Laparoscopic repair of hiatal hernia after minimally invasive esophagectomy

Strangulated Bowel Obstruction Due to Hiatal Hernia After Laparoscopic Total Gastrectomy

Laparoscopic total gastrectomy results in more internal hernias than open surgery. However, there are few reports of incarcerated hiatal hernia after laparoscopic total gastrectomy. Here, we report a case of a 79-year-old male who underwent urgent surgical intervention for a strangulated intestinal obstruction due to an incarcerated hernia through the esophageal hiatus following laparoscopic total gastrectomy. In this case, an esophageal hiatal hernia was present before gastrectomy, but was not repaired. Additionally, the patient experienced significant weight loss after gastrectomy. Preoperative hiatal hernia and marked postoperative weight loss may pose risks.

[Laparoscopic repair of hiatal hernia after minimally invasive esophagectomy]

Postoperative hiatal hernia is a rare and specific complication after esophagectomy. This complication leads to emergency and affects mortality. Incidence of this complication has increased due to the great number of minimally invasive procedures over the past decades. In addition, chronic cough, preoperative hiatal hernia and transhiatal approach also increase the risk of recurrent hernias. Most post-esophagectomy hiatal hernias do not require emergency surgery. About 70% of patients have symptoms reducing the quality of life. About 25% of cases are asymptomatic and discovered incidentally during follow-up examinations. The role of surgery for asymptomatic post-esophagectomy hernias is a matter of debate because the risk of symptoms or complications is poorly predictable. Surgical treatment is the only radical method for symptomatic or complicated hernias. However, there is still no consensus regarding surgical approach and technique. Most surgeons prefer open surgery fearing severe adhesive process and other technical difficulties. Laparoscopic approach is widely accepted as the "gold standard" for primary hiatal hernia. However, minimally invasive access for post-esophagectomy hiatal hernias is not sufficiently studied and described in several case reports. Currently, it is very important to study the risk factors of hiatal hernias after esophagectomy. We present successful laparoscopic repair of hiatal hernia after hybrid McKeown esophagectomy.

Postesophagectomy Diaphragmatic Prolapse after Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)

BACKGROUND

Postesophagectomy diaphragmatic prolapse (PDP) is a major complication after esophagectomy with significant mortality and morbidity. However, in the current literature, treatment and outcomes are not evaluated for patients undergoing an Ivor Lewis Robot-assisted minimally invasive esophagectomy (IL-RAMIE). The aim of this study is to evaluate the incidence of PDP after IL-RAMIE. Moreover, the study aims to determine whether using a minimally invasive approach in the management of PDP after an IL-RAMIE procedure is safe and feasible.

MATERIALS AND METHODS

This study includes all patients who received an IL-RAMIE at our high-volume center (>200 esophagectomies/year) between April 2017 and December 2022 and developed PDP. The analysis focuses on time to prolapse, symptoms, treatment, surgical method, and recurrence rates of these patients.

RESULTS

A total of 185 patients underwent an IL-RAMIE at our hospital. Eleven patients (5.9%) developed PDP. Patients presented with PDP after a medium time of 241 days with symptoms like reflux, nausea, vomiting, and pain. One-third of these patients did not suffer from any symptoms. In all cases, a CT scan was performed in which the colon transversum always presented as the herniated organ. In one patient, prolapse of the small intestine, pancreas, and greater omentum also occurred. A total of 91% of these patients received a revisional surgery in a minimally invasive manner with a mean hospital stay of 12 days. In four patients, PDP recurred (36%) after 13, 114, 119 and 237 days, respectively.

CONCLUSION

This study shows that a minimally invasive approach in repositioning PDP is a safe and effective option after IL-RAMIE.

Postoperative Hiatal Hernia after Ivor Lewis Esophagectomy-A Growing Problem in the Age of Minimally Invasive Surgery

BACKGROUND

Even though minimally invasive esophagectomy is a safe and oncologically effective procedure, several authors have reported an increased risk of postoperative hiatal hernia (PHH). This study evaluates the incidence and risk factors of PHH after hybrid minimally invasive (HMIE) versus open esophagectomy (OE).

METHODS

A retrospective single-center analysis was performed on patients who underwent Ivor Lewis esophagectomy between January 2009 and April 2018. Computed tomography scans and patient files were reviewed to identify the PHH.

