Diaphragmatic hernia after Ivor Lewis esophagectomy for cancer: a retrospective analysis of risk factors and post-repair outcomes.

Abstract

BackgroundEsophageal cancer surgery has historically been associated with high levels of postoperative morbidity and mortality. Post-esophagectomy diaphragmatic hernia (PEDH) represents a potentially life-threatening surgical complication, with incidence and risk factors not clearly demonstrated. This study evaluates presenting characteristics and repair outcomes in PEDH after Ivor Lewis esophagectomy for cancer.MethodsAll consecutive patients who underwent esophageal cancer surgery between March 1997 and April 2018 at two high-volume centers were included. The patients underwent Ivor Lewis esophagectomy and were managed according to a standardized follow-up care plan. The primary outcomes included PEDH incidence, risk factor identification, and surgical results after hernia repair. Patient characteristics and perioperative data were collected and a multivariate analysis was performed to identify risk factors for PEDH.ResultsA total of 414 patients were enrolled and 22 (5.3%) were diagnosed with PEDH during a median follow-up period of 16 (range, 6–177) months. All patients underwent surgical repair and 16 (73%) required treatment within 24 hours. PEDH repair was mainly performed through a laparoscopic approach (77.3%), with an overall postoperative morbidity of 22.7% and one mortality case. The median length of hospital stay was 6 (range, 2–95) days, and no early recurrences were observed, although three (13.6%) cases relapsed over a median follow-up of 10.1 months after hernia repair. Univariate analysis demonstrated a statistically significant association between PEDH and neoadjuvant chemoradiotherapy (P=0.016), pathological complete response (P=0.001), and lymph node harvest (P=0.024). On the other hand, multivariate analysis identified pathological complete response [3.616 (1.384–9.449), P=0.009] and lymph node harvest [3.029 (1.140–8.049), P=0.026] as the independent risk factors for developing PEDH.ConclusionsPEDH represents a relevant surgical complication after Ivor Lewis esophagectomy for cancer, including a 5.3% incidence and requiring surgical repair. Pathological complete response and lymph node harvest were found to be independent risk factors for PEDH, independently of the esophagectomy technique.