Surgical Treatment of Acute Symptomatic Postesophagectomy Diaphragmatic Hernia

Background: Postesophagectomy diaphragmatic hernia (PEDH) is a rare yet potentially life-threatening complication following esophagectomy, particularly when acute symptoms such as ischemia or organ perforation arise. Prompt diagnosis and emergency surgical intervention are crucial. This study reports the experience of a tertiary care center in managing acute symptomatic PEDH. Methods: We performed a retrospective analysis of patients who underwent esophagectomy for cancer at our institution between 2013 and 2023. Early PEDH was defined as hernia onset within 30 days postoperatively. Patients presenting with respiratory symptoms, volvulus, ischemia, or perforation underwent emergency surgery. Primary outcomes included the method of diaphragmatic repair, use of mesh, and surgical success. Results: Out of 358 patients, 11 (3.1%) developed PEDH requiring emergency surgery. Five cases were early PEDH and 3 developed an anastomotic leak. Organ or omental resection was performed in 4 patients. Laparoscopic repair was successful in 8 cases, while 2 patients required laparotomy and thoracotomy. Cruroplasty was performed in 8 patients, in 2 a mesh was added and in 6 the falciform ligament was used to buttress the closure. Mortality was nil. Recurrence rate was 18%. No preoperative risk factors for PEDH were identified. Conclusions: Diaphragmatic hernia is a rare but serious complication after esophagectomy, often associated with high morbidity and mortality. Early recognition is critical and life-saving. In high-volume centers, laparoscopic repair is the preferred approach and the decision to perform cruroplasty with or without mesh reinforcement should be individualized based on patient characteristics.