- Email: [email protected]
Mesh erosion after inguinal hernia repair: a rare cause of acute lower GI bleeding (with video)
Brief Reports
REFERENCES 1. Hirahashi M, Matsumoto T, Esaki M, et al. Diminutive gastrointestinal lesions in cholesterol crystal embolization. Endoscopy 2005;37:408. 2. Ben-Horin S, Bardan E, Barshack I, et al. Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism. Am J Gastroenterol 2003;98:1471-9. 3. Imanaka K, Kyo S, Ban S. Possible close relationship between nonocclusive mesenteric ischemia and cholesterol crystal embolism after cardiovascular surgery. Eur J Cardiothorac Surg 2002;22:1032-4. 4. Miller FH, Kline MJ, Vanagunas AD. Detection of bleeding due to small bowel cholesterol emboli using helical CT examination in gastrointestinal bleeding of obscure origin. Am J Gastroenterol 1999;94:3623-5.
5. Paraf F, Jacquot C, Bloch F, et al. Cholesterol crystal embolization demonstrated on GI biopsy. Am J Gastroenterol 2001;96:3301-4.
Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan. Reprint requests: Mitsunobu Matsushita, MD, Third Department of Internal Medicine, Kansai Medical University, 2-3-1 Shinmachi, Hirakata, Osaka 5731191, Japan. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.08.052
Mesh erosion after inguinal hernia repair: a rare cause of acute lower GI bleeding (with video) Kevin A. Karls, MD, Keith D. Lillemoe, MD, John M. DeWitt, MD, FASGE Indianapolis, Indiana, USA
Prosthetic mesh has become a routine component in the tension-free surgical repair of inguinal hernias since its description by Lichtenstein and Shulman1 in 1986. Since that time, there have been multiple reports of complications attributed to the erosion of the mesh after its placement. We report a case of acute lower GI bleeding caused by erosion of mesh through the wall of the sigmoid colon in a patient with a remote history of a laparoscopic inguinal hernia repair.
CASE REPORT A 75-year-old male presented to the emergency department with 2 episodes of painless, large-volume, dark red, bloody stools over the preceding 2 days. Twelve years prior to the current presentation, he had an attempted laparoscopic bilateral inguinal hernia repair with polypropylene mesh, which included reduction of an incarcerated sigmoid colon. This surgery was complicated by colonic injury with fecal spillage and required conversion to an open procedure with sigmoid colon resection. At the patient’s last colonoscopy 2 years earlier, the endoscopist noted a “postoperative suture” in the wall of the colon around 30 cm from the anal verge. Approximately 1 year before the current presentation, the patient was hospitalized briefly because of acute-onset nausea, vomiting, and cramping abdominal pain. A CT scan performed at the time suggested a 4-cm “inflammatory mass” in the left pelvic area, adjacent to the sigmoid colon. The patient was treated with antibiotics for presumed diverticulitis and was discharged. The patient was lost to follow-up. On current presentation to our hospital emergency department, the patient was hemodynamically stable and in 1062 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 5 : 2011
no distress. His abdomen was nontender and nondistended, with normal bowel sounds. Laboratory studies revealed a hemoglobin level of 12.2 mg/dL (normal 14.018.0 mg/dL) but a normal leukocyte count, platelet count, and coagulation parameters. A CT scan without intravenous contrast material showed “postoperative changes” in the left inguinal area but no identifiable source of hematochezia (Fig. 1). After admission, the patient had no further episodes of bleeding. Colonoscopy the following day showed luminal narrowing in the sigmoid colon, along with adjacent patchy black discoloration of the mucosa. At 30 cm proximal to the anus, blackcolored mesh was noted to protrude through the ulcerated colon wall. The adjacent and surrounding mucosa was also inflamed, ulcerated, and congested (Fig. 2; Video 1, available online at www.giejournal.org). No active bleeding was seen. No attempt was made endoscopically to remove the mesh. A few small sigmoid diverticula were also seen, but they showed no evidence of bleeding. Elective resection of the sigmoid colon and mesh was performed. At laparotomy, a large, dense, inflammatory mass was found that contained the mesh, sigmoid colon, and a loop of small bowel. The entire inflammatory mass, including most of the mesh from the abdominal wall, was resected en bloc with a left colon resection and segmental small-bowel resection with primary anastomoses performed. The patient’s postoperative course was prolonged and included a pelvic abscess that required percutaneous drainage. At follow-up 4 months later, the patient had fully recovered, with normal bowel function and no evidence of recurrent inguinal hernia. www.giejournal.org
Brief Reports
Figure 1. CT scan of the abdomen and pelvis without intravenous contrast material reveals an inflammatory-appearing mass (arrows) adjacent to the sigmoid colon. Radiopaque clips within the area identify this as the prior surgical site, but no mesh is visible. No contrast material from the adjacent sigmoid colon is seen entering the area.