RESULTS

306 patients were included (152 HMIE; 154 OE). Of these, 23 patients (8%) developed PHH. Most patients (13/23, 57%) were asymptomatic at the time of diagnosis and only 4 patients (17%) presented in an emergency setting with incarceration. The rate of PHH was significantly higher after HMIE compared to OE (13.8% vs. 1.3%, p < 0.001). No other risk factors for the development of PHH were identified in uni- or multi-variate analysis. Surgical repair of PHH was performed in 19/23 patients (83%). The recurrence rate of PHH after surgical repair was 32% (6/19 patients).

CONCLUSIONS

The development of PHH is a relevant complication after hybrid minimally invasive esophagectomy. Although most patients are asymptomatic, surgical repair is recommended to avoid incarceration with potentially fatal outcomes. Innovative techniques for the prevention and repair of PHH are urgently needed.

Increased risk of diaphragmatic herniation following esophagectomy with a minimally invasive abdominal approach

OBJECTIVE

Diaphragmatic herniation is a rare complication following esophagectomy, associated with risks of aspiration pneumonia, bowel obstruction, and strangulation. Repair can be challenging due to the presence of the gastric conduit. We performed this systematic review and meta-analysis to determine the incidence and risk factors associated with diaphragmatic herniation following esophagectomy, the timing and mode of presentation, and outcomes of repair.

METHODS

A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed using four major databases. A meta-analysis of diaphragmatic herniation incidence following esophagectomies with a minimally invasive abdominal (MIA) approach compared with open esophagectomies was conducted. Qualitative analysis was performed for tumor location, associated symptoms, time to presentation, and outcomes of postdiaphragmatic herniation repair.

RESULTS

This systematic review consisted of 17,052 patients from 32 studies. The risk of diaphragmatic herniation was 2.74 times higher in MIA esophagectomy compared with open esophagectomy, with pooled incidence of 6.0% versus 3.2%, respectively. Diaphragmatic herniation was more commonly seen following surgery for distal esophageal tumors. Majority of patients (64%) were symptomatic at diagnosis. Presentation within 30 days of operation occurred in 21% of cases and is twice as likely to require emergent repair with increased surgical morbidity. Early diaphragmatic herniation recurrence and cardiorespiratory complications are common sequelae following hernia repair.

CONCLUSIONS

In the era of MIA esophagectomy, one has to be cognizant of the increased risk of diaphragmatic herniation and its sequelae. Failure to recognize early diaphragmatic herniation can result in catastrophic consequences. Increased vigilance and decreased threshold for imaging during this period is warranted.

Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis

Introduction

The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer.

Materials and methods

Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted.

Results

Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0–22.0%), 1.4% (95% CI = 0.8–2.2%), 35% (95% CI = 20.0–54.0%), and 5.0% (95% CI = 3.0–8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0–21.6%).

Conclusions

Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.

Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single-center experiences with a potential surgical emergency

PURPOSE

Trans-hiatal herniation after esophago-gastric surgery is a potentially severe complication due to the risk of bowel incarceration and cardiac or respiratory complaints. However, measures for prevention and treatment options are based on a single surgeon´s experiences and small case series in the literature.

METHODS

Retrospective single-center analysis on patients who underwent surgical repair of trans-hiatal hernia following gastrectomy or esophagectomy from 01/2003 to 07/2020 regarding clinical symptoms, hernia characteristics, pre-operative imaging, hernia repair technique and perioperative outcome.

RESULTS

Trans-hiatal hernia repair was performed in 9 patients following abdomino-thoracic esophagectomy (40.9%), in 8 patients following trans-hiatal esophagectomy (36.4%) and in 5 patients following conventional gastrectomy (22.7%). Gastrointestinal symptoms with bowel obstruction and pain were mostly prevalent (63.6 and 59.1%, respectively), two patients were asymptomatic. Transverse colon (54.5%) and small intestine (77.3%) most frequently prolapsed into the left chest after esophagectomy (88.2%) and into the dorsal mediastinum after gastrectomy (60.0%). Half of the patients had signs of incarceration in pre-operative imaging, 10 patients underwent emergency surgery. However, bowel resection was only necessary in one patient. Hernia repair was performed by suture cruroplasty without (n = 12) or with mesh reinforcement (n = 5) or tension-free mesh interposition (n = 5). Postoperative pleural complications were most frequently observed, especially in patients who underwent any kind of mesh repair. Three patients developed recurrency, of whom two underwent again surgical repair.

