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

Discussion

Gastroesophageal Reflux Disease (GERD) is a common disease, affecting 18.1% to 27.8% of the population in the United States.[1] More than 90% of patients with GERD have a hiatal hernia on radiologic imaging.[2] While medical management remains a popular treatment choice, surgery has been found to be an effective alternative to medical therapy.[3] Indications for surgical repair of a hiatal hernia include failing medical management, opting for surgery despite successful medical management, complications of GERD such as Barrett's esophagus, or having extra-esophageal manifestations.[4] A laparoscopic Nissen fundoplication, without or with mesh, is one of the mainstays of surgical management for hiatal hernia. Common complications include esophageal perforations, fibrosis, stenosis at the gastroesophageal junction, visceral erosion, and erosion of the mesh.[5] Transluminal migration of the mesh into the gastric lumen is a rare complication, with approximately 10 cases found during our literature search. These patients with transluminal migration often present with dysphagia as their primary complaint, with chest pain and heart burn being the next most common symptoms.[5] Removal of the intraluminal mesh with esophagogastroduodenoscopy (EGD) has been performed; however, several patients have required gastrectomy, esophagectomy, and/or open surgery to reverse the repair.

This study highlights the possibility of complete transmural migration of mesh after multiple hiatal hernia repairs. Erosion of foreign objects placed around the hiatus has been a known complication for many decades. When the Angelchik prosthesis was first implemented over 30 years ago, gastric erosion was estimated to have occurred in 0.15 percent of procedures.[6] After examining how often erosion of mesh occurs, one particular prospective trial found the incidence to be 0.49 percent. Transmural migration has rarely been cited in the literature; thus, there is no known incidence. Our report seems to be the first case report looking at transluminal migration of a mesh resulting in a gastric outlet obstruction.

In reviewing the literature, three main types of repair mesh were used: biological, polytetrafluoroethylene, and polypropylene. Previous case series have shown erosion occurring with all three types.[7] In studies showing transluminal migration, only polytetrafluoroethylene, polypropylene, and teflon have been reported. Unfortunately for our case report, the type of prosthetic mesh used is unknown.

For patients with erosion of mesh, a surgical procedure was often required to remove the mesh. These procedures included mesh resection, esophagectomy, gastrectomy, or laparotomy for mesh resection.[8] These procedures all have significant morbidity associated with them. For the case reports of transluminal migration, most could be removed by EGD, with one case requiring surgical intervention to remove the mesh off the gastric wall without perforation.[9] Whether the mesh could have fully migrated into the gastric lumen and not required surgery is uncertain.

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