Post-esophagectomy hiatal hernias: a systematic review and meta-analysis

Post-esophagectomy hiatal hernia (PEHH) is a rare but potentially serious complication of esophagectomy, particularly following minimally invasive approaches. This study aims to evaluate the incidence, risk factors, diagnostic methods, and therapeutic strategies for PEHH through a systematic review and meta-analysis. MEDLINE, Scopus and Cochrane bibliographical databases were systematically searched according to PRISMA guidelines for studies concerning PEHH (last search: 22nd February 2025). A meta-analysis was conducted with pooled odds ratios (ORs) to assess potential risk factors. Thirty-four studies with 837 PEHH cases were included. The overall incidence of PEHH was 4.1%. Minimally invasive esophagectomy (MIE) was associated with an increased risk for PEHH (OR: 5.70, p-value < 0.001). Obesity (BMI > 25 kg/m²) significantly reduced PEHH rates (OR 0.84, p-value < 0.001). Neoadjuvant chemoradiotherapy was also associated with increased PEHH incidence (OR: 3.53, p-value < 0.001). A minimally invasive surgical repair of PEHH was performed in 50.4% of cases. Postoperative morbidity rate was 31.7% and mortality rate was 2.1%. PEHH incidence is rising, with MIE approach and neoadjuvant therapy being possible risk factors. Surgical repair remains the standard for symptomatic cases, while an individualized approach is recommended for asymptomatic patients with consideration of long-term cancer prognosis.