Grant O Lee, MD, Hui Sen Chong, MD. Department of Surgery, University of Iowa Hospitals and Clinics.
Background: Hiatal hernia repairs are known to have a high recurrence rate, with opinions divided between the use of mesh and type of mesh for crural reinforcement during a repair. Recent data suggest that mesh reinforcement is associated with a lower recurrence rate in a six month follow up period without a significant difference in recurrence rate at the five year mark when compared to patients without mesh reinforcement. Although there is a trend towards a lower recurrence rate with mesh reinforcement, many are weary of the possible complications associated with it. This is especially true for usage of permanent at the hiatal region. We report a case of a patient who underwent open hiatal hernia repair with permanent mesh reinforcement, who subsequently developed severe stenosis at the distal esophagus requiring surgical intervention.
Method: The patient is a 69 year-old woman who underwent open paraesophageal hernia repair with usage of a Crurasoft mesh at the hiatal region. Since her surgery in 2009, she has had chronic dysphagia requiring at least 19 esophageal dilatation at the level of the hiatus. Two years later, she was referred to our institution for continued dysphagia and a 30lb weight loss. The Crurasoft mesh is a polytetrafluoroethylene (PTFE) mesh that includes two limbs on either side designed as a cradle to protect the esophagus. It is also claimed to encourage tissue ingrowth into the mesh. Repeated upper endoscopy, computed tomography, and upper gastrointestinal contrast studies revealed that the mesh was the cause of constriction around the gastroesophageal (GE) junction. The patient was therefore brought for laparoscopic removal of the Crurasoft mesh. This was performed using four laparoscopic ports. Adhesiolysis was initiated along both right and left to the stomach, identifying the right and left diaphragmatic crura. Fibrous scar tissue around the GE junction was sharply dissected and allowed identification of the limbs of the PTFE mesh. This circumferential mesh had its right and left limbs sutured to each other along the anterior portion of the GE junction. These were released. As the posterior portion of the mesh could not be safely dissected off the GE junction, a decision was made to cut off 90% of the mesh while leaving the posterior portion in place. Upon completion, intraoperative esophagogastroscopy was performed showing no trasmural esophageal injury and a negative leak test. The Nissen fundoplication was left in place as the patient did not have a recurrence of her hiatal hernia or a slipped Nissen. A JP drain was left next to the hiatal dissection.
Result: The patient had an uneventful postoperative recovery. An upper GI was performed on POD1 showing no leak, the JP drain was removed and the patient and discharged POD2. At her two weeks follow-up visit,she was tolerating a general diet without dysphagia and only reported mild GERD symptoms that were well-controlled with oral proton pump inhibitor.