Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis

How to repair a para-conduit hernia post minimally invasive oesophagectomy: the left hiatoplasty approach

Repair of a paraconduit hernia post oesophagectomy can be challenging. We present a safe and effective method of left hiatoplasty which is feasible in the majority of cases, achieving primary no-mesh repair while protecting the gastric conduit. Operative photos and videos describe the technique and key considerations.

Presentation and management of post-esophagectomy or Gastrectomy Hiatal Hernia

PURPOSE

Hiatal hernia may development after esophagectomy or Gastrectomy. Post- esophago-gastric hiatal hernia is a rare but challenging condition. Nearly half of reported cases involve emergent situations, underscoring the urgency of addressing this condition. However, there is currently no consensus on the optimal treatment approach for this type of hernia.

METHODS

All consecutive patients who underwent repair for Post- esophago-gastric hiatal hernia over the past five years were retrospectively reviewed. Patient characteristics and perioperative data were collected. The primary outcomes, repair methods, and surgical results following post-esophago-gastric hiatal repair were analyzed.

RESULTS

A total of eight patients with post-esophago-gastric hiatal hernia were included in this study. All patients presented with emergent conditions, specifically bowel obstruction. Laparoscopic repair was successful in four cases, with a conversion rate to open surgery of 50% (4 out of 8). Primary suture was performed in three cases, while biological mesh repair was carried out in four cases, and one case was left unrepaired. Bowel gangrene and perforation occurred in one case. The most notable postoperative complications included wound infection and pleural fluid collection. Importantly, there were no instances of hernia recurrence during the follow-up period, which ranged from 2 to 55 months, with a 100% follow-up rate observed.

CONCLUSION

Post-esophago-gastric hiatal hernia is a rare yet significant condition, often presenting emergently and linked to higher morbidity and mortality rates. Therefore, symptomatic patients warrant surgical repair, and immediate intervention should be provided to those with acute-onset symptoms and clinical signs of bowel obstruction. Primary suture repair, with or without biological mesh, appears to be a durable method of repair.

Internal Hernia Through a Mesenteric Defect Following Esophagectomy and Reconstruction With a Stomach-Preserved Ileocolic Interposition

Esophagectomy is the standard treatment for esophageal cancer and often involves the stomach as a substitute organ for esophageal reconstruction. However, we actively perform stomach-preserved ileocolic interposition because of its advantages in gastrointestinal function and the prevention of reflux esophagitis. Despite its benefits, few facilities perform esophageal reconstruction with ileocolic interposition; hence, postoperative complications following this procedure have rarely been reported. We present the first case of internal hernia through a mesenteric defect following esophagectomy and reconstruction with a stomach-preserved ileocolic interposition. This type of internal hernia after esophageal cancer surgery is a rare complication following a common gastric pull-up reconstruction. A 66-year-old Japanese female underwent esophagectomy and reconstruction with stomach-preserved ileocolic interposition for stage I esophageal cancer. One month after surgery, the patient experienced abdominal pain and vomiting. CT showed a dilated small bowel and a suspected postoperative adhesive bowel obstruction. Despite conservative management, the patient experienced recurrent episodes that required hospitalization. Although an exact preoperative diagnosis was not made, we decided on a surgical exploration six months after the first symptoms appeared. Laparotomy revealed an internal herniation through a mesenteric defect between the transverse mesocolon and the ileum mesentery following ileocolic interposition. We then repositioned the fitted small intestine and closed the mesenteric defects. The patient recovered uneventfully without a hernia recurrence. Minimally invasive techniques for treating esophageal cancer are becoming more common. As survival rates improve, the number of internal hernia cases, such as those described in this report, will likely increase. Therefore, more cases are needed to determine whether closing mesenteric defects can effectively prevent herniation. However, immediate surgical treatment should be considered based on the symptoms, even when a preoperative diagnosis is difficult.

[Hiatal hernia after esophagectomy]

OBJECTIVE

To analyze the causes and surgical treatment of hiatal hernia after esophagectomy, technical features of surgery and methods of prevention.

MATERIAL AND METHODS

We retrospectively analyzed the incidence of postoperative hiatal hernias after esophagectomy in patients with esophageal cancer between 2018 and 2023. Structure of hernias, surgical options and postoperative results were assessed.

RESULTS

We analyzed 161 patients after Ivor Lewis (n=101) and McKeown (n=60) esophagectomies (open surge surgeries - 43.5%, thoraco- and laparoscopic procedures - 23%, hybrid procedures - 33.5%). The incidence of postoperative hiatal hernia was 3.7%. Hernia occurred within 1-15 months. There were 5 men and 1 woman (mean age 65 years). In all cases, partial or complete dissection of the left diaphragmatic crura was performed. The incidence of hernia after minimally invasive surgery was 4.4%, after open surgery - 2.9%. Two (33.3%) patients underwent urgent surgery for ileus within 2 months after primary esophageal surgery. Three (50%) patients underwent elective surgery. One (16.6%) patient is currently followed-up. The complication was asymptomatic in 2 (33.3%) patients. One (16.6%) patient died after emergency surgery in a COVID hospital due to strangulated hernia and progressive respiratory failure. Mean follow-up period was 16 months. No recurrent hernias were diagnosed.

CONCLUSION

Hiatal hernias occur 2 times more often after minimally invasive esophagectomies. Active surgical strategy is necessary for symptomatic hernias due to high risk of strangulation and emergency interventions. The incidence of this complication is lower without wide diaphragmotomy, transection of the left diaphragmatic crus and high abdominal pressure during laparoscopic stage.