there was a predisposition to migration because of placement of the mesh during a surgery in which there was peritoneal compromise, fecal spillage, and resection of adjacent bowel. Symptoms from mesh migration can develop weeks to years after surgery and vary depending on both the route of migration and destination of the mesh.3 Erosion of mesh into the bowel typically presents with abdominal pain,4,5,8 an abdominal mass,5 or symptoms of obstruction7,9,10 or with episodic bleeding per rectum.4,8 To our knowledge, ours is only the third reported case of mesh erosion into the colon presenting as overt lower GI bleeding. Colonoscopy is the single most effective test for the diagnosis of erosion of mesh into the colon.4 A CT scan may detect further complications of erosion into the bowel, such as frank perforation,8 fistula,8,11,12 or abscess.8,12,13 In the absence of typical symptoms, however, the diagnosis of mesh erosion into the bowel may be missed by imaging alone.4 Although endoscopic removal has been described,2 surgical removal of mesh with resection of the involved portion of the bowel is generally recommended for symptom relief and prevention of further complications. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. REFERENCES
Figure 2. Endoscopic photograph revealing the migrated hernia mesh and surrounding ulceration.
DISCUSSION Mesh migration and erosion are rare but well-described late complications of both laparoscopic2-4 and open5-7 inguinal hernia repairs. Migration occurs by movement of unrestrained mesh along a path of least resistance into adjacent anatomic spaces (primary migration) or by foreign body reaction–induced erosion through tissue layers (secondary migration).3 Proposed etiologies for migration include inadequate fixation of the prosthetic device during initial placement, placement of a mesh plug too deeply within the inguinal canal, or intraperitoneal migration because of peritoneal damage during surgery.5,6 In this case, www.giejournal.org
1. Lichtenstein I, Shulman A. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986; 71:1-4. 2. Celik A, Kutun S, Kockar C, et al. Colonoscopic removal of inguinal hernia mesh: report of a case and literature review. J Laparoendosc Adv Surg Tech 2005;15:408-11. 3. Agrawal A, Avill R. Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 2006;10:779-82. 4. Lange B, Langer C, Markus P, et al. Mesh penetration of the sigmoid colon following a transabdominal preperitoneal hernia repair. Surg Endosc 2003;17:157. 5. Ojo P, Abenthroth A, Fiedler P, et al. Migrating mesh mimicking colonic malignancy. Am Surg 2006;72:1210-1. 6. Jeans S, Williams G, Stephenson B. Migration after open mesh plug inguinal hernioplasty: a review of the literature. Am Surg 2007;73:207-9. 7. Lo D, Billimoria K, Pugh C. Bowel complications after prolene hernia system (PHS) repair: a case report and review of the literature. Hernia 2008:12:437-40. 8. Benedetti M, Albertario S, Niebel T, et al. Intestinal perforation as a longterm complication of plug and mesh inguinal hernioplasty: case report. Hernia 2005;9:93-5. 9. Chuback J, Singh R, Sills C, et al. Small bowel obstruction resulting from mesh plug migration after open inguinal hernia repair. Surgery 2000; 127:475-6. 10. Stout C, Foret A, Christie D, et al. Small bowel volvulus caused by migrating mesh plug. Am Surg 2007;73:796-7. 11. Barreto S, Schoemaker D, Siddins M, et al. Colovesical fistula following an open preperitoneal “Kugel” mesh repair of an inguinal hernia. Hernia 2009;13:647. 12. Murphy J, Misra D, Silverglide B. Sigmoid colonic fistula secondary to Perfix-plug, left inguinal hernia repair. Hernia 2006;5:436-8.
