Irrespective of the anatomic space, where the mesh is placed, it is amenable to complications including seroma, mesh infection, abscess, mesh migration, and erosion of the bowel causing mesh-related enterocutaneous fistula (ECF) which is the most dreaded complication in hernia surgery.[1],[3] Its etiology is multifactorial including the inflammatory response against foreign body, characteristics of the mesh, surgical technique, and factors related to patient.
We present a case of incisional hernia repair treated by intraperitoneal on lay repair with a self-expanding bioresorbable coated permanent mesh (Ventrio™ ST, BARD) and complicated by abscess and ECF due to mesh erosion of the small bowel.
| Case Presentation | | |
A 46-year-old man, morbidly obese (body mass index 44), was followed in our clinic having a supraumbilical midline discharging pus fistula. The patient had a history of biliopancreatic diversion which was reversed due to metabolic complications. He developed a recurrent incisional hernia which was repaired using a bioresorbable coated partially absorbable type mesh (Ventrio™ ST Hernia patch by BARD, USA), containing two layers: the top (fascial) layer was monofilament polypropylene mesh and the bottom (visceral) layer was co-knitted polypropylene and polyglycolic acid fibers mesh for minimizing the tissue attachment to the mesh which was placed intraperitoneal on lay.
Eight months later, he presented to emergency room with an abscess extending around the scar of the previous laparotomy. Computerized tomography (CT) scan abdomen showed a mid-line subcutaneous thick-walled collection, measuring 16 cm × 6 cm, 7 cm × 5 cm [Figure 1]. The abscess was drained and the abdominal fascia was found intact, although there was a suspicious air leak at the lower end of the incision. CT scan abdomen repeated 6 days after with oral gastrografine did not confirm an ECF [Figure 2]. The abscess cavity was leaving a low output fistula. Another abdomen CT scan five months later failed to show any communication with the bowel but due to high clinical suspicion, a fistulogram depicted an ECF through the eroding mesh [Figure 3]. | Figure 1: Abdomen CT showing the midline abscess with extensive fat stranding
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 | Figure 2: (A) Abdomen CT with oral contrast and no extra luminal contrast leak identified. (B) Abdomen CT with oral contrast 5 months later with closure of midline drained abscess and no evidence of contrast leak or enterocutaneous fistula
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 | Figure 3: Fistulogram with opacification of small bowel loops delineating a fistulous tract between the skin and the opacified small bowel loop
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As he was not septic and the output of the fistula was low (<15 ml/day) he was advised to lose weight. He was operated nine months later, after losing 15 kg. The abdomen was accessed through an elliptical mid line incision including the orifice of the fistula [Figure 4]. The adherent small bowel was carefully released from the abdominal wall, the mesh was found eroding in one jejunal loop creating an ECF [Figure 5]. The whole mesh was excised en block with 40 cm of jejunum. The continuity of the bowel was restored by a jejunojejunal anastomosis. The subcutaneous tissue was released up to the midclavicular line bilateral, and the abdomen was closed primarily with nylon loop no1. The repair was reinforced using a porcine dermal matrix surgical graft XenMatrix™ from Bard by an on lay fashion [Figure 6]. The subcutaneous space was drained and the skin was closed. The drain was removed 46 days after when the output was minimal. A year after, there is no hernia recurrence or seroma. | Figure 4: (A) The probe is delineating the enterocutaneous fistula. (B) The mesh, which eroded the small bowel is depicted as well as the enterocutaneous fistula opening
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 | Figure 6: Reinforcement of the repair with biological mesh Xen Matrix-Bard
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| Discussion | | |
Mesh migration and small bowel erosion with ECF were first reported in 1981. It is a serious complication in hernia surgery with an incidence of 0.3%–23%.[2],[3] After implantation, the mesh provokes one of the three reactions: (a) distraction or lysis, (b) inclusion or tolerance, and (c) rejection or removal.[3] The inflammatory response includes: (a) the acute response with absorption of proteins, platelets, and chemo attraction of neutrophils, macrophages, and fibroblasts, (b) chronic inflammation where monocytes differentiate to macrophages, (c) the third stage in which macrophages form giant cells fusing with the mesh, and (d) the fourth stage lasting about 12 weeks and various cells increase the overall strength of the repair.[1],[4] At the latter stage, the mesh adheres to the underlying viscera and when fibroblastic activity persists it leads to mesh contraction, erosion of the bowel and eventually fistula formation.
Technical factors affect this complication, including the type, size, shape, method of fixation and anatomic plane of placing the mesh.[3],[5] The mesh can be positioned on lay, sublay, or intraperitoneal. When placed intraperitoneal, the best way to avoid such complication is to interposition the greater omentum between the intestines and the mesh.[3],[6] In our case, the greater omentum was resected in one of the previous procedures and so it could not be placed as a protective barrier.
The period of fistula formation can range from few months to several years.[3],[7],[8] CT abdomen can help in the diagnosis of the ECF but in case of high suspicion with negative CT scan findings, fistulography can delineate the fistulous communication.[1] In our case, three CT abdomen scans failed to show the ECF and only the fistulogram secured the diagnosis.
The resection of the mesh fistula is a technically demanding, complex, and difficult surgical procedure. Any attempt to treat it conservatively is condemned to fail.[1],[7] The approach should include complete removal of the infected mesh en block with the fistulous tract. When the synthetic mesh is not removed completely, the patient has 4- or 5-fold risk to develop recurrence.[8] The involved part of the bowel should be resected with restoration of the continuity of the gastrointestinal tract. Primary closure of the abdomen vs definite repair with mesh has the drawback of high rate of hernia recurrence (12%–54%).[8] Definite repair of the hernia in the setting of the contaminated surgical field at the time of excision of the mesh fistula using a biological or as an alternative option a biosynthetic/slowly absorbable mesh is recommended.[9],[10] We followed up our case for 12 months with no hernia recurrence, but longer follow-up period is required to have conclusive results of the repair.
| Conclusions | | |
Mesh erosion of the bowel with ECF is a serious complication of hernia repair. It does not close spontaneously, and its resection is a complex and difficult procedure involving the complete removal of the mesh to decrease the rate of recurrence. Repair of the hernia with biological or biosynthetic/slowly absorbable mesh and control of the infection appears to be the optimal treatment.
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
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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