[Laparoscopic repair of hiatal hernia after minimally invasive esophagectomy]

Postoperative hiatal hernia is a rare and specific complication after esophagectomy. This complication leads to emergency and affects mortality. Incidence of this complication has increased due to the great number of minimally invasive procedures over the past decades. In addition, chronic cough, preoperative hiatal hernia and transhiatal approach also increase the risk of recurrent hernias. Most post-esophagectomy hiatal hernias do not require emergency surgery. About 70% of patients have symptoms reducing the quality of life. About 25% of cases are asymptomatic and discovered incidentally during follow-up examinations. The role of surgery for asymptomatic post-esophagectomy hernias is a matter of debate because the risk of symptoms or complications is poorly predictable. Surgical treatment is the only radical method for symptomatic or complicated hernias. However, there is still no consensus regarding surgical approach and technique. Most surgeons prefer open surgery fearing severe adhesive process and other technical difficulties. Laparoscopic approach is widely accepted as the "gold standard" for primary hiatal hernia. However, minimally invasive access for post-esophagectomy hiatal hernias is not sufficiently studied and described in several case reports. Currently, it is very important to study the risk factors of hiatal hernias after esophagectomy. We present successful laparoscopic repair of hiatal hernia after hybrid McKeown esophagectomy.

Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia

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.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Para-conduit diaphragmatic hernia following esophagectomy-the new price of minimally invasive surgery?

Esophageal Cancer is the seventh commonest cancer worldwide with poor overall survival. Significant morbidity related to open esophagectomy has driven practice toward hybrid, totally minimally invasive and robotic procedures. With the increase in minimally invasive approaches, it has been suggested that there might be an increased incidence of subsequent para-conduit diaphragmatic hernia. To assess the incidence, modifiable risk factors and association with operative approach of this emerging complication, we evaluated outcomes following esophagectomy from two Australian Centers. Prospectively collected databases were examined to identify patients who developed versus did not develop a para-conduit hernia. Patient characteristics, disease factors, treatment factors, operative and post-operative factors were compared for these two groups. A total of 24 of 297 patients who underwent esophagectomy were diagnosed with a symptomatic para-conduit diaphragmatic hernia (8.1%). The significant risk factor for hernia was a minimally invasive abdominal approach (70.8% vs. 35.5%; P = 0.004, odds ratio = 12.876, 95% CI 2.214-74.89). Minimally invasive thoracic approaches were not associated with increased risk. Minimally invasive abdominal approaches to esophagectomy doubled the risk of developing a para-conduit diaphragmatic hernia. Effective operative solutions to address this complication are required.

Intrathoracic liver herniation after pericardial fenestration - a case report

BACKGROUND

Pericardial effusions with its potential life threatening progression towards cardiac tamponade have to be often managed with surgical intervention. In our case study we describe a complication after a common surgical procedure which has only scarce literature mentions.

CASE PRESENTATION

We present a case of a 22-year-old male patient who underwent subxiphoidal pericardial fenestration, due to symptomatic pericardial effusion with the Chamberlain procedure and biopsy of enlarged mediastinal lymph nodes. The histology report confirmed classical Hodgkin lymphoma and subsequently the patient underwent oncological treatment. Later on he was admitted to the hospital with dyspnoea and chest pain. The initial examinations stated a suspicion for intrathoracic tumour arising from the pericardium or liver. Further investigation revealed symptomatic intrathoracic liver herniation for which the patient underwent laparoscopic surgery with the mobilisation of liver and placement of a perforated Parietene^™ composite mesh.

CONCLUSION

The purpose of this case report is to describe a rare complication after pericardial fenestration with its potential clinical implications.

Post-Esophagectomy Hiatal Hernia: A Case Series

Post-esophagectomy hiatal hernia is a rare complication having varied presentation from asymptomatic cases detected incidentally on follow-up imaging to acute surgical emergency for strangulation or gangrene. Patients presenting as a surgical emergency have a prolonged post-operative course with significant morbidity. We present three cases of post-esophagectomy hiatal hernia. Two of the three cases were operated for esophageal squamous cell carcinoma (SCC) and one patient was operated for esophageal leiomyomatosis. Two of the three cases (SCC and esophageal leiomyomatosis) underwent minimally invasive Mckeown's esophagectomy and one case underwent robotic transthoracic Ivor-Lewis esophagectomy. All cases underwent contrast enhanced CT (CECT) and were biopsy proven prior to their index surgery. Both cases of SCC had prior neoadjuvant chemoradiation followed by surgery while esophageal leiomyomatosis underwent upfront surgery. All three cases have improved symptomatically and are doing well on follow up (case 1 - 12 months, cases 2 and 3 - 3 months).  All three of our cases have different clinical presentation in terms of symptoms, severity, and time duration from index surgery. Two of the three cases underwent emergency surgery and one case which was asymptomatic detected incidentally on surveillance imaging and was managed conservatively. Post-esophagectomy hiatal hernia is a rare entity with varying presentation. The management options in such cases vary depending on the severity of symptoms and time after index surgery. In cases presenting as surgical emergency, successful management depends on prompt detection, early surgery, proper post-operative care, and rehabilitation.

C-reactive Protein and Procalcitonin Levels to Predict Anastomotic Leak After Colorectal Surgery: Systematic Review and Meta-analysis

BACKGROUND

Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery.

METHODS

Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD).

RESULTS

Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7-9%), and the median time to diagnosis was 6.9 days (range 3-10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23-0.85), 0.84 (95% CIs 0.18-0.86) and 0.84 (95% CIs 0.18-0.89) respectively. Negative likelihood ratios (LR-) showed moderate evidence to rule out AL on POD 3 (LR- 0.29), POD4 (LR- 0.24) and POD5 (LR- 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (-0.18) showed moderate evidence to rule out AL.

CONCLUSIONS

In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development.