Volume 73, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1063
Brief Reports
13. Wong R, Vargo D. Abscess from a hernia mesh presenting as a colon mass. Gastrointest Endosc 2007;66:1027-8. Division of Gastroenterology and Hepatology (K.A.K.), Department of Surgery (K.D.L.), Indiana University School of Medicine, Division of Gastroenterology and Hepatology (J.M.D.W.), Indiana University Medical Center, Indianapolis, Indiana, USA.
Reprint requests: John M. DeWitt, MD, FASGE, Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 N University Blvd, UH 4100, Indianapolis, IN 46202. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.08.057
Confocal endomicroscopic evaluation of colorectal squamous metaplasia and dysplasia in ulcerative colitis James D. Lord, MD, PhD, Melissa P. Upton, MD, Joo Ha Hwang, MD, PhD Seattle, Washington, USA
CASE REPORT A 52-year-old woman with a 20-year history of ulcerative colitis (UC) underwent surveillance colonoscopy. She had received prednisone and then started infliximab therapy 4 months before colonoscopy for diarrhea and rectal bleeding, which resolved, but arthralgias and paresthesias led to infliximab discontinuation after the third induction dose. At the time of colonoscopy, the patient was asymptomatic on mesalamine monotherapy. Colonoscopy revealed only left-sided colitis and pseudopolyps abutting the anal verge. Random biopsies revealed moderate active colitis consistent with UC in the distal 40 cm of the colon. Rectal biopsy specimens 10 cm from the anus incidentally also contained areas of squamous epithelium with at least intermediate-grade squamous intraepithelial neoplasia. Biopsies of the distal rectum revealed inflammatory pseudopolyps as well as squamous epithelium with high-grade squamous intraepithelial neoplasia.
The patient was brought back for sigmoidoscopy. White-light evaluation revealed only subtle changes at 10 cm from the anal verge (Fig. 1A), but narrow-band imaging revealed 2 distinct fields of mucosa lining the rectum (Fig. 1B). Magnification endoscopy revealed a clear line demarcating 2 fields (Fig. 2A). Probe-based confocal laser endomicroscopy (pCLE) revealed the mucosa on the left of Figure 2A to be squamous epithelium (Fig. 2B), confirmed by histology (Fig. 2C). Further examination of this mucosa with pCLE revealed foci suspicious for dysplasia (Fig. 2D) because of the irregular cellular architecture, lack of uniformity in cell size, and increased density of cell nuclei leading to a dark appearance on pCLE imaging. The presence of squamous dysplasia was confirmed histologically with targeted biopsies (Fig. 2E). Curiously, the areas with the greatest mucosal irregularity by gross inspection did not contain dysplasia. Dysplasia extended all the way to the anal verge; therefore, the patient underwent total proctocolectomy with an end-ileostomy. Her resected specimen confirmed squamous metaplasia in the rectum,
Figure 1. White-light versus narrow-band imaging of colonic squamous metaplasia. A proximal rectal field of squamous metaplasia in the upper left quadrant of images is only subtly evident by conventional white-light endoscopy (A) but stands out as a pale field with speckled vascular markings on narrow-band imaging (B).
1064 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 5 : 2011
www.giejournal.org
REFERENCES 1. Hirahashi M, Matsumoto T, Esaki M, et al. Diminutive gastrointestinal lesions in cholesterol crystal embolization. Endoscopy 2005;37:408. 2. Ben-Horin S, Bardan E, Barshack I, et al. Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism. Am J Gastroenterol 2003;98:1471-9. 3. Imanaka K, Kyo S, Ban S. Possible close relationship between nonocclusive mesenteric ischemia and cholesterol crystal embolism after cardiovascular surgery. Eur J Cardiothorac Surg 2002;22:1032-4. 4. Miller FH, Kline MJ, Vanagunas AD. Detection of bleeding due to small bowel cholesterol emboli using helical CT examination in gastrointestinal bleeding of obscure origin. Am J Gastroenterol 1999;94:3623-5.
5. Paraf F, Jacquot C, Bloch F, et al. Cholesterol crystal embolization demonstrated on GI biopsy. Am J Gastroenterol 2001;96:3301-4.
Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan. Reprint requests: Mitsunobu Matsushita, MD, Third Department of Internal Medicine, Kansai Medical University, 2-3-1 Shinmachi, Hirakata, Osaka 5731191, Japan. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.08.052
Mesh erosion after inguinal hernia repair: a rare cause of acute lower GI bleeding (with video) Kevin A. Karls, MD, Keith D. Lillemoe, MD, John M. DeWitt, MD, FASGE Indianapolis, Indiana, USA
Prosthetic mesh has become a routine component in the tension-free surgical repair of inguinal hernias since its description by Lichtenstein and Shulman1 in 1986. Since that time, there have been multiple reports of complications attributed to the erosion of the mesh after its placement. We report a case of acute lower GI bleeding caused by erosion of mesh through the wall of the sigmoid colon in a patient with a remote history of a laparoscopic inguinal hernia repair.
CASE REPORT A 75-year-old male presented to the emergency department with 2 episodes of painless, large-volume, dark red, bloody stools over the preceding 2 days. Twelve years prior to the current presentation, he had an attempted laparoscopic bilateral inguinal hernia repair with polypropylene mesh, which included reduction of an incarcerated sigmoid colon. This surgery was complicated by colonic injury with fecal spillage and required conversion to an open procedure with sigmoid colon resection. At the patient’s last colonoscopy 2 years earlier, the endoscopist noted a “postoperative suture” in the wall of the colon around 30 cm from the anal verge. Approximately 1 year before the current presentation, the patient was hospitalized briefly because of acute-onset nausea, vomiting, and cramping abdominal pain. A CT scan performed at the time suggested a 4-cm “inflammatory mass” in the left pelvic area, adjacent to the sigmoid colon. The patient was treated with antibiotics for presumed diverticulitis and was discharged. The patient was lost to follow-up. On current presentation to our hospital emergency department, the patient was hemodynamically stable and in 1062 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 5 : 2011
no distress. His abdomen was nontender and nondistended, with normal bowel sounds. Laboratory studies revealed a hemoglobin level of 12.2 mg/dL (normal 14.018.0 mg/dL) but a normal leukocyte count, platelet count, and coagulation parameters. A CT scan without intravenous contrast material showed “postoperative changes” in the left inguinal area but no identifiable source of hematochezia (Fig. 1). After admission, the patient had no further episodes of bleeding. Colonoscopy the following day showed luminal narrowing in the sigmoid colon, along with adjacent patchy black discoloration of the mucosa. At 30 cm proximal to the anus, blackcolored mesh was noted to protrude through the ulcerated colon wall. The adjacent and surrounding mucosa was also inflamed, ulcerated, and congested (Fig. 2; Video 1, available online at www.giejournal.org). No active bleeding was seen. No attempt was made endoscopically to remove the mesh. A few small sigmoid diverticula were also seen, but they showed no evidence of bleeding. Elective resection of the sigmoid colon and mesh was performed. At laparotomy, a large, dense, inflammatory mass was found that contained the mesh, sigmoid colon, and a loop of small bowel. The entire inflammatory mass, including most of the mesh from the abdominal wall, was resected en bloc with a left colon resection and segmental small-bowel resection with primary anastomoses performed. The patient’s postoperative course was prolonged and included a pelvic abscess that required percutaneous drainage. At follow-up 4 months later, the patient had fully recovered, with normal bowel function and no evidence of recurrent inguinal hernia. www.giejournal.org
Brief Reports
Figure 1. CT scan of the abdomen and pelvis without intravenous contrast material reveals an inflammatory-appearing mass (arrows) adjacent to the sigmoid colon. Radiopaque clips within the area identify this as the prior surgical site, but no mesh is visible. No contrast material from the adjacent sigmoid colon is seen entering the area.
there was a predisposition to migration because of placement of the mesh during a surgery in which there was peritoneal compromise, fecal spillage, and resection of adjacent bowel. Symptoms from mesh migration can develop weeks to years after surgery and vary depending on both the route of migration and destination of the mesh.3 Erosion of mesh into the bowel typically presents with abdominal pain,4,5,8 an abdominal mass,5 or symptoms of obstruction7,9,10 or with episodic bleeding per rectum.4,8 To our knowledge, ours is only the third reported case of mesh erosion into the colon presenting as overt lower GI bleeding. Colonoscopy is the single most effective test for the diagnosis of erosion of mesh into the colon.4 A CT scan may detect further complications of erosion into the bowel, such as frank perforation,8 fistula,8,11,12 or abscess.8,12,13 In the absence of typical symptoms, however, the diagnosis of mesh erosion into the bowel may be missed by imaging alone.4 Although endoscopic removal has been described,2 surgical removal of mesh with resection of the involved portion of the bowel is generally recommended for symptom relief and prevention of further complications. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. REFERENCES
Figure 2. Endoscopic photograph revealing the migrated hernia mesh and surrounding ulceration.
DISCUSSION Mesh migration and erosion are rare but well-described late complications of both laparoscopic2-4 and open5-7 inguinal hernia repairs. Migration occurs by movement of unrestrained mesh along a path of least resistance into adjacent anatomic spaces (primary migration) or by foreign body reaction–induced erosion through tissue layers (secondary migration).3 Proposed etiologies for migration include inadequate fixation of the prosthetic device during initial placement, placement of a mesh plug too deeply within the inguinal canal, or intraperitoneal migration because of peritoneal damage during surgery.5,6 In this case, www.giejournal.org
1. Lichtenstein I, Shulman A. Ambulatory outpatient hernia surgery, including a new concept, introducing tension-free repair. Int Surg 1986; 71:1-4. 2. Celik A, Kutun S, Kockar C, et al. Colonoscopic removal of inguinal hernia mesh: report of a case and literature review. J Laparoendosc Adv Surg Tech 2005;15:408-11. 3. Agrawal A, Avill R. Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 2006;10:779-82. 4. Lange B, Langer C, Markus P, et al. Mesh penetration of the sigmoid colon following a transabdominal preperitoneal hernia repair. Surg Endosc 2003;17:157. 5. Ojo P, Abenthroth A, Fiedler P, et al. Migrating mesh mimicking colonic malignancy. Am Surg 2006;72:1210-1. 6. Jeans S, Williams G, Stephenson B. Migration after open mesh plug inguinal hernioplasty: a review of the literature. Am Surg 2007;73:207-9. 7. Lo D, Billimoria K, Pugh C. Bowel complications after prolene hernia system (PHS) repair: a case report and review of the literature. Hernia 2008:12:437-40. 8. Benedetti M, Albertario S, Niebel T, et al. Intestinal perforation as a longterm complication of plug and mesh inguinal hernioplasty: case report. Hernia 2005;9:93-5. 9. Chuback J, Singh R, Sills C, et al. Small bowel obstruction resulting from mesh plug migration after open inguinal hernia repair. Surgery 2000; 127:475-6. 10. Stout C, Foret A, Christie D, et al. Small bowel volvulus caused by migrating mesh plug. Am Surg 2007;73:796-7. 11. Barreto S, Schoemaker D, Siddins M, et al. Colovesical fistula following an open preperitoneal “Kugel” mesh repair of an inguinal hernia. Hernia 2009;13:647. 12. Murphy J, Misra D, Silverglide B. Sigmoid colonic fistula secondary to Perfix-plug, left inguinal hernia repair. Hernia 2006;5:436-8.
Volume 73, No. 5 : 2011 GASTROINTESTINAL ENDOSCOPY 1063
Brief Reports
13. Wong R, Vargo D. Abscess from a hernia mesh presenting as a colon mass. Gastrointest Endosc 2007;66:1027-8. Division of Gastroenterology and Hepatology (K.A.K.), Department of Surgery (K.D.L.), Indiana University School of Medicine, Division of Gastroenterology and Hepatology (J.M.D.W.), Indiana University Medical Center, Indianapolis, Indiana, USA.
Reprint requests: John M. DeWitt, MD, FASGE, Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 N University Blvd, UH 4100, Indianapolis, IN 46202. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.08.057
Confocal endomicroscopic evaluation of colorectal squamous metaplasia and dysplasia in ulcerative colitis James D. Lord, MD, PhD, Melissa P. Upton, MD, Joo Ha Hwang, MD, PhD Seattle, Washington, USA
CASE REPORT A 52-year-old woman with a 20-year history of ulcerative colitis (UC) underwent surveillance colonoscopy. She had received prednisone and then started infliximab therapy 4 months before colonoscopy for diarrhea and rectal bleeding, which resolved, but arthralgias and paresthesias led to infliximab discontinuation after the third induction dose. At the time of colonoscopy, the patient was asymptomatic on mesalamine monotherapy. Colonoscopy revealed only left-sided colitis and pseudopolyps abutting the anal verge. Random biopsies revealed moderate active colitis consistent with UC in the distal 40 cm of the colon. Rectal biopsy specimens 10 cm from the anus incidentally also contained areas of squamous epithelium with at least intermediate-grade squamous intraepithelial neoplasia. Biopsies of the distal rectum revealed inflammatory pseudopolyps as well as squamous epithelium with high-grade squamous intraepithelial neoplasia.
The patient was brought back for sigmoidoscopy. White-light evaluation revealed only subtle changes at 10 cm from the anal verge (Fig. 1A), but narrow-band imaging revealed 2 distinct fields of mucosa lining the rectum (Fig. 1B). Magnification endoscopy revealed a clear line demarcating 2 fields (Fig. 2A). Probe-based confocal laser endomicroscopy (pCLE) revealed the mucosa on the left of Figure 2A to be squamous epithelium (Fig. 2B), confirmed by histology (Fig. 2C). Further examination of this mucosa with pCLE revealed foci suspicious for dysplasia (Fig. 2D) because of the irregular cellular architecture, lack of uniformity in cell size, and increased density of cell nuclei leading to a dark appearance on pCLE imaging. The presence of squamous dysplasia was confirmed histologically with targeted biopsies (Fig. 2E). Curiously, the areas with the greatest mucosal irregularity by gross inspection did not contain dysplasia. Dysplasia extended all the way to the anal verge; therefore, the patient underwent total proctocolectomy with an end-ileostomy. Her resected specimen confirmed squamous metaplasia in the rectum,
Figure 1. White-light versus narrow-band imaging of colonic squamous metaplasia. A proximal rectal field of squamous metaplasia in the upper left quadrant of images is only subtly evident by conventional white-light endoscopy (A) but stands out as a pale field with speckled vascular markings on narrow-band imaging (B).
1064 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 5 : 2011
www.giejournal.org