Diaphragmatic hernia after Ivor Lewis esophagectomy for cancer: a retrospective analysis of risk factors and post-repair outcomes
Francesco Puccetti, Andrea Cossu, Paolo Parise, Lavinia Barbieri, Ugo Elmore, Agnese Carresi, Stefano De Pascale, Uberto Fumagalli Romario, Riccardo Rosati
Abstract
BACKGROUND: Esophageal 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. METHODS: All 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. RESULTS: A 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. CONCLUSIONS: PEDH 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.