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Revista argentina de cirugía

Print version ISSN 2250-639XOn-line version ISSN 2250-639X

Rev. argent. cir. vol.112 no.3 Cap. Fed. June 2020

http://dx.doi.org/10.25132/raac.v112.n3.1440.es 

Articles

Mesh migration: a fearsome complication

Bárbara G. Lambré1  * 

Matías G. Espín1 

Leonardo PérezMonteleone1 

Federico Risté1 

Dante E. Abbate1 

1 Hospital Regional Diego Paroissien, Maipú, Mendoza, Argentina.

Herrera was the first to report mesh migration in 19761, followed by a second report by Majeski2 of a woman who underwent incisional hernia repair with wire mesh and presented bowel obstruction 30 years later.

A case of mesh migration after incisional hernia repair can be found in the literature, which resulted in an inflammatory mass with small bowel involvement and adhesion to the abdominal wall3. The diagnosis is difficult due to the variability of signs and symptoms. In most cases abdominal pain may be the single symptom, while weight loss, anorexia, bowel obstruction and palpable mass are less common4.

We report the case of a 37-year-old female patient with a history of tobacco use, BMI = 30, umbilical hernia mesh repair three years before and three c-sections who attended the emergency department due to abdominal pain in the right hypochondrium and epigastric region within the 10 past days, with guarding and without rebound tenderness, associated with fever, diarrhea and class II dyspnea.

The abnormal results of the lab tests were hematocrit 37%, hemoglobin 12, white blood cell count 20,420 with neutrophilia. Pleural effusion, predominantly in the right lung was present. The patient was hospitalized for better monitoring.

On physical examination, vesicular breath sounds were bilaterally decreased, particularly at the right lung and oxygen saturation was 85% breathing room air. The abdomen was asymmetric with a midline subumbilical scar and presented an indurated area with continuous serous discharge. On palpation, the abdomen was soft and depressible, and the right hypochondrium and epigastric region were tender without rebound tenderness.

A computed tomography (CT) scan of the abdomen and pelvis reported showed wall thickening of the terminal ileum associated with abnormal density of the pericolic fat and a trabecular and micronodular pattern and inflammatory changes. Two hypodense, fluid-containing images were also observed: a 31-mm image in the right lumbar region, in contact with the bowel loops, and a 50-mm image in the subhepatic space with air bubbles, suggestive of abscess (Fig. 1).

Figure 1 Oral contrast-enhanced computed tomography. A fluid-filled mass with air bubbles is seen in the right lumbar region involving the as cending colon and the abdominal wall 

The patient underwent diagnostic laparoscopy. Palmer’s point was used for creating pneumoperitoneum; T1 was placed through a supraumbilical incision and the abdominal cavity was explored. A large process of fibrotic adhesions was observed in the right hemiabdomen and multiple wall defects were detected in the midline; for this reason, conversion was decided. A supraumbilical midline incision was performed to approach the defects. On exploration, a mass was observed in the right lumbar region involving the colon and distal ileum (with bowel perforation) with adhesions to the abdominal wall. A right hemicolectomy with ileotransverse end-to-end anastomosis was performed. The surgical specimen was submitted for pathology examination.

On postoperative day 2, the patient was afebrile, hemodynamically stable and tolerating oral fluid intake. On palpation, the abdomen was soft and depressible, slightly tender at the site of the surgical site, with no signs of guarding or rebound tenderness and presence of bowel sounds. A small seroma spontaneously draining was observed in the surgical site.

Ten days after surgery the patient was discharged.

On follow-up visits 15 and 30 days later, the patient was in good general condition, tolerating oral intake and without surgical site complications.

Pathology report

The pathology examnation reported fibroconnective and adipose tissue with signs of granulomatous chronic inflammation due to foreign body reaction (metallic and synthetic threads), with areas of acute inflammation, abscesses, dystrophic calcification and elastolysis, with fistulas and granulomatous tissue (chronic plastron) which compromised the serosa, the ileal wall and the colon. (Fig. 2A and 2B).

