Blanco, Paola, MD

Shah, Shashin, MD

Sullivan, Matthew J, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineNone Shall Pass: Migrated Surgical Mesh CausingGastric Outlet Obstruction with EndoscopicExtractionMatthew J. Sullivan DOLehigh Valley Health Network, Matthew.Sullivan@lvhn.orgShashin Shah MDLehigh Valley Health Network, Shashin.Shah@lvhn.orgPaola Blanco MDLehigh Valley Health Network, Paola_G.Blanco@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/medicinePart of the Gastroenterology CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtSullivan, M. J., Shah, S. Blanco, P. (2018, October 8-9). None Shall Pass: Migrated Surgical Mesh Causing Gastric Outlet Obstruction withEndoscopic Extraction. Poster Presented at: The (ACG) American College of Gastroenterology National Scientific Meeting,Philadelphia, PA.LVHN.org© 2018 Lehigh Valley Health NetworkBACKGROUND•  Paraesophageal hiatal hernias account for 5-10% of all hiatal hernias and are more common in elderly patients1•  Laparoscopic Nissen fundoplication, with or without mesh, is a mainstay of surgical management2•  Complications from surgical mesh include erosion, stenosis, and dense fibrosis3•  Surgical mesh migration is an uncommon and unpredictable complication which is rarely reported in the literature4•  Clinical presentation is variable and based on the involved organ, but can be complicated by bleeding, fistula formation, or abscess4None Shall Pass: Migrated Surgical Mesh Causing  Gastric Outlet Obstruction with Endoscopic Extraction Matthew J. Sullivan, DO, Shashin Shah, MD, and Paola Blanco, MDDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Lehigh Valley Health Network, Allentown, Pa.REFERENCES1  Sathasivam R, Bussa G, Viswanath Y, et al. “Mesh hiatal hernioplasty’ versus ‘suture cruroplasty’ in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis. Asian Journal of Surgery (2018), https://doi.org/10.1016/j.asjsur.2018.05.0012  Berg B, Cobb R, Panzer K, et al. Complete gastric transmural migration of a prosthetic hiatal hernia. Appl Radiol 2018; 47(1): 40-42.3  Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23(6): 1219-1226.4  Gandhi D, Marcin S, Xin Z, et al. Chronic abdominal pain secondary to mesh erosion into cecum following incisional hernia repair: a case report and literature review. Ann Gastroenterol 2011; 24(4): 321-324.CASE PRESENTATION•  A 77-year-old female presented to an outside hospital with nausea, vomiting, and a 10 pound weight loss•  She underwent Nissen fundoplication with mesh reinforcement three years prior•  An EGD at the outside hospital demonstrated a foreign body in the stomach; due to its size she was referred back to General Surgery and a CT scan was ordered (Figure 1)•  A repeat EGD was performed demon-strating a large mobile foreign body which appeared to be surgical mesh with  multiple metallic rivets (Figures 2-5)•  The foreign body was too large to be extracted through the fundoplication  using a standard upper endoscope despite attempts using various tools  and an advanced endoscopist was  called into the room•  Using a double channel therapeutic upper endoscope, nets were passed through both channels and the foreign body was able to be completely encompassed and gradually compressed to a diameter which allowed for successful extraction through the mouthDISCUSSION•  Surgical mesh migration is an uncommon complication of hernia repair with transmural migration being exceedingly rare4, with only approximately 10 cases reported in the literature as of January 20182•  There are reports in the literature of mesh migration from various surgeries into the colon, small bowel, stomach, urinary bladder, and scrotum4•  Repeat surgery is often required for extraction of the mesh and repair of complications2•  Transmural migration can allow for endoscopic removal2 and avoidance of repeat surgery•  Mesh migration should be considered in atypical pre-sentations of abdominal pain in patients with a history of hernia repair with mesh, especially as complications from surgical mesh tend to occur years after surgery4Figure 1. CT of abdomen and pelvis demonstrating a thin radiopaque object with multiple ring foci of metallic density within the distal stomach.Figure 2. Surgical mesh in the gastric antrum. Figure 3. Surgical mesh with metallic rivets freely mobile within the gastric lumen.Figure 4. Retroflexed view of freely mobile surgical mesh within the gastric lumen.Figure 5. Close-up view of the sharp edge of one of the metallic rivets.

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

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

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