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Fecopneumothorax due to gangrene and perforation of the colon in post-esophagectomy diaphragmatic hernia. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2022; 19:170-172. [PMID: 36268488 PMCID: PMC9574579 DOI: 10.5114/kitp.2022.119771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/18/2022] [Indexed: 11/06/2022]
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Ligamentum teres augmentation (LTA) for hiatal hernia repair after minimally invasive esophageal resection: a new use for an old structure. Langenbecks Arch Surg 2021; 406:2521-2525. [PMID: 34611750 PMCID: PMC8578099 DOI: 10.1007/s00423-021-02284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/18/2021] [Indexed: 01/07/2023]
Abstract
Purpose Hiatal hernias with intrathoracic migration of the intestines are serious complications after minimally invasive esophageal resection with gastric sleeve conduit. High recurrence rates have been reported for standard suture hiatoplasties. Additional mesh reinforcement is not generally recommended due to the serious risk of endangering the gastric sleeve. We propose a safe, simple, and effective method to close the hiatal defect with the ligamentum teres. Methods After laparoscopic repositioning the migrated intestines, the ligamentum teres is dissected from the ligamentum falciforme and the anterior abdominal wall. It is then positioned behind the left lobe of the liver and swung toward the hiatal orifice. Across the anterior aspect of the hiatal defect it is semi-circularly fixated with non-absorbable sutures. Care should be taken not to endanger the blood supply of the gastric sleeve. Results We have used this technique for a total of 6 patients with hiatal hernias after hybrid minimally invasive esophageal resection in the elective (n = 4) and emergency setting (n = 2). No intraoperative or postoperative complications have been observed. No recurrence has been reported for 3 patients after 3 months. Conclusion Primary suture hiatoplasties for hiatal hernias after minimally invasive esophageal resection can be technically challenging, and high postoperative recurrence rates are reported. An alternative, safe method is needed to close the hiatal defect. Our promising preliminary experience should stimulate further studies regarding the durability and efficacy of using the ligamentum teres hepatis to cover the hiatal defect. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02284-9.
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Postoperative hiatal herniation after open vs. minimally invasive esophagectomy; a systematic review and meta-analysis. Int J Surg 2021; 93:106046. [PMID: 34411750 DOI: 10.1016/j.ijsu.2021.106046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Post-esophagectomy hiatal hernia (PEHH) is a known, but relatively uncommon, complication after esophagectomies. The incidence of PEHH seems to be increasing since the introduction of minimally invasive esophagectomy. This systematic review and meta-analysis aimed to determine the pooled incidence of PEHH after esophagectomy, and to evaluate if minimally invasive technique is associated with increased risk for PEHH compared to open esophagectomy. METHODS A systematic search of PubMed, Medline via Ovid and Web of Science was performed. Retrospective and prospective studies in English language describing the incidence or risk factors for PEHH were included. Weighted incidence of PEHH after all types of esophagectomy, and after open or minimally invasive technique was calculated. RESULTS A total of 7943 esophagectomy patients were included in the analysis. In total, 310 patients (3.9%) were diagnosed with PEHH. The estimated weighted incidence rate for PEHH after open esophagectomy was 0.024 (95% confidence interval: 0.012-0.045) compared to 0.065 (95% confidence interval: 0.040-0.106) after minimally invasive esophagectomy. Odds ratio for PEHH after minimally invasive esophagectomy compared to open esophagectomy was 2.76 (95% confidence interval: 1.49-5.11). CONCLUSION The risk for post-esophagectomy hiatal hernia was significantly higher after minimally invasive esophagectomy compared to open technique. Heterogeneity and retrospective designs of the included studies were important limitations of the analysis. Future studies should investigate preventive measures to reduce PEHH after minimally invasive esophagectomy.
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Chung SK, Bludevich B, Cherng N, Zhang T, Crawford A, Maxfield MW, Whalen G, Uy K, Perugini RA. Paraconduit Hiatal Hernia Following Esophagectomy: Incidence, Risk Factors, Outcomes and Repair. J Surg Res 2021; 268:276-283. [PMID: 34392181 DOI: 10.1016/j.jss.2021.06.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Paraconduit hiatal hernia (PCHH) is a known complication of esophagectomy with significant morbidity. PCHH may be more common with the transition to a minimally invasive approach and improved survival. We studied the PCHH occurrence following minimally invasive esophagectomy to determine the incidence, treatment, and associated risk factors. METHODS We retrospectively reviewed records of patients who underwent esophagectomy at an academic tertiary care center between 2013-2020. We divided the cohort into those who did and did not develop PCHH, identifying differences in demographics, perioperative characteristics and outcomes. We present video of our laparoscopic repair with mesh. RESULTS Of 49 patients who underwent esophagectomy, seven (14%) developed PCHH at a median of 186 d (60-350 d) postoperatively. They were younger (57 versus 64 y, P< 0.01), and in cases of resection for cancer, more likely to develop tumor recurrence (71% versus 23%, P= 0.02). There was a significant difference in 2-y cancer free survival of patients with a PCHH (PCHH 19% versus no hernia 73%, P< 0.01), but no significant difference in 5-y overall survival (PCHH 36% versus no hernia 68%, P= 0.18). Five of seven PCHH were symptomatic and addressed surgically. Four PCHH repairs recurred at a median of 409 d. CONCLUSIONS PCHH is associated with younger age and tumor recurrence, but not mortality. Safe repair of PCHH can be performed laparoscopically with or without mesh. Further studies, including systematic video review, are needed to address modifiable risk factors and identify optimal techniques for durable repair of post-esophagectomy PCHH.
