Hiatal Hernia After Open versus Minimally Invasive Esophagectomy: A Systematic Review and Meta-analysis

Abstract

Hiatal hernia (HH) is an infrequent yet potentially life-threatening complication after esophagectomy. Several studies have reported the incidence of this complication after both open and minimally invasive esophagectomy (MIE). This meta-analysis aimed to determine the pooled incidence of HH after both types of esophagectomy and, importantly, to provide insight in the outcome of subsequent HH repair. A systematic search was performed of the PubMed, Embase, CINAHL, and Cochrane databases. Article selection was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria. Articles describing the incidence of HH after different open and minimally invasive techniques were included. Only when five or more comparable studies reported on the same outcome were data pooled. The incidence of postoperative HH and the outcome of HH repair were analyzed. Twenty-six studies published between 1985 and 2015 were included, describing a total of 6058 patients who underwent esophagectomy, of whom 240 were diagnosed with a postoperative HH. The pooled incidence of symptomatic HH after MIE was 4.5 %, compared to a pooled incidence of 1.0 % after open esophagectomy. 11 studies reported on the outcome of HH repair in 125 patients. A pooled morbidity rate after HH repair of 25 % was found. During follow-up, a pooled recurrence rate of 14 % was reported in 11 of the included studies. The pooled incidence of HH after MIE is higher compared to open esophagectomy. Most importantly, surgical repair of these HHs is associated with a high morbidity rate. Both radiologists and surgeons should be aware of this rare yet potentially life-threatening complication.

Hiatal Hernia After Esophagectomy for Cancer

“…Thus, the true incidence of HH is most likely between 7% and 10%. These numbers are comparable to a recent meta-analysis and a recent UK study [18,19] that reported an incidence of 5% and 6%, respectively. HH after esophagectomy will become an increasing problem as cancer survival improves.…”

“…The influence of MIE on the occurrence of HH is currently an important topic of debate. A recent meta- analysis of 6,058 patients found a higher incidence of a symptomatic HH after MIE (4.5%) compared with after open esophagectomy (1.0%) [18]. A frequently reported explanation is the reduced formation of peritoneal adhesions after MIE, although there is no evidence to prove this theory.…”

Recent Advances in Minimally Invasive Esophagectomy

“…A hiatus hernia has an increased incidence after minimally invasive approach (7-9%) compared to open esophagectomy possibly due to the reduction in postoperative adhesion formation and is becoming more relevant due to the increase in survival rate (74). The laparoscopic approach can be used to treat a hernia and the use of a mesh should avoid the risk of vascular injury of the gastric conduit (75).…”

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 a well-known complication of esophageal cancer surgery that can be associated with significant morbidity and mortality [ 1 – 6 ]. The risk of developing PDH after esophagectomy seems to be much higher when minimally invasive techniques are employed [ 2 – 5 , 7 ]. Several mechanisms and risk factors may be involved in the pathogenesis of PDH, and many measures have been suggested in order to minimize its occurrence, although little evidence is available on this regard [ 1 – 11 ].…”