Laparoscopic repair of giant diaphragmatic hernia after minimal invasive esophagectomy: a case report and review of the literature

Introduction

The incidence of esophageal cancer (EC) is growing worldwide, in 2015, 1,700 new cases were reported in the United states, among which the 32% already had a locally advanced disease at the time of the diagnosis (1,2). The bedrock to guarantee a long-term survival to patients with EC, along with multimodal therapy, is, definitely, represented by the complete surgical resection (3-5).

Various surgical techniques are available aiming to this purpose, such as Ivor Lewis esophagectomy, transhiatal esophagectomy, 3-field esophagectomy and minimally invasive esophagectomy (MIE) (6). All of them include the resection of the esophagus with the advancement of the gastric tube or a colon interposition in the thoracic cavity through the diaphragmatic hiatus, this leads to an alteration of the normal anatomy exposing to a remarkable higher risk of diaphragmatic hernia (DH) (7).

DH is defined as an abnormal movement of abdominal organs into the thoracic cavity, which may bring to life threatening complications, raising the morbidity and mortality post-esophagectomy rate (8). It can occur more frequently after MIE, as an immediate post-operative event or a late post-operative complications, with cases reported from 2 days after surgery up to 7 years after the procedure, with a mean time presentation of 2 years (9,10). The incidence of this rare but morbid complications has been recently reported ranging from 0.7% to 26% (10,11), but this is likely underestimated, given the short time follow-up and the high rate of disease recurrence in this patient (7), and at the same time it will shortly become more and more relevant with the enhanced overall survival of EC, given the outstanding improvement of its multimodal treatment (12).

Nevertheless, little is known on risk factor and gold standard therapy of DH, so that, we present a case of giant DH post-MIE, with the aim of enriching our knowledge on this specific field.

We present the following article in accordance with the CARE reporting checklist (available at https://ls.amegroups.com/article/view/ls-20-134/rc).

Case presentation

A 61-year-old man underwent MIE for locally advanced EC post neoadjuvant RT-CT. The immediate postoperative course was characterized by the absence of major complication and he was discharged after 14 days of hospitalization.

At 8-month follow-up, the patients presented to our observation with unspecific abdominal pain and vomiting. A CT scan was performed, which highlighted a DH with ascension of the small bowel and the transverse colon behind the gastric tube (Figure 1).

Figure 1 CT scan: DH with small bowel and transverse colon ascended through a defect in the left hemi-diaphragm post-MIE. DH, diaphragmatic hernia; MIE, minimally invasive esophagectomy.

So that, the patient was hospitalized to our surgical unit immediately after the diagnosis and he underwent to a laparoscopy repair of his giant DH. At surgical exploration we found a large defect of the left hemi diaphragm with the small bowel and transverse colon, which ascended into the thoracic cavity. After the laparoscopic transabdominal reduction of the hernial content, a direct suture of the diaphragmatic pillars was performed. The hernia orifice was closed by approximation of the left diaphragm pillar according to the Beaulieu technique.

The postoperative course was uneventful, and the patient was discharged 6 days after surgery.

At 2 years follow-up the patients come back to our observation presenting gastrointestinal symptoms such as non-specific abdominal pain, vomiting and respiratory difficulties, at CT scan control, we found a recurrence of DH with ascending stomach and transverse colon (Figure 2). After expressing his consent the patient underwent an open repair of its DH, with the employ of a dual mesh prothesis placed on the left hemi diaphragm, 1.5 cm distant from the esophagus along with the performance of an exhaust incision of the left hemidiaphragm. The post-operative course was again uneventful, the