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Affiliation(s)
- Sebastian K Chung
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA.
| | - Bryce Bludevich
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Nicole Cherng
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Tracy Zhang
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Allison Crawford
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Mark W Maxfield
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Giles Whalen
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Karl Uy
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Richard A Perugini
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA
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Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single-center experiences with a potential surgical emergency. Hernia 2021; 26:259-278. [PMID: 33713205 PMCID: PMC8881432 DOI: 10.1007/s10029-021-02380-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/14/2021] [Indexed: 10/24/2022]
Abstract
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.
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Fuchs HF, Knepper L, Müller DT, Bartella I, Bruns CJ, Leers JM, Schröder W. Transdiaphragmatic herniation after transthoracic esophagectomy: an underestimated problem. Dis Esophagus 2020; 33:5841798. [PMID: 32440678 DOI: 10.1093/dote/doaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Laura Knepper
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Dolores T Müller
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Isabel Bartella
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Jessica M Leers
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation surgery, University of Cologne, Cologne, Germany
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Iwasaki H, Tanaka T, Miyake S, Yoda Y, Noshiro H. Postoperative hiatal hernia after minimally invasive esophagectomy for esophageal cancer. J Thorac Dis 2020; 12:4661-4669. [PMID: 33145039 PMCID: PMC7578511 DOI: 10.21037/jtd-20-1335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Minimally invasive esophagectomy (MIE) can reduce various complications compared with conventional thoracotomic esophagectomy. However, several reports suggested that MIE promoted incidence of post-operative hiatal hernia (HH). In current reports, we retrospectively analyzed incidence and risk factors of HH development after MIE. Methods A total of 113 patients undergoing MIE (McKeown esophagectomy) at our institute from April 2009 to December 2015 were included in this study. Patients with clinical stage II and III received neoadjuvant chemotherapy (NAC). Results Eleven of 113 patients (9.7%) undergoing MIE developed HH. Four of them were female and the ratio of female among the patient with HH was higher than that among the patient without HH after MIE (36.4% vs. 13.7%, P=0.05). Sixty-six patients (58.4%) during the study period were administered NAC and 10 of 11 patients with HH (90.9%) received NAC according to the clinical stage, which was significantly more than in the non-HH group (P=0.02). Type and route of graft organ were not related to HH development. Moreover, the fixation of the conduit organ at the hiatus does not contribute to post-operative HH. Conclusions In the current study, we showed that NAC was a major risk factor of HH development after MIE.
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Affiliation(s)
- Hironori Iwasaki
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Department of Surgery, Saga University Hospital, Saga, Japan
| | - Tomokazu Tanaka
- Department of Surgery, Saga University Hospital, Saga, Japan
| | - Shuusuke Miyake
- Department of Surgery, Saga University Hospital, Saga, Japan.,Department of Surgery, Takagi Hospital, Fukuoka, Japan
| | - Yukie Yoda
- Department of Surgery, Saga University Hospital, Saga, Japan
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Emergency Laparoscopic Repair of Giant Left Diaphragmatic Hernia following Minimally Invasive Esophagectomy: Description of a Case and Review of the Literature. Case Rep Surg 2018; 2018:2961517. [PMID: 30298114 PMCID: PMC6157200 DOI: 10.1155/2018/2961517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/07/2018] [Accepted: 09/05/2018] [Indexed: 11/18/2022] Open
Abstract
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.
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West C, Erskine K, Hamdan K. Transthoracic Littre's hernia presenting with faecopneumothorax following perforation of the Meckel's diverticulum: a late complication of oesophagectomy. BMJ Case Rep 2017; 2017:bcr-2017-220902. [PMID: 29054892 DOI: 10.1136/bcr-2017-220902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A Littre's hernia is an unusual phenomenon where a Meckel's diverticulum protrudes through a potential abdominal opening. We wish to present a unique case of a 79-year-old man with respiratory distress following a fall from standing, initially managed as a haemothorax. After a chest drain was placed, bowel contents were drained from the pleural cavity and he was taken to theatre. He had a history of minimally invasive oesophagectomy for cancer and had subsequently developed a diaphragmatic hernia. A blind ending diverticulum with a perforation at its tip was found in the left oblique lung fissure that was subsequently confirmed histologically as a perforated Meckel's diverticulum. The patient had a prolonged stay on the intensive care unit with a left-sided empyema that was managed radiologically prior to discharge. Unfortunately 4 months postoperatively, he passed away from hospital-acquired pneumonia on a rehabilitation ward.
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Affiliation(s)
- Charles West
- Digestive Diseases Specialty, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Karen Erskine
- Digestive Diseases Specialty, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Khaled Hamdan
- Digestive Diseases Specialty, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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