CONCLUSION

Trans-hiatal herniation after esophago-gastric surgery is rare but relevant. The role of surgical repair in asymptomatic patients is disputed. However, early hernia repair prevents patients from severe complications. Measures for prevention and adequate closure techniques are not yet defined.

Incarcerated hiatal hernia - A rare postoperative complication following gastrectomy for stomach cancer. A case report and literature review

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Complicated hiatal hernia following gastrectomy for carcinoma is a rare surgical entity.

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The early diagnosis is often challenging, therefore, a high index of suspicion and an appropriate imaging diagnosis are paramount.

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Crural exploration and repair during primary surgery are recommended to avoid future revisional surgery.

Introduction

Diaphragmatic complications following gastrostomies for gastric malignancies are extremely rare. The incidence of hiatal hernias after total gastrectomy for carcinoma is not well documented because of the poor prognosis associated with gastric cancer and the short life expectancy.

Presentation of case

This case report presents a 66-year-old male patient who developed an acute incarcerated hiatal hernia 8 month after total gastrectomy for gastric adenocarcinoma. The patient was found to have a herniated alimentary limb and dilated, incarcerated loops of the bowel through the 3.5-cm hiatal defect. The hernia was gently reduced. Posterior cruroplasty without mesh augmentation was performed with nonabsorbable sutures. The patient was discharged in good general condition. His history highlights an important and potentially morbid complication following gastrectomy.

Discussion

To our knowledge, only 5 cases have been reported in the literature. The incidence of symptomatic hiatal hernias following esophageal and gastric resection for carcinoma is 2.8%, and the median time between primary surgery and the diagnosis of hiatal hernias is 15 months.

Conclusion

During primary surgery, it is recommended, in the cases of pre-existing hiatal hernias or a crural dissection, to perform cruroplasty after adequate mobilization of the lower thoracic esophagus and a tension-free subdiaphragmatic anastomosis.

Diaphragmatic hernia after Ivor Lewis esophagectomy for cancer: a retrospective analysis of risk factors and post-repair outcomes

Background

Esophageal cancer surgery has historically been associated with high levels of postoperative morbidity and mortality. Post-esophagectomy diaphragmatic hernia (PEDH) represents a potentially life-threatening surgical complication, with incidence and risk factors not clearly demonstrated. This study evaluates presenting characteristics and repair outcomes in PEDH after Ivor Lewis esophagectomy for cancer.

Methods

All consecutive patients who underwent esophageal cancer surgery between March 1997 and April 2018 at two high-volume centers were included. The patients underwent Ivor Lewis esophagectomy and were managed according to a standardized follow-up care plan. The primary outcomes included PEDH incidence, risk factor identification, and surgical results after hernia repair. Patient characteristics and perioperative data were collected and a multivariate analysis was performed to identify risk factors for PEDH.

Results

A total of 414 patients were enrolled and 22 (5.3%) were diagnosed with PEDH during a median follow-up period of 16 (range, 6–177) months. All patients underwent surgical repair and 16 (73%) required treatment within 24 hours. PEDH repair was mainly performed through a laparoscopic approach (77.3%), with an overall postoperative morbidity of 22.7% and one mortality case. The median length of hospital stay was 6 (range, 2–95) days, and no early recurrences were observed, although three (13.6%) cases relapsed over a median follow-up of 10.1 months after hernia repair. Univariate analysis demonstrated a statistically significant association between PEDH and neoadjuvant chemoradiotherapy (P=0.016), pathological complete response (P=0.001), and lymph node harvest (P=0.024). On the other hand, multivariate analysis identified pathological complete response [3.616 (1.384–9.449), P=0.009] and lymph node harvest [3.029 (1.140–8.049), P=0.026] as the independent risk factors for developing PEDH.

Conclusions

PEDH represents a relevant surgical complication after Ivor Lewis esophagectomy for cancer, including a 5.3% incidence and requiring surgical repair. Pathological complete response and lymph node harvest were found to be independent risk factors for PEDH, independently of the esophagectomy technique.

