Radiological Case: Complete Gastric Transmural Migration of a Prosthetic Hiatal Hernia

Brian Berg; Ryan Cobb, MD; Kyle Panzer; Benjamin Powers, MD; Sonia Gupta, MD; Tejas Patel, MD

Disclosures

Appl Radiol. 2018;47(1) 

In This Article

Case Summary

A 54-year-old female presented to the general surgery outpatient office with acutely worsening "aching and burning" chronic abdominal pain. She had an extensive past medical and surgical history pertinent for chronic abdominal pain, gastroesophageal reflux disease (GERD), hiatal hernia, ventral incisional hernia status post Nissen fundoplication, and two revision fundoplication procedures with hiatal hernia repair with prosthetic mesh. Workup included a computed tomography (CT) exam of the abdomen and pelvis without intravenous contrast, which revealed erosion of the mesh through the gastric fundus (Figure 1). An EGD was scheduled for attempted endoscopic mesh removal, however, during the EGD, the protruding mesh could not be retrieved. Post-procedural CT of the abdomen and pelvis with IV contrast was performed to exclude hemorrhage, and this CT revealed mesh protrusion into the distended gastric lumen (Figure 2). General surgery was then consulted. The patient was scheduled for nonemergent surgical resection of the mesh. In the interim, the patient developed gastric outlet obstruction symptoms, and had to be taken urgently to the operating room. Intraoperative EGD prior to skin incision revealed complete transmural migration of the mesh through the gastric wall. The mesh was impacted in the pylorus and easily retrieved endoscopically (Figure 3). Endoscopic evaluation of the gastric lumen revealed no evidence of perforation. Follow-up chest radiograph and fluoroscopic upper gastrointestinal series confirmed that the gastric wall was intact. The patient was discharged.

Figure 1.

Initial CT of the abdomen and pelvis without IV contrast showed diffuse inflammation at the level of the hiatal hernia repair with mesh. The prosthetic mesh is noted to be eroding through the gastric wall and partially protruding within the gastric lumen surrounded by gastric contents. No extraluminal air or fluid collection is present to suggest perforation or leakage of gastric contents into the peritoneum.

Figure 2.

(A, B) CT of the abdomen and pelvis with IV contrast after the initial EGD demonstrates protrusion of the hiatal hernia mesh into the gastric lumen. The post-procedural air, acting as negative enteric contrast, delineates the true intraluminal nature of the mesh. In addition, there is soft tissue inflammation involving the gastric fundus, gastrosplenic ligament, and gastrohepatic ligament. No evidence of extraluminal air or fluid collection to suggest perforation and/or spillage of gastric contents. (C) A three-dimensional reconstruction of the gastric lumen with field-of-view projecting towards the gastroesophageal junction exhibits intraluminal mesh with preservation of the lower esophageal sphincter.

Figure 3.

Intraoperative EGD images provided by the surgical team display the transmural progression of the entire mesh, which is lodged in the pylorus.

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