Obstructive shock and cardiac arrest due to diaphragmatic hernia after esophageal surgery: a case report

We report the exceedingly rare case of diaphragmatic hernia after esophageal surgery resulting in obstructive shock and cardiac arrest.

An 82-year-old man, who had undergone a robotic-assisted thoracoscopic esophagectomy and gastric tube reconstruction via a subcutaneously route with three-field lymphadenectomy for esophagogastric junction cancer at another hospital 3 months prior, complaining of persistent epigastric pain and nausea. Computed tomography revealed that the proximal jejunum had herniated through the esophageal hiatus into the left thoracic cavity, with dilation of the subcutaneous gastric tube and duodenum. He was urgently admitted, and a nasogastric tube was inserted. His respiratory and circulatory parameters were normal upon admission, however, nine hours after admission, there was a rapid increase in oxygen demand, and he subsequently developed shock. His blood pressure was 106/65 mmHg, pulse rate of 150bpm, respiratory rate of 30/min with an O2 saturation of 97% on High-flow nasal cannula FiO2:0.4, cyanosis and peripheral coldness appeared. Chest X-ray showed a severe mediastinal shift to the right, suggesting obstructive shock due to intestinal hernia into the thoracic cavity. Emergency surgery was planned, but shortly after endotracheal intubation, the patient experienced cardiac arrest. It was found that approximately 220 cm of small intestine had herniated into the thoracic cavity through the esophageal hiatus, and it was being strangulated by the diaphragmatic crura. A portion of the diaphragmatic crura was incised to manually reduce the herniated small intestine back into the abdominal cavity. The strangulated intestine was congested, but improvement in coloration was observed and it had not become necrotic. The procedure finished with closure of the esophageal hiatus. Intensive care was continued, but he died on postoperative day 29 because of complications including perforation of the descending colon and aspiration pneumonia.

Rapid progression of small intestine hernia into the thoracic cavity, leading to obstructive shock, was suspected. While this case was rare, early recognition of the condition and prompt reduction could have potentially led to life-saving outcomes.