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Liu F, Wen Q, Yang Y, Chen J, Jin G, Yu L, He J. Diaphragmatic dysfunction is associated with postoperative pulmonary complications in the aged patients underwent radical resection of esophageal cancer: a prospective observational study. J Thorac Dis 2024; 16:3623-3635. [PMID: 38983161 PMCID: PMC11228742 DOI: 10.21037/jtd-24-197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/26/2024] [Indexed: 07/11/2024]
Abstract
Background Diaphragmatic dysfunction escalates the susceptibility to postoperative pulmonary complications (PPCs). Currently, no study reports the occurrence of diaphragmatic dysfunction correlated with PPCs following radical resection of esophageal cancer in aged patients. We aimed to diagnose diaphragmatic dysfunction via ultrasonography and analyze diaphragmatic dysfunction's relation with PPCs after radical resection of esophageal cancer surgery in aged patients. Methods This prospective observational study comprised 86 aged patients undergoing radical resection of esophageal cancer. Patient characteristics data and intraoperative details were collected. Ultrasonography was performed before (preoperative) and after (first, third, and fifth day postoperatively) surgery. Outcome measures included PPCs within seven days postoperative, occurrence of diaphragmatic dysfunction, and short-term prognosis. Results After excluding 14 patients, we finally analyzed clinical data from 72 patients. The prevalence of PPCs was higher in the patients with diaphragmatic dysfunction than those without (19 of 23, 83% vs. 21 of 49, 43%, P=0.004). Postoperative diaphragmatic dysfunction was positively correlated with PPCs in patients who underwent elective radical esophageal cancer surgery (r=0.37, P=0.001). Persistent diaphragmatic dysfunction, furthermore, was positively correlated with the development of multiple PPCs (r=0.43, P<0.001). The logistic regression analysis revealed that age, total open procedure, and postoperative diaphragmatic dysfunction were identified as significant risk factors for PPCs, while total open procedure was an independent risk factor for diaphragmatic dysfunction. Conclusions Postoperative diaphragmatic dysfunction positively correlates with developing PPCs. Continuous monitoring of postoperative diaphragmatic function can screen high-risk patients with PPCs, which has specific clinical significance. Age, total open procedure, and diaphragmatic dysfunction are identified as risk factors for developing PPCs, while total open procedure specifically increases the risk for postoperative diaphragmatic dysfunction.
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Affiliation(s)
- Fuqiang Liu
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Qian Wen
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Yiwen Yang
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Jiahui Chen
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Guangshan Jin
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Ling Yu
- Department of Ultrasound, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianhua He
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
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Takeuchi A, Ojima T, Hayata K, Kitadani J, Goda T, Tominaga S, Fukuda N, Nakai T, Yamaue H, Kawai M. Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia. Dis Esophagus 2023; 36:doad037. [PMID: 37259637 DOI: 10.1093/dote/doad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/10/2023] [Indexed: 06/02/2023]
Abstract
Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.
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Affiliation(s)
- Akihiro Takeuchi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Keiji Hayata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Taro Goda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Shinta Tominaga
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Naoki Fukuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Tomoki Nakai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama 641-0045, Japan
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Brunner S, Müller DT, Eckhoff JA, Lange V, Chon SH, Schmidt T, Schröder W, Bruns CJ, Fuchs HF. Postesophagectomy Diaphragmatic Prolapse after Robot-Assisted Minimally Invasive Esophagectomy (RAMIE). J Clin Med 2023; 12:6046. [PMID: 37762986 PMCID: PMC10531742 DOI: 10.3390/jcm12186046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/30/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Stefanie Brunner
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Dolores T. Müller
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Jennifer A. Eckhoff
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Valentin Lange
- Faculty of Medicine, University of Cologne, 50923 Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Christiane J. Bruns
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
| | - Hans F. Fuchs
- Department of General, Visceral, Cancer and Transplantat Surgery, University Hospital of Cologne, 50937 Cologne, Germany
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Kuvendjiska J, Jasinski R, Hipp J, Fink M, Fichtner-Feigl S, Diener MK, Hoeppner J. Postoperative Hiatal Hernia after Ivor Lewis Esophagectomy-A Growing Problem in the Age of Minimally Invasive Surgery. J Clin Med 2023; 12:5724. [PMID: 37685791 PMCID: PMC10488699 DOI: 10.3390/jcm12175724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Jasmina Kuvendjiska
- Department of General and Visceral Surgery, University Medical Center, 79106 Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
| | - Robert Jasinski
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
| | - Julian Hipp
- Department of General and Visceral Surgery, University Medical Center, 79106 Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
| | - Mira Fink
- Department of General and Visceral Surgery, University Medical Center, 79106 Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, University Medical Center, 79106 Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
| | - Markus K. Diener
- Department of General and Visceral Surgery, University Medical Center, 79106 Freiburg, Germany
| | - Jens Hoeppner
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79085 Freiburg, Germany
- Department of Surgery, University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany
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Abstract
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.
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Bona D, Lombardo F, Matsushima K, Cavalli M, Panizzo V, Mendogni P, Bonitta G, Campanelli G, Aiolfi A. Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:1819-1829. [PMID: 34129106 PMCID: PMC8481172 DOI: 10.1007/s00423-021-02214-9] [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: 04/02/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Francesca Lombardo
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Marta Cavalli
- Department of Surgery, University of Insubria, Milan, Italy
| | - Valerio Panizzo
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 35, Milan, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | | | - Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
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