Figure 2 A. Pieza enviada a anatomía patológica. Perforación en íleon termi nal. B. Pieza macroscópica donde se evidencian restos de polipropi leno en la luz intestinal 

Incisional hernias are common immediately after abdominal surgery or during late follow-up. The incidence of incisional hernia is 10-15% and recurrence rate is 20-45%1. Meshes are commonly used to minimize the recurrence of abdominal hernia repair.

Polypropylene mesh is mostly preferred because of its price and long-term outcomes besides the complications reported. The complications associated with the use of meshes are seroma-hematoma 30%, recurrence 20-45% and superficial infection (less than 2%), while other less common complications include foreign body reaction, deep infection with mesh migration and hollow viscus perforation. The incidence of these complications has not been reported in the international literature4.

In a retrospective multicenter study on 2418 patients in 2018, Mavros et al. reported that tobacco use and obesity (BMI > 30) are risk factors for mesh infection after incisional hernia repair5. Our patient had both risk factors but did not present mesh infection.

Two probable mechanisms have been described as causes of migration:

The mesh is not properly fixed and migrates through the anatomic planes, particularly along the paths of low resistance, or though properly fixed, external factors produce migration.

As a result of deep infection of the surgical site, the inflammatory reaction produced by the foreign body erodes the abdominal wall. The mesh migrates through the layers of the abdominal wall. This process is gradual and occurs through many years4. Mesh migration produces an inflammatory foreign body reaction and can cause bowel obstruction, pseudotumor, bowel perforation or chronic abdominal pain with different clinical presentations. These complications are more common with polypropylene meshes5.

The diagnosis and treatment of these type of patients are difficult due to the wide spectrum of signs and symptoms. Mesh migration should be suspected, and surgical repair is complex with high morbidity6. The complementary tests include:

▪▪Abdominal ultrasound, which has limited sensitivity and specificity.

▪▪CT scan, which provides better images but is not useful for the definite diagnosis.

▪▪Colonoscopy, which allows visualization of the eroded mesh prosthesis protruding into the intestinal lumen6. In our example, the clinical presentation (infectious diarrhea associated with pneumonia) delayed the diagnosis of acute abdomen due to an inflammatory tumor. Imaging tests and video-assisted laparoscopy were useful for the diagnosis and localization of the cause and to decide on the best approach, avoiding inadequate incisions. There are a few cases reported in the literature.

The diagnosis and treatment of these type of patients are difficult due to the wide spectrum of signs and symptoms. Mesh migration should be suspected and surgical repair is complex with high morbidity.

Referencias bibliográficas /References

1. Bostanci O. A Rare Complication of Composite Dual Mesh: Mi gration and Enterocutaneous Fistula Formation. Case Rep Surg. 2015; 2015 : Article ID 293659. [ Links ]

2. Ahmed K. Mesh migration into the colonic lumen post abdomi nal hernia repair: A Case Report. Surgical case reports. 2017; 4:1095. [ Links ]

3. Ripetti V. Mesh Infection and Migration after Umbilical Hernia Re pair. Surgical Science. 2013;4:421-5. [ Links ]

4. Sha Liu, Xin-Xin Zhou, Lin Li, Mo-Sang Yu, Hong Zhang, Wei-Xiang Zhong, Feng Ji. Mesh migration into the sigmoid colon after in guinal hernia repair presenting as a colonic polyp: A case report and review of literature . World Journal of Clinical Cases. 2018; 6:564-9. [ Links ]

5. Yilmaz I, Karakas DO, Sucullu I, Ozdemir Y, Yucel E. A rare cause of mechanical bowel obstruction: mesh migration. Hernia. 2013; 17(2):267-9. [ Links ]

6. Millas SG, Mesar T, Patel RJ. Chronic abdominal pain after ventral hernia due to mesh migration and erosion into the sigmoid colon from a distant site: a case report and review ofliterature. Hernia. 2015; l.19(5):.849-52. [ Links ]

Received: June 24, 2019; Accepted: March 16, 2020

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