Transdiaphragmatic herniation after transthoracic esophagectomy: an underestimated problem

Diaphragmatic transposition of intestinal organs is a major complication after esophagectomy and can be associated with significant morbidity and mortality. This study aims of to analyze a large series of patients with this condition in a single high-volume center for esophageal surgery and to suggest a novel treatment algorithm. Patients who received surgery for postesophagectomy diaphragmatic herniation between October 2003 and December 2017 were included. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were initial clinical presentation, postoperative complications, in-hospital mortality and herniation recurrence. A total of 39 patients who had surgery for postesophagectomy diaphragmatic herniation were identified. Diaphragmatic herniation occurred after a median time of 259 days following esophagectomy with the highest prevalence between 1 and 12 months. A total of 84.6% of the patients had neoadjuvant radiochemotherapy prior to esophagectomy. The predominantly effected organ was the transverse colon (87.2%) prolapsing into the left hemithorax (81.6%). A total of 20 patients required emergency surgery. Surgery always consisted of reposition of the intestinal organs and closure of the hiatal orifice; a laparoscopic approach was used in 25.6%. Major complications (Dindo-Clavien ≥ IIIb) were observed in 35.9%, hospital mortality rate was 7.7%. Three patients developed recurrent diaphragmatic herniation during follow-up. Postesophagectomy diaphragmatic herniation is a functional complication of the late postoperative course and predominantly occurs in patients with locally advanced adenocarcinoma having chemoradiation before Ivor-Lewis esophagectomy. Due to a high rate of emergency surgery with life-threatening complications not a 'wait-and-see' strategy but early surgical repair may be indicated.

Transverse colon perforation in the mediastinum after esophagectomy: a case report

Background

While anastomotic leakage, recurrent laryngeal nerve paralysis, and pneumonia are well-known complications of esophagectomy, the incidence of hiatal hernia after esophagectomy for carcinoma has been reported to only be between 0.6 and 10%. We report a very rare case of hiatal hernia with transverse colon rupture in the mediastinum after esophagectomy in a 65-year-old woman.

Case presentation

The patient underwent definitive chemoradiotherapy for clinical stage IIA esophageal squamous cell carcinoma and salvage esophagectomy with gastric tube reconstruction through a posterior mediastinum route for residual carcinoma. Three years after the initial surgery, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT and were treated with oral anticancer drugs. After 6 months, the patient was readmitted for anorexia. Upon admission, computed tomography revealed an ileus caused by a hiatal hernia. Emergent operative repair was performed; an incarcerated herniation of the transverse colon was perforated in the mediastinum, and partial transverse colon resection and colostomy were performed. Intensive care was required to control septic shock after surgery, and the patient was discharged on the 53rd postoperative day.

Conclusions

Cases of hiatal hernia with digestive tract prolapsing into the mediastinum after esophagectomy with reconstruction through posterior mediastinum are rare but potentially life-threatening complications.

Hiatal Hernia after Esophagectomy: An Underappreciated Complication?

BACKGROUND

The natural history of hiatal herniation of small and/or large bowel post-esophagectomy (HHBPE) in the current era of improving long-term survival and evolving surgical technique is unknown. The aim of this study was to describe the rate and risk factors of HHBPE at our hospital.

METHODS

Patients undergoing esophagectomy between January 2011 and June 2017 were included if both follow-up information and axial imaging were available beyond 3 months post-esophagectomy. Patient characteristics, disease information, and treatment factors were all included in univariate analysis comparing patients with and without HHBPE, and multivariate regression was used to identify significant independent risk factors associated with HHBPE.

RESULTS

Of 310 esophagectomy patients analyzed, 258 patients were included in the study, with 79 patients (31%) showing evidence of an HHBPE and an overall median follow-up of 24 months; 44 of 79 patients (56%) had symptoms possibly referable to HHBPE and 17 of 79 patients (22%) underwent surgical repair. On univariate analysis, neoadjuvant therapy (n = 176), higher clinical stage, minimally invasive approach (n = 154), and transhiatal esophagectomy (n = 189) were significant predictors of HHBPE (p < 0.05). On multivariate analysis, neoadjuvant therapy and transhiatal approach remained significant independent predictors (p < 0.05). The rate of HHBPE was 44% in the 131 patients (51%) that had both factors.

CONCLUSIONS

HHBPE in the current era of neoadjuvant therapy and minimally invasive esophagectomy is common. HHBPE can cause gastrointestinal symptoms, but operation to repair HHBPE is uncommon on intermediate follow-up. Additional study and long-term follow-up are required to fully assess the impact of HHBPE and to potentially modify surgical practice to prevent or minimize HHBPE.

Complications After Esophagectomy

Esophagectomy is the mainstay for treating esophageal cancers and other pathology. Even with refinements in surgical techniques and the introduction of minimally invasive approaches, the overall morbidity remains formidable. Complications, if not quickly recognized, can lead to significant long-term sequelae and even death. Vigilance with a high degree of suspicion remains the surgeon's greatest ally when caring for a patient who has recently undergone an esophagectomy. In this review, we highlight different approaches in dealing with anastomotic leaks, chyle leaks, cardiopulmonary complications, and later functional issues after esophagectomy.

