Incidence of diaphragmatic (paragastric) hernias following transthoracic esophagectomy: Comparison of open, MIS, and hybrid approaches in 115 patients

Brian Biggerstaff, MD, Steven Cheung, MD, Bertellotti Carrie, APRN, Sumeet Mittal, MBBS. Creighton University Department of Surgery

Objectives: Compare incidence of post-esophagectomy paragastric hernias (PGH) based on type of surgical access (MIS vs open) with respect to thoracic and abdominal approaches.

Methods: After institutional review board approval the esophageal center database was queried to identify patients who underwent Ivor-Lewis or McKeown esophagectomy for malignant disease and extracted into an excel sheet.  All patients underwent surveillance CT scans at routine intervals (3,6,9,12,18,24,36,48 and 60  months).  Patients were classified as having undergone open, MIS, or hybrid procedures.  PGH was defined as radiographic evidence of herniated viscera through the diaphragmatic hiatus next to the stomach. We compared the incidence of PGH according to surgical access. Patients with less than 1 year survival were excluded.

Results: Between September 2004 and December 2014, 279 esophagectomies were performed at a single institution.  115 patients (avg age 62.0 yrs, 98 Males) met inclusion criteria: 59 had Ivor-lewis and 56 McKeown procedures.  Overall incidence of PGH was 13%. Mean time to diagnosis was 7.8 months (0-24 months).   Open thoracic (10.6% vs 14.7%) and open abdominal (5.6% vs 16.5%) approaches were associated with lower incidence of PGH compared to their MIS counterparts.   Individual groups were associated with the following incidences (thoracic/abdominal): 1) open/open: 6.7%, 2) open/MIS 17.6%, 3) MIS/open: 0%, and 4) MIS/MIS: 16.2% (p=0.42). There were 8/59 (13.6%) PGH in Ivor-Lewis group compared to 6/56 (10.7%) in the McKeown group.  None of these achieved statistical significance.

Conclusion: MIS approach, especially for abdominal access, appears to be associated with a higher incidence of PGH following transthoracic esophagectomy.  Series with higher power are needed to confirm these findings. 

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