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

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.

Diaphragmatic hernia after Ivor-Lewis esophagectomy: a case report and literature review

“…In the last decade, only 42 articles have been reported in the literature and they mainly deal with the herniation of the small bowel, transverse colon, and spleen in the left hemithorax. The hiatal hernia more often affects the left thoracic side [10]. Computerized tomography (CT) is the gold standard for diagnosis, allowing physicians to evaluate the size, location, and extent of a diaphragmatic hernia [11].…”

“…However, considering the relatively high incidence of urgent repairs (22%), the conservative approach must be evaluated against the risk of rapid progression, strangulation, and subsequent perforation, all of which can be fatal. After repair, the pooled morbidity rate is about 25%, but for urgent treatments, where the death rate is estimated to be between 8 and 20%, it may be signi cantly higher [10]).…”