Paraconduit hernia after esophagectomy: Impact of operative technique on its incidence and recurrence

Paraconduit hernia is a challenging complication after esophagectomy, with the potential to compromise the neo-esophagus and risk of bowel incarceration or strangulation. This study aimed to assess the incidence and risk factors associated with paraconduit hernia after esophagectomy and to evaluate its surgical management, recurrence rates, and contributing factors.

A single-institution retrospective cohort study was conducted on patients who underwent esophagectomy between 2008 and 2024. Freedom from paraconduit hernia was estimated using the Kaplan-Meier method, and Cox regression analysis was employed to determine the associated risk factors.

Of 349 patients, 27 (7.4%) developed a paraconduit hernia (Ivor Lewis, 66.7% vs McKeown approach, 22.2%; transhiatal, 11.1%). The median time between esophagectomy and its clinical manifestation was 1.38 years (IQR, 0.13-4.89). The cumulative incidence of paraconduit hernia was 11.9% at the 5-year follow-up. Notably, 21 patients presented with symptoms, including abdominal pain in 51.9%, nausea and vomiting in 59.3%, and dysphagia and chest pain in 44.4%. Approximately 33% of patients required emergency surgical repair because of conduit distension and delayed conduit emptying. Risk factors associated with a higher risk of development of paraconduit hernia were the presence of hiatal hernia (hazard ratio [HR]: 3.0) during esophagectomy and a prior history of hiatal hernia repair with antireflux procedures (HR: 3.68). Extreme body mass index (BMI) was also associated; a lower BMI (<18.5 kg/m²) was associated with a higher risk (HR: 4.39), whereas obesity was a protective factor (HR: 0.26). Recurrence of paraconduit hernia occurred in approximately 38% of patients, necessitating reoperation at a median of 1.25 years from the initial presentation.

Paraconduit hernia is an uncommon but clinically significant complication after esophagectomy, with an 11.9% incidence at 5 years. Its development is influenced by intraoperative factors, such as hiatal hernia repair, as well as low BMI and prior hiatal hernia surgery. Prompt surgical intervention with hernia reduction and cruroplasty is essential because delayed treatment increases morbidity.