Diaphragmatic hernia after conventional or laparoscopic-assisted transthoracic esophagectomy

Diaphragmatic herniation is a rare but morbid complication after esophagectomy. This retrospective study estimates its incidence after transthoracic esophagectomy and describes the clinical spectrum of diaphragmatic herniation.

Between February 1, 1997, and June 31, 2007, 355 consecutive patients with esophageal cancer underwent transthoracic esophagectomy. A diaphragmatic hernia was detected in 9 patients (2.5%) after transthoracic esophagectomy. All patients were men, with a median age of 50 years. A retrospective analysis of clinicopathologic characteristics of these patients was performed.

The median time between esophagectomy and diagnosis of herniation was 8 months. The 9 patients presented with different degrees of symptoms: 3 were asymptomatic, 2 had minor symptoms, and 4 had acute symptoms. All had a herniation of abdominal organs into the left hemithorax. One patient was asymptomatic, and no surgical repair was performed. Another patient refused the recommended reoperation. The other 7 patients underwent surgical repair of the diaphragmatic hernia by an abdominal approach. All had reduction of the herniated bowel into the abdominal cavity and closure of the hiatal defect. Resection of small bowel was performed in 1 patient for strangulation, and another patient underwent splenectomy for bleeding. Median hospital stay was 16 days. One patient died secondary to mediastinitis from an anastomotic leakage of the esophagogastrostomy.

Diaphragmatic herniation after esophagectomy mostly occurs into the left chest. Surgeons should be aware of this rare complication in patients presenting with symptoms of intestinal obstruction or respiratory complaints after esophagectomy.