[Diaphragmatic herniation after oesophagectomy: a report of two cases]

Diaphragmatic herniation is the protrusion of abdominal structures into the chest through a defect in the diaphragm. It is a rare complication following oesophagectomy. Preoperative diagnosis is important in order to establish both the nature and extent of the diaphragmatic defect. The treatment of choice is surgery. In a series of 574 intrathoracic oesophagogastroplasties performed at our Institution from 1990 to 2004, the prevalence of diaphragmatic herniation was 0.35%. We report two cases of major diaphragmatic herniation after oesophagectomy for cancer performed using a laparotomic-thoracotomic (case 1) and a laparoscopicthoracotomic approach (case 2). The case 1 patient was asymptomatic: hernia repair involved hiatoplasty and mesh positioning. The case 2 patient presented with vomiting and abdominal pain: she underwent emergency laparoscopic surgery and direct closure of the diaphragmatic tear. At 12 months' follow-up, both patients were symptom-free. A barium swallow confirmed that the previously herniated abdominal viscera had returned to the abdomen. Diaphragmatic herniation following oesophagectomy is a rare complication which may be asymptomatic or present as bowel obstruction. Several aetiopathogenetic factors may be responsible for diaphragmatic hernias: enlargement of the diaphragmatic hiatus, a combination of negative pressure in the chest and positive pressure in the abdomen, and small number of adhesions in the case of patients operated on with minimally invasive surgery. Surgical repair is the treatment of choice and is mandatory as emergency treatment in the case of symptomatic hernias.