Internal hernia to the retrosternal space is a rare complication after minimally invasive esophagectomy: three case reports

Background

Minimally invasive esophagectomy is considered a beneficial approach to esophageal cancer, although a hiatal hernia occurs more frequently in this approach than in open esophagectomy with reconstruction via the mediastinal route. Development of an internal hernia to the retrosternal space is not a recognized complication of reconstruction via the retrosternal route after esophagectomy. We herein report three cases of the development of an internal hernia to the retrosternal space after minimally invasive esophagectomy.

Case presentation

Thoracolaparoscopic esophagectomy with cervical anastomosis by retrosternal route reconstruction was performed in all three cases. All patients were men ranging in age from 60 to 80 years. Two patients had abdominal pain, and one had experienced syncope. All patients were diagnosed by computed tomography with an internal hernia to the retrosternal space and thoracic cavity (retrosternal hernia) without ischemic change to the incarcerated intestine. Two patients received medical therapy to relieve their intra-abdominal pressure, which allowed for a successful reduction of the intestine into the abdomen. Open laparotomy was performed to repair the hernia in the third patient. After reducing the intestine into the abdomen, reefing of the retrosternal orifice was performed, and the gastric conduit was anchored to the abdominal wall. No relapse occurred in three cases throughout follow-up.

Conclusion

Hiatal hernia is a well-recognized complication after minimally invasive esophagectomy; however, retrosternal hernia is a rare complication following this procedure. Based on the present report, if no ischemic change is present in the herniated intestine, two types of potentially curative treatments are available: medical or surgical. As minimally invasive esophagectomy is performed more frequently, retrosternal hernia may become an increasingly more common complication in the near future.

Emergency Laparoscopic Repair of Giant Left Diaphragmatic Hernia following Minimally Invasive Esophagectomy: Description of a Case and Review of the Literature

Postoperative diaphragmatic hernia (PDH) is an increasingly reported complication of esophageal cancer surgery. PDH occurs more frequently when minimally invasive techniques are employed, but very little is known about its pathogenesis. Currently, no consensus exists concerning preventive measures and its management. A 71-year-old man underwent minimally invasive esophagectomy for esophageal cancer. Three months later, he developed a giant PDH, which was repaired by direct suture via laparoscopic approach. A hypertensive pneumothorax occurred during surgery. This complication was managed by the anaesthesiologist through a high fraction of inspired O₂ and several recruitment manoeuvres. The patient remained free of hernia recurrence until he died of neoplastic cachexia 5 months later. Laparoscopic repair of PDH may be safe and effective even in the acute setting and in the case of massive herniation. However, surgeons and anaesthesiologists should be aware of the risk of intraoperative pneumothorax and be prepared to treat it promptly.

Esophageal hiatal hernia: risk, diagnosis and management

Esophageal hiatal hernia involves abnormal abdominal entry into thoracic cavity. It is classified based on orientation between esophageal junction and diaphragm. Sliding hiatal hernia (Type-I) comprises the most frequent category, emanating from right crus of diaphragm. Type-II esophageal hernia engages both left and right muscular crura. Type-III and IV additionally include the left crus. Age and increased body mass index are key risk factors, and congenital skeletal aberrations trigger pathogenesis through intestinal malrotations. Familiar manifestations include gastric reflux, nausea, bloating, chest and epigastric discomfort, pharyngeal and esophageal expulsion and dysphagia. Weight loss and colorectal bleeding are severe symptoms. Areas covered: This review summarizes updated evidence of pathophysiology, risk factors, diagnosis and management of hiatal hernias. Laparoscopy and oesophagectomy procedures have been discussed as surgical procedures. Expert commentary: Endoscopy identifies untreatable gastric reflux; radiology is better for pre-operative assessments; manometry measures esophageal peristalsis, and CT scanning detects gastric volvulus and associated organ ruptures. Gastric reflux disease is mitigated using antacids and proton pump and histamine-2-receptor blockers. Severe abdominal penetration into chest cavity demands surgical approaches. Hence, esophagectomy has chances of post-operative morbidity, while minimally invasive laparoscopy entails fewer postoperative difficulties and better visualization of hernia and related vascular damages.