Increased risk of diaphragmatic herniation following esophagectomy with a minimally invasive abdominal approach

Summary Objective Diaphragmatic herniation is a rare complication following esophagectomy, associated with risks of aspiration pneumonia, bowel obstruction, and strangulation. Repair can be challenging due to the presence of the gastric conduit. We performed this systematic review and meta-analysis to determine the incidence and risk factors associated with diaphragmatic herniation following esophagectomy, the timing and mode of presentation, and outcomes of repair. Methods A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed using four major databases. A meta-analysis of diaphragmatic herniation incidence following esophagectomies with a minimally invasive abdominal (MIA) approach compared with open esophagectomies was conducted. Qualitative analysis was performed for tumor location, associated symptoms, time to presentation, and outcomes of postdiaphragmatic herniation repair. Results This systematic review consisted of 17,052 patients from 32 studies. The risk of diaphragmatic herniation was 2.74 times higher in MIA esophagectomy compared with open esophagectomy, with pooled incidence of 6.0% versus 3.2%, respectively. Diaphragmatic herniation was more commonly seen following surgery for distal esophageal tumors. Majority of patients (64%) were symptomatic at diagnosis. Presentation within 30 days of operation occurred in 21% of cases and is twice as likely to require emergent repair with increased surgical morbidity. Early diaphragmatic herniation recurrence and cardiorespiratory complications are common sequelae following hernia repair. Conclusions In the era of MIA esophagectomy, one has to be cognizant of the increased risk of diaphragmatic herniation and its sequelae. Failure to recognize early diaphragmatic herniation can result in catastrophic consequences. Increased vigilance and decreased threshold for imaging during this period is warranted.

Successful Surgical Repair of Left-Sided Diaphragmatic Hernia after Adult Orthotopic Liver Transplantation: Case Report

Postoperative delayed diaphragmatic hernia (DH) is a rare and uncommon event after adult orthotopic liver transplantation (OLT), which however could be potentially life-threatening complication, especially in the absence of early and correct diagnosis and appropriate surgical treatment. We present a case of 48 year-old male with left diaphragmatic herniation of left part of transverse colon, who thirty nine months before underwent OLT with right-sided allograft implantation and which was recently successfully managed by open abdominal approach in our institution. The postoperative course was uneventful and he was discharged at the 8th day after surgery. Our case illustrates, that delayed DH after the OLT in adults could be a new problem, which affect transplant recipients with long-term follow-up period. Hence, we consider, that once the diagnosis of DH is confirmed, the patient should be operated immediately, in order to avoid the possible life-threatening complications.

Pediatric Thoracoscopic Repair of Diaphragmatic Herniation Following Liver Transplantation

Diaphragmatic Hernia (DH) after Liver Transplantation (LT) is a rare complication with unclear pathophysiology. Among 261 LT, we recognized six DH during the post transplant period (2.30%). All patients with DH had received a left lateral segment (LLS) reduced graft. The mean graft weight was 340g with a mean graft-to-recipient body weight ratio (GBWR) of 4.20%. LLS grafts, a GBWR > 4%, previous abdominal surgery and direct trauma during surgery can be enumerated as potential risk factors for DH post-LT. These children underwent prompt surgical intervention to DH without complications. Three patients were treated via laparotomy and three by thoracoscopy. No clinical recurrences were accounted at a mean follow up of 5 years. Historically, the treatment has always been surgical repair via laparotomy but the use of minimally invasive techniques in pediatric surgery has been increasing, and the thoracoscopic approach for DH can bring advantages. The patients in which the thoracoscopic approach was used had shorter operative times and a faster recovery with better cosmetic results. As previous surgical manipulation had been done to the abdominal cavity, thoracoscopy seems to be a safe approach in DH in pediatric LT recipients.

A delayed post-operative diaphragmatic hernia with hemothorax due to a strangulated stomach

Traumatic diaphragmatic hernias (TDHs) are uncommon, and they mostly occur following blunt or penetrating traumatic injury and rarely as a complication of Iatrogenic procedure. The management of TDHs is through surgical repair. In this article, we present the case of a diaphragmatic herniation presenting 1 year after thoracic surgery in a 16-year-old male. The patient presented with gastrointestinal obstruction symptoms and later developed a hypovolemic shock due to stomach bleeding. Immediate exploratory thoracotomy was performed, and the patient reached a full recovery afterward.

Transdiaphragmatic herniation after transthoracic esophagectomy: an underestimated problem

Summary Diaphragmatic transposition of intestinal organs is a major complication after esophagectomy and can be associated with significant morbidity and mortality. This study aims of to analyze a large series of patients with this condition in a single high-volume center for esophageal surgery and to suggest a novel treatment algorithm. Patients who received surgery for postesophagectomy diaphragmatic herniation between October 2003 and December 2017 were included. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were initial clinical presentation, postoperative complications, in-hospital mortality and herniation recurrence. A total of 39 patients who had surgery for postesophagectomy diaphragmatic herniation were identified. Diaphragmatic herniation occurred after a median time of 259 days following esophagectomy with the highest prevalence between 1 and 12 months. A total of 84.6% of the patients had neoadjuvant radiochemotherapy prior to esophagectomy. The predominantly effected organ was the transverse colon (87.2%) prolapsing into the left hemithorax (81.6%). A total of 20 patients required emergency surgery. Surgery always consisted of reposition of the intestinal organs and closure of the hiatal orifice; a laparoscopic approach was used in 25.6%. Major complications (Dindo–Clavien ≥ IIIb) were observed in 35.9%, hospital mortality rate was 7.7%. Three patients developed recurrent diaphragmatic herniation during follow-up. Postesophagectomy diaphragmatic herniation is a functional complication of the late postoperative course and predominantly occurs in patients with locally advanced adenocarcinoma having chemoradiation before Ivor–Lewis esophagectomy. Due to a high rate of emergency surgery with life-threatening complications not a ‘wait-and-see’ strategy but early surgical repair may be indicated.