Paraconduit Hiatal Hernia Following Esophagectomy: Incidence, Risk Factors, Outcomes and Repair

Outcomes of esophagectomy in patients with previous foregut surgery: a matched retrospective cohort study

BACKGROUND

Esophagectomy is a challenging procedure indicated for esophageal cancer and complex benign esophageal conditions. The primary aim of this study was to determine the impact of previous foregut surgeries on postoperative outcomes following esophagectomy.

METHODS

A retrospective cohort study was performed on patients undergoing esophagectomy between March 1st, 2008, and December 17th, 2024. Two groups were identified, patients with previous foregut surgery (PFS) and patients without previous foregut surgery (No-PFS). PFS (N = 37) was matched in a 3:1 ratio to patients with No-PFS (N = 111) by age, gender, race, and smoking status with "nearest neighbor" method. Demographics and perioperative variables were collected and compared between both groups. Kaplan-Meier method estimated survival and freedom from long-term complications, such as anastomotic stricture and paraconduit hernia.

RESULTS

Of 349 patients undergoing esophagectomy, 37 had PFS. These included 43% anti-reflux procedures, 35% Heller myotomy for achalasia, and 14% bariatric surgeries. Diagnosis of cancer was an indication for esophagectomy in 59.5% of cases. After matching, significant difference was found regarding operative time (PFS: 463 vs No-PFS: 426 min; p = 0.038). No difference was observed in conversions to open, early complications, reinterventions or leak rate (p value > 0.05). In 3 cases, an interposition graft (colon, jejunum) was used as conduit instead of stomach. As regards freedom from late anastomotic stricture, although not statistically significant, a trend toward a lower freedom from anastomotic stricture was observed in PFS group. The survival analysis, limited to patients with esophageal cancer, indicated higher survival rates in the PFS group (p = 0.06).

CONCLUSIONS

PFS does not impact the approach or outcomes of esophagectomy and is safe with no increased risk of complications. Patients with PFS who had indication of esophagectomy for cancer tended to have better survival rates due to earlier detection and lower clinical stages at diagnosis because of more frequent follow-ups.

Paraconduit hiatus hernia after esophageal cancer surgery: incidence, risk factors, and management

In parallel with improved operative and oncologic outcomes for esophageal cancer, paraconduit hiatus hernia (PHH) is an increasingly recognized entity, both in the early postoperative phase and in long-term follow-up. The aim of this study was to assess the incidence of and risk factors for PHH, and to describe management approaches in a tertiary referral center. All patients undergoing surgery with curative intent for esophageal cancer from 2008 to 2022 at a single center were included. Early PHH was defined as occurring within three months of index surgery, with all other cases defined as late PHH. Surveillance computed tomography scans were undertaken among all disease-free patients to 5 years postoperatively. Kaplan Meier and Cox proportional hazards regression models were used to determine independent risk factors for PHH. Overall, 897 patients were studied. Totally, 62 patients (6.9%) developed PHH during follow-up. The 5-year survival-adjusted incidence of PHH was 9.7%. PHH was an asymptomatic radiologic finding in 45.5% of early and 84.3% of late cases (P = 0.070). Surgical intervention was required in 16 cases (25.8%), more commonly following early (63.6%) as compared with late PHH (17.6%, P < 0.01). Younger age (P < 0.039), initial transhiatal operative approach (P < 0.006) and extended resection of the crura (P < 0.001) were independently associated with increased risk of PHH on multivariable analysis. PHH was identified in almost 1 in 10 patients using surveillance imaging in long-term follow-up, independently associated with the transhiatal surgical approach and resection of crura, which raises consideration of prevention strategies. Surgical intervention is often required for patients with PHH presenting early after surgery, but many patients presenting with late PHH may be managed expectantly.

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

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.