Hiatal Herniation After Transhiatal Esophagectomy: an Underreported Complication

Comparison of substernal and posterior mediastinal route of reconstruction after minimally invasive esophagectomy for esophageal cancer

BACKGROUND

Substernal (ST) and posterior mediastinal (PM) routes are the two most common for reconstruction after esophagectomy with cervical anastomosis. Recent evidence showed similar outcomes between the routes; thus, the superior choice remained controversial. This study aimed to compare the short-term outcomes of the ST to the PM route for reconstruction after esophagectomy for esophageal cancer (EC).

METHOD

This retrospective cohort study included 132 patients who underwent McKeown minimally invasive esophagectomy (MIE) with gastric conduit for EC between March 2015 and December 2022. Among these, 89 and 43 patients received the ST route and PM route for reconstruction, respectively. Short-term outcomes including operative characteristics, postoperative morbidity, and mortality were evaluated.

RESULT

There was no conversion from ST to PM route. The ST group had longer operating time (375 min vs. 341 min). Oral feeding initiation, postoperative hospital stays, and overall complication rates were comparable in the two groups. The rate and severity of anastomotic leakage were similar between the groups. The ST group had a significantly lower incidence of postoperative ICU admission and pneumonia compared to the PM group (5.6% vs. 16.3% and 19.1% vs. 37.2%, respectively). Azygos vein bleeding, obstruction at feeding jejunostomy site, and conduit-trachea fistula were severe complications that only occurred in PM route.

CONCLUSION

ST route was superior to PM route in term of postoperative ICU admission and pneumonia. This route may prevent severe complications that only occur in PM route. ST route can be favorable option for reconstruction after McKeown MIE for EC.

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.

Imaging of postoperative complications following Ivor-Lewis esophagectomy

Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.

Incidence and Risk Factors for Diaphragmatic Herniation following Esophagectomy for Cancer

OBJECTIVE

To evaluate the incidence and risk factors of diaphragmatic herniation following esophagectomy for cancer (DHEC), and assess the results of surgical repair.

SUMMARY BACKGROUND DATA

The current incidence of DHEC is discussed with conflicting data regarding its treatment and natural course.

METHODS

Monocentric retrospective cohort study(2009-2018). From 902 patients, 719 patients with a complete follow-up of CT-scans after transthoracic esophagectomy for cancer were reexamined to identify the occurrence of a DHEC. The incidence of DHEC was estimated using Kalbfleisch and Prentice method and risk factors of DHEC were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. Survival was analyzed.

RESULTS

5-year DHEC incidence was 10.3% [95%CI, 7.8%-13.2%](n = 59), asymptomatic in 54.2% of cases. In the multivariable analysis, the risk factors for DHEC were: presence of hiatal hernia on preoperative CT scan (HR = 1.72[1.01-2.94], p = 0.046), previous hiatus surgery (HR = 3.68[1.61-8.45], p = 0.002), gastroesophageal junction tumor location (HR = 3.51[1.91-6.45], p < 0.001), neoadjuvant chemoradiotherapy (HR = 4.27[1.70-10.76], p < 0.001), and minimally invasive abdominal phase (HR = 2.98[1.60-5.55], p < 0.001). A cure for DHEC was achieved in 55.9%. The postoperative mortality rate was nil, the overall morbidity rate was 12.1%, and the DHEC recurrence rate was 30.3%. Occurrence of DHEC was significantly associated with a lower hazard rate of death in a time-varying Cox's regression analysis (HR = 0.43[0.23-0.81], p = 0.010).

CONCLUSIONS

The 5-year incidence of DHEC is 10.3% and is associated with a favorable prognosis. Surgical repair of symptomatic or progressive DHEC is associated with an acceptable morbidity. However, the optimal surgical repair technique remains to be determined in view of the large number of recurrences.

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.

Hiatal Hernia with Acute Obstructive Symptoms After Minimally Invasive Oesophagectomy

BACKGROUND

To evaluate the incidence, treatment and postoperative outcomes of an acute hiatal hernia (HH) after totally minimally invasive esophagectomy (tMIE) for oesophageal cancer.

METHODS

The incidence and treatment of acute HH were analysed from our prospective database including all patients that were surgically treated for oesophageal cancer in the period between January 2011 and December 2018.

RESULTS

Within the study period, the database contained 307 patients that underwent minimally invasive oesophagectomy. Patients' characteristics were in line with the literature of Western data. The incidence of acute HH was 2.6% (N = 8). All patients presented with gastro-intestinal obstruction symptoms, that required acute operation, repositioning of the intrathoracic organs in combination with a crural repair. Mesh reinforcement was used in 38% (N = 3). In two patients, the intestines were partially resected due to ischemia. Postoperative complications, as atrial fibrillation, respiratory failure and anastomotic leakage, were seen in 63% (N = 5). Recurrence-rate was 38% (N = 3).

CONCLUSIONS

This present study demonstrates that an acute HH after tMIE is a serious complication with an incidence of 2.6%. When symptomatic and acute, HH requires surgical intervention and has high postoperative morbidity and recurrence-rate. Therefore, this requires treatment in a centre specialised in oesophageal surgery.

Hiatal hernia after oesophagectomy: a large European survey

OBJECTIVES

Hiatal hernias (HH) after oesophagectomy are rare, and their surgical management is not well standardized. Our goal was to report on the management of HH after oesophagectomy in high-volume tertiary European French-speaking centres.

METHODS

We conducted a retrospective multicentre study among 19 European French-speaking departments of upper gastrointestinal and/or thoracic surgery. All patients scheduled or operated on for the repair of an HH after oesophagectomy were collected between 2000 and 2016. Demographics, details of the initial procedure, surgical management and long-term outcome were analysed.

RESULTS

Seventy-nine of 6608 (1.2%) patients who had oesophagectomies were included in the study. The postoesophagectomy diagnostic interval of an HH after oesophagectomy was ≤90 days (n = 17; 21%), 13 were emergency cases; between 91 days and 1 year, n = 21 (27%), 13 in emergency; ≥1 year, n = 41 (52%), 17 in emergency. The time to occurrence of HH after oesophagectomy was shorter after laparoscopy (median 308 days; interquartile range 150-693) compared to that after laparotomy (median 562 days, interquartile range 138-1768; P = 0.01). The incidence of HH after oesophagectomy was 0.73% (22/3010) after open surgery and 1.4% (26/1761) after laparoscopy (P = 0.03). Among the 79 patients, 78 were operated on: 35 had laparotomies (45%), 19 had laparoscopies (24%) and 24 (31%) had transthoracic approaches. Among the 43 urgent surgeries, 35 were open (25 laparotomies and 10 transthoracic approaches) and 8 were laparoscopies (conversion rate, 25%). Nine patients required bowel resections. Morbidity occurred in 36 (46%) patients with 1 postoperative death (1.2%). During the follow-up period, recurrent HH after oesophagectomy requiring revisional surgery developed in 8 (6 days-26 months) patients.

CONCLUSIONS

Surgical management of HH after oesophagectomy could be done by laparoscopy in patients with scheduled surgery but laparotomy or thoracotomy was preferred in urgent situations. The incidence of HH after oesophagectomy is higher and its onset earlier when laparoscopy is used at the initial oesophagectomy.

Esophageal stent migration to the transverse colon, entrapped within a hiatal hernia status post esophagectomy

Self-expandable metal stents are used in both benign and malignant esophageal conditions for the treatment of strictures, leaks and perforations. With this intervention, the most common complication is stent migration. Those in whom migration occurs are subject to additional procedures with significant risk. We present a unique case of stent migration in a 61-year-old male who underwent transhiatal esophagectomy secondary to esophageal adenocarcinoma. Postoperatively, two covered stents were applied to relieve anastomotic stricture and proximal esophageal occluding web. Several months thereafter, the initial stent was found to have migrated to the transverse colon subsequently entrapped in a hiatal hernia defect. Fortunately, the migrated stent was amenable to colonoscopic retrieval. As endoscopic stent use grows, it is important to recognize that covered stents may migrate through anatomic narrowing’s such as pylorus and ileocecal valve, but can also become entrapped in nonanatomic narrowing’s such as a hernia leading to further 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.