Hiatal hernia after transthoracic esophagectomy for cancer: Omentectomy might prevent its onset

Introduction: Hiatal Hernia (HH) after esophagectomy for cancer represents a potentially life-threatening complication whose pathogenesis is still unclear. However, its incidence is higher after minimally-invasive procedures. In our high-volume center this complication was almost unknown since we started our minimally-invasive program. We observed that the only difference between our open and minimally-invasive procedures is that while we divide the gastrocolic ligament below the omentum and always perform an omentectomy during open surgery, this step is avoided during minimally-invasive approaches, and the omentum is left in site adherent to the transvers colon. Aim of this study was to investigate the incidence of HH after open vs minimally-invasive esophagectomy and to look for specific risk factors associated with its onset.

Methods: Our prospectively maintained database was retrospectively quired for patients who underwent transthoracic esophagectomy (Ivor Lewis or McKeown) for cancer over a 15 years period. The groups were defined according to the procedure (open=omentectomy VS minimally-invasive=non-omentectomy). Minimally-invasive procedures were performed both laparoscopic and robotic assisted. In case of a conversion to laparotomy the patient was included in the open group. The 2 groups were compared according to demographics, operative, histologic and postoperative parameters. Risk factors for HH after esophagectomy were investigated in the minimally-invasive group.

Results: In total, 897 patients were included. A HH was registered in 1/490 (0.20%) open and 21/407 (5.16%) minimally-invasive treated patients [Odds ratio=26.6 (95% CI: 3.56-198.7), p=0.0001]. Otherwise, significant differences (two-tailed p<0.05) between the two groups were noted only in 8 out of further 31 investigated variables, as a parameter of homogeneity between the groups. Within the minimally-invasive group, patients with ASA Score of 2 and 3 had significantly lower risk to develop a HH when compared to ASA 1 subjects (Odds ratio 0.18, 95% CI 0.06 – 0.55, p=0.002 and 0.11, 95% CI 0.03 – 0.39, p=0.0007 respectively). No further risk factors were identified.

Conclusions: In our cohort, HH was significantly lower in patients who underwent open esophagectomy. Omentectomy might prevent the onset of post-esophagectomy HH and should be considered also during minimally-invasive procedures, however a RCT is needed to prove our postulation.

Publication History

Article published online:
26 September 2024