Revisional surgery after esophagectomy: an analysis of 43 patients

Reflux and postprandial fullness are common after esophagectomy. On occasion, these symptoms have an anatomic basis that requires operative correction. Two such conditions are the following: (1) a diaphragmatic hernia in which bowel herniates into the chest; and (2) a redundant conduit that impairs gastric emptying. The recognition of these conditions and the results of operative correction are the subject of this analysis.

A retrospective review from 1995 to 2007 identified patients who developed either a diaphragmatic hernia or a redundant gastric conduit after esophagectomy. The presenting symptoms, operative approach, and outcomes after surgery were recorded.

Forty-three patients (representing 4% of the esophagectomy volume in this time period) were identified with a diaphragmatic hernia (n = 21), redundant gastric conduit (n = 19), or both (n = 3). Mean time from esophagectomy to diagnosis was 32 months for diaphragmatic hernia and 18 months for redundant conduit. The majority of hernias occurred to the left of the gastric conduit. A mechanical obstruction to gastric emptying was noted in 54% of patients with a redundant conduit. Forty patients underwent revisional surgery (minimally invasive: 35; open: 5). The recurrence rate after repair of a diaphragmatic hernia was 29%. Symptoms improved in 85% of patients after revision of a redundant conduit.

A diaphragmatic hernia or redundant conduit may occur years after esophagectomy. Hernias almost always occur adjacent to the greater curve of the stomach. The development of a redundant conduit may be associated with a functional outflow obstruction. Surgical correction of these conditions can alleviate symptoms in the majority of patients.