What are the risks of suturing a mesh to the Esophageal Outlet Area (EOA)?

Risks of Suturing Mesh to the Esophageal Outlet Area (EOA)

Suturing mesh to the esophageal outlet area carries significant risk of mesh erosion into the esophagus, which can lead to serious complications including dysphagia, pain, bleeding, and potentially require complex surgical interventions including esophagectomy.

Mesh-Related Complications at the EOA

Risk of Erosion

• Mesh erosion into the esophagus is a severe complication that occurs when mesh material directly contacts and gradually erodes through the esophageal wall 1
• The esophagus is the most common site of erosion (50% of cases), followed by the stomach (25%) and gastroesophageal junction (23%) 1
• Erosion can occur with various mesh types, including polypropylene and polytetrafluoroethylene (PTFE) 1, 2

Timeline and Presentation

• 79% of erosions occur within 2 years after mesh placement, but the latent period can vary significantly 1
• Patients with mesh erosion typically present with:
  • Dysphagia (most common symptom)
  • Chest pain
  • Heartburn
  • Weight loss
  • Fever (in cases of infection) 2

Severity of Complications

• Management of mesh erosion may require:
  • Endoscopic mesh retrieval (15.7% of cases)
  • Laparoscopic mesh removal (11.8%)
  • Open surgical mesh removal (19.6%)
  • Distal esophageal resection (19.6%)
  • Gastric resection (5.9%) 1
• Some patients require tube feeding for nutrition after complications 2

Guidelines for Mesh Use Near the Esophagus

Recommendations for Diaphragmatic Hernia Repair

• In clean-contaminated and contaminated diaphragmatic hernia repair, biologic or biosynthetic meshes can be considered safer than synthetic options 3
• When mesh is used, it should overlap the defect edge by 1.5-2.5 cm 3
• Tackers should be avoided in proximity to vital structures like the pericardium 3

Considerations for Hiatal Hernia

• The true incidence of mesh erosion after hiatal hernia repair may be higher than previously reported 1
• Mesh erosion risk appears higher in recurrent hiatal hernia repair 1
• Mesh should be used very selectively for hiatal hernia repair due to potential complications 1

Perforation Risk and Management

Risk of Perforation

• Perforation is a serious complication of procedures involving the esophageal area 3
• Perforation should be suspected when patients develop pain, breathlessness, fever, or tachycardia 3
• Transient chest pain is common after esophageal procedures, but persistent pain warrants immediate investigation 3

Management of Perforation

• Iatrogenic perforation is a medical emergency requiring assessment by experienced physicians and surgeons 3
• Patients with perforations who are hemodynamically unstable or have peritoneal signs should be surgically managed without attempting endoscopic closure 3
• Chest x-ray may show pneumomediastinum, pneumothorax, air under the diaphragm, or pleural effusion, but normal appearances do not exclude perforation 3

Alternative Approaches

Safer Mesh Techniques

• If mesh must be used, consider:
  • Using biologic or biosynthetic meshes in contaminated fields 3
  • Ensuring adequate distance between mesh and the esophagus
  • Using fixation techniques that avoid direct contact with the esophageal wall

Non-Mesh Options

• Primary repair with non-absorbable sutures should always be attempted when possible 3
• Component separation techniques can be considered for definitive closure of abdominal defects 3

Conclusion

Suturing mesh directly to the esophageal outlet area poses significant risks of erosion and serious complications. When mesh is required near the esophagus, extreme caution should be exercised with proper patient selection, appropriate mesh type, and careful fixation techniques that avoid direct contact with the esophageal wall. Patients should be informed about the potential for erosion and related complications when mesh is placed in this area.