Iatrogenic diaphragmatic hernia - a serious delayed complication: Three cases report and literature review

Iatrogenic diaphragmatic hernia (IDH) is rare, however, its incidence has increased with the growing number of thoracic and abdominal operations. IDH is a serious delayed complication that is easily missed and may lead to severe consequences. Recognizing and emphasizing the occurrence of IDH may help reduce its incidence. We report three cases of IDH from the past decade, each resulting from different operations, and managed with distinct treatments.

The first case occurred 4 months after a left upper lobectomy. Due to a lack of awareness, improper placement of a gastric tube resulted in gastric perforation.The second patient presented with symptoms 10 years after endoscopic full-thickness resection of a gastric fundus gastrointestinal stromal tumor and was diagnosed 12 years after the operation. The cause was likely diaphragmatic injury during endoscopic full-thickness resection, owing to the proximity of the diaphragm to the gastric fundus.The third case occurred 9 months after radiofrequency ablation (RFA) for liver cancer, which involved penetration through the diaphragm and caused iatrogenic damage.

The first patient was initially misdiagnosed at a local hospital and was finally diagnosed with IDH and gastric perforation using computerized tomography (CT), gastroscopy, and upper gastrointestinal radiography. The second patient was diagnosed by CT and upper gastrointestinal radiography. The third patient was diagnosed by enhanced CT.

Surgical repair was performed on the first and third patients. The second patient declined surgery due to advanced age and having adapted to the discomfort caused by IDH.

The first patient recovered well postoperatively and showed no recurrence during the 10-year follow-up period. The second patient was experienced persistent discomfort, which did not worsen throughout the 5-year follow-up. The third patient also recovered well postoperatively and showed no recurrence during the 1-year follow-up period.

We emphasize that when a patient presents with relevant symptoms and significant unilateral diaphragmatic elevation is observed on imaging, the possibility of a diaphragmatic hernia should be highly suspected, and early diagnosis and treatment are essential. Furthermore, during operations that carry a risk of diaphragmatic injury-particularly hepatic operations - we recommend meticulous protection of the diaphragm to prevent IDH.