784 TRANSHIATAL HERNIA: AN UNDERDIAGNOSED BUT OVER-TREATED COMPLICATION AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract

Abstract Postoperative transhiatal hernia is a possible life-threatening complication following esophagectomy. The incidence and indications to treat remain open to debate with apparently an increase after minimally invasive esophagectomy (MIE). The aim of this study is to analyze a large series of patients after MIE in a single high-volume center with a transhiatal herniation after minimally invasive esophagectomy (THAMIE) and obtain new insights in this pathology. Methods We included all patients who underwent a MIE (Ivor Lewis and McKeown procedure) in our hospital between 2015 and 2020. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were incidence, initial clinical presentation, treatment of choice, postoperative complications and symptoms, herniation recurrence. Results In 341 MIE 25 (7.3%) patients were diagnosed with a THAMIE postoperatively. 4 patients (16.0%) were asymptomatic at the time of presentation. 5 patients (20%) were treated conservatively because of recurrent carcinoma. 20 patients received a laparoscopic reduction of the transhiatal hernia and cruraplasty (19 non-absorbable sutures, 1 mesh) regardless whether they were symptomatic or not. 25.0%(5/20) of the patients were operated in emergency settings and 5.0% (1/20) was converted to a laparotomy. Postoperatively 6 of the 18 symptomatic patients (33.3%) experienced no relief of symptoms and 40.0% (8/20) of the THAMIE recurred. 35% had serious postoperative complications (clavien-dindo IIIa or more) and mortality was 0.0%. Conclusion The incidence of 7.33% found in our data suggests that THAMIE is a common complication after MIE. We almost exclusively (95.0%) treated patients in a laparoscopic way. Due to the high percentage of morbidity (35.0% ≥ CD IIIa), recurrence (40.0%) and patients with unrelieved symptoms(33.3%) we recommend a conservative treatment for the asymptomatic patients, and further analysis of predictive symptoms associated with a THAMIE to evolve to a shared decision making algorithm for elective symptomatic patients.