J. Coloproctol. (Rio J.) vol.37 número2

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jcoloproctol(rioj).2017;37(2):144–146

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Colovesical

fistula

secondary

to

hernia

mesh

migration:

an

unusual

incident

Sabarinathan

Ramanathan

∗

_,

_{Veeraraghavan}

_{Krishnamoorthy,}

_Kini

_Ratnakar,

Pugazhendhi

Thangavel,

Raju

Sundarraj

RajivGandhiGovernmentGeneralHospital,MadrasMedicalCollege,Chennai,India

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Articlehistory:

Received16September2016 Accepted16October2016 Availableonline4February2017

Keywords:

Colovesicalfistula Inguinalherniarepair Meshmigration Poliomyelitis

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b

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Weevaluateda27-yearoldmalewithpneumaturiaandfecaluriawithapasthistoryofright inguinalherniarepair.Though,cystoscopyandcontrastenhancedcomputedtomography didnotfurnishanyevidencetoarriveatadiagnosis,interestingly,colonoscopyrevealeda meshinthesigmoidcolonmakingapparentthediagnosisofcolovesicalfistulasecondary tomeshmigration.Later,surgicalremovalofthemeshfromthesigmoidcolonwithrent closureofthefistulousopeningwasdonesuccessfully.Ourcasethus,highlightsthevital roleofcommondiagnostictoollikecolonoscopyinmakinganuncommondiagnosis.

Fístula

colovesical

secundária

à

migrac¸ão

da

malha

para

reparo

de

hérnia:

um

incidente

incomum

Palavras-chave:

Fístulacolovesical Reparodehérniainguinal Migrac¸ãoderede Poliomielite

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s

u

m

o

Avaliamosum homem de27 anos compneumaturia e fecalúriacom antecedentesde reparodahérniainguinaldireita.Emboraacistoscopiaeatomografiacomputadorizada comcontraste(TCC)nãotenhamfornecidonenhumaevidênciaparaobter-seum diagnós-tico,curiosamente,acolonoscopiarevelouumamalhanocólonsigmoide,estabelecendoo diagnósticodefístulacolovesical(FCV)secundáriaàmigrac¸ãodamalha.Maistarde,foifeita aremoc¸ãocirúrgicadamalhadocólonsigmoidecomfechamentodaaberturafistulosacom sucesso.Nossocaso,portanto,destacaopapelvitaldeumaferramentadiagnósticacomum, comoacolonoscopia,paraobter-seumdiagnósticoincomum.

∗ _{Corresponding}_author_.

E-mail:sabari98@yahoo.co.in(S.Ramanathan).

http://dx.doi.org/10.1016/j.jcol.2016.10.002

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145 Introduction

Enterovesical fistula is the existence of abnormal tract betweenthe bowelandthe bladder,withcolovesicalfistula (CVF)asits mostcommon type.Diverticulitisisdeemedas thecommonestetiologyaccountingforabout65–79%.1 _CVF

subsequenttomeshmigrationisanunusualincident,andis rarelyreportedinliterature.WereportacaseofCVFsecondary tomeshmigration,followinginguinalherniarepair.

Case

report

A27-year-oldgentlemanpresentedwitha15dayshistoryof fecaluria and pneumaturiawith anincreasedfrequency of about20timesadaywithoutdiurnalvariation.Healso pre-sentedwithayearhistoryofrecurrentepisodesoffeverwith chills,dysuria,suprapubicpainandtenesmus.Herevealeda pasthistoryofright-sidedpostpoliomyelitisresidual paral-ysis.Abdominalexaminationrevealedtendernessintheleft iliacfossaanddigitalrectalexaminationshowedminimal ten-dernesswithnoothersignificantfindings.Hemoglobinwas 8.6g%suggestiveofanemia,whiletotalleukocytecountand plateletcountwerenormalwith9200cells/c.mmand1.47lakh cells/c.mmrespectively,whereas urinemicroscopyrevealed plenty ofpus cells with its culturegrowing Escherichia coli. Allotherlaboratoryinvestigationswerenormal.Ultrasound abdomen showed debris in the bladder while cystoscopy demonstrated ared glowwith debris inaddition toa bul-lousedemaobservedat7′_o_clock_position._Contrast_enhanced

computedtomography(CECT)scanalsofailedtorevealany phenomenalfinding.Interestingly,colonoscopyvisualized a meshinthesigmoidcolonobscuringthelumen,thus preven-tingthescopetobepassedbeyondthatlevel(Fig.1).Anormal mucosalandvascularpatternwasseenuptothatlevel.On furtherprobingweelicitedthepasthistoryofhaving under-gone alaparoscopicright inguinalhernioplasty using inlay polypropylenemeshsevenyearsback,whichusheredusclose totheplausiblediagnosisofmeshmigration.

Fig.1–Colonoscopicpictureshowingmeshinthesigmoid

colon.

Fig.2–Themesherodingintothesigmoidcolonand

bladder.

Therefore,anexploratorylaparotomywasplanned.Under general anesthesia, a lower midline incision was made, whereintheintra-operativefindingsrevealedtheadherence ofsigmoidloopandleftanterolateralwallofbladderwiththat oftheparietalwallatleftinguinalregion.Subsequently, sig-moid colonwasmobilizedwithutmostcareandopenedin theanti-mesentricborder,transpiredapolypropylenemeshof 11×7cmwiththreetackersprotrudingintothelumenwhile

theotherendofthemeshfounderodingtheleftanterolateral wallofbladder(Figs.2and3).Shortly,theedgesofthefistulous openingonthebladderweretrimmedwithrentclosuredone

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146

Fig.4–Post-oppictureshowingrentclosureofthefistulous

opening.

intwolayerswith28Frmalecotcatheter(Fig.4).Post-operative periodwasuneventful.

Discussion

Laparoscopicinguinalherniarepairusingmeshisknownto reducetherecurrenceofherniabyabout30–50%in compar-ison toopen hernia repair.2 _Long _term _{complications}_that

frequently evinced withthe use ofmeshfor hernia repair arerecurrenceandpain.3_Agrawal_and_Avill4_have_inscribed

twoprobablemechanismsofmeshmigrationleadingtoCVF; theeventualityofmeshdisplacementalonganalleyoflow resistance being a consequence of inadequate fixation or anyexternaldisplacingforces.Yetanotherprobable explana-tionissecondarymigrationwhichoccursinsidiouslypastthe anatomicplanesduetoforeignbodyreactionmediated ero-sion,basedonthenatureofthemeshbiomaterialusedand thetypeoffixationofthemesh.

Poliomyelitisexplicitlyreducesthemuscletonepotentially contributingtoplausibleoccurrenceofherniainthispatient.5

Thusthethirdpossiblemechanismwhichcanbeascribedin thisparticularcaseisweaknessofbladderandcolonicwall musclesleadingtomeshmigrationandCVF.

CVFisesteemedasanunusualincident,withonlythree casesbeingreportedinliteraturetilldate,ofwhichtwocases presentedasasequeloflaparoscopicherniarepairandone subsequenttokugelmeshrepair. Soourreportisthethird caseofCVFfollowinglaparoscopicherniarepair.

Conclusion

CVFasaconsequenceofmeshrepair,thoughaveryrare pre-sentation,canbeeasilybediagnosedinsymptomaticpatients presentingyearsafterherniarepairifthereisahighindexof suspicion.Thisisthefirstcaseofmeshmigrationintosigmoid colonbeingdiagnosedbycolonoscopy,indicatingthe cardi-nalroleofcolonoscopywhentheimagingmodalitiesfailin suspectedcaseofmeshmigrationintobowel.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.McCormackK,ScottNW,GoPM,RossS,GrantAM,EUHernia TrialistsCollaboration.Laparoscopictechniquesversusopen techniquesforinguinalherniarepair.CochraneDatabaseSyst Rev.2003:CD001785.

3.MuschallaF,SchwarzJ,BittnerR.Effectivityoflaparoscopic inguinalherniarepair(TAPP)indailyclinicalpractice:early andlong-termresult.SurgEndosc.2016;30:4985–94.

4.AgrawalA,AvillR.Meshmigrationfollowingrepairofinguinal hernia:acasereportandreviewofliterature.Hernia.

2006;10:79–82.