Facing mishaps around the hiatus

Stylianos Tzedakis, MD1, Bernard Dallemagne1, Carter Lebares2, Didier Mutter1, Jacques Marescaux1, Silvana Perretta1. 1CHU – Nouvel Hopital Civil, Strasbourg, 2university hospital california san fransisco (UCSF)

Introduction

Laparoscopic hiatal hernia repair has a recurrence rate that can reach up to 66%. Mesh reinforcement for crural repair may reduce this risk. Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported. The use of prosthetic materials has been associated with esophageal stricture, erosion, and perforation. Contributing factors include infection, ischemia and ongoing friction between the mesh and the esophagus. The risk of erosion with synthetic mesh is reported in 2.3% of prosthetic hiatal reinforcement. Biomaterial grafts were introduced with the promise of providing a reinforced crural repair while minimizing these risks. The aim of this video is to discuss four emblematic complications related to the use of both synthetic and biological mesh hiatal reinforcement.

Methods

Case 1: A 60-year-old patient presented with severe dysphagia, chronic coughing and reflux symptoms one year after redo Nissen fundoplication with prosthetic crural repair (key-hole double-sided composite polypropylene/silicon mesh) for recurrent GERD 4 months after the first fundoplication. A third floppy Nissen fundoplication was performed with simple cruroplasty. A resorbable Vicryl mesh was used to prevent early migration. The patient is symptom-free at 8 months.

Case 2: A 70-year-old man presented with new-onset dysphagia and weight loss seven months after a Nissen-Rossetti fundoplication with hiatal hernia prosthetic mesh repair (double-sided composite polyethylene/collagen mesh). Esophago-gastro-duodenoscopy (EGD) showed mesh erosion into the esophageal wall at the gastroesophageal junction (GEJ). Decision was made to remove the mesh under endoscopy. Fluoroscopy showed a persistent small peri-esophageal cavity for which a covered self-expanding metal stent (SEMS) was delivered to seal the cavity and prevent stenosis. Five weeks later, a new SEMS was placed. At removal, there was no stricture and no residual cavity. The patient is symptom-free 1 year later.

Case 3: A 61-year-old woman presented to the emergency department for an incarcerated type III hiatal hernia. A laparoscopic partial posterior fundoplication with U-shaped collagen mesh reinforcement was performed as an emergency. A second operation was carried out electively 5 months later for severe persistent dysphagia. The mesh was partially removed to free the esophagus and enlarge the hiatus. At 5 years follow up a significant amelioration of symptomatology is observed though persisting occasional dysphagia is present.

Case 4: A 50-year-old woman presented with severe dysphagia and significant weight loss one year after open redo Nissen fundoplication with prosthetic crural repair (polypropylene mesh) for recurrent GERD and para-esophageal hernia. At re-operation, esophageal stenosis and angulation were found. The esophagus was freed from the dense fibrotic capsule surrounding the mesh allowing the enlargement of the hiatus. An esophageal myotomy was also performed. At 6 years follow up there is a significant amelioration of symptomatology although persisting occasional dysphagia is still present.

Conclusions

Mesh reinforcement biological or synthetic may reduce but not suppress the risk of recurrence in the setting of large para-esophageal hernias, and is obviously not the single factor responsible for recurrence. In addition, meshes can lead to significant complications with devastating consequences.

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