MESH REINFORCEMENT IN ANTIREFLUX SURGERY – ADVERSE EVENTS AND ENDOSCOPIC MANAGEMENT

A 86-year-old woman with a large paraesophageal hiatal hernia (PEHH) underwent laparoscopic cruroplasty with Nissen fundoplicature and placement of an expanded polytetrafluoroethylene dual mesh. She presented 24 months later with dysphagia for solids. Endoscopy revealed a stenosis at the gastroesophageal junction, submitted to a 6-month period of through-the-scope endoscopic balloon dilation. One month after last dilation, the patient presented with subacute onset of severe dysphagia. Endoscopy showed an esophageal mucosal discontinuity upstream from a stenosis, with the surgical mesh being apparent through the defect. A fully covered 80 mm long × 20 mm diameter self-expandable metal stent (Hanarostent M.I.Tech Co., Inc, Seoul, South Korea) was placed across the stricture with clinical improvement and hospital discharge two days later. The stent was removed 6 weeks later without adverse events (AEs), however, the surgical mesh was partially migrated and embedded in the esophageal lumen. A further CT excluded any other AEs. Due to worsening of dysphagia, a 4 cm-long fully covered diablo-shape stent (Hanarostent 26/16/26 mm) was placed two days later, with the patient reporting weight gain and resolution of dysphagia. Removal of the stent is not planned.

A PEHH is an uncommon type of hiatal hernia that mainly affects older adults. Laparoscopic antireflux surgery with mesh reinforcement is an effective means of preventing migration or ‘‘slipping'’ of the wrap into the chest, but it comes at a price, namely, higher temporary postoperative dysphagia and the potential for mesh migration. This case highlights the potential for morbidity from use of mesh reinforcement in hiatal hernias, as well as endoscopic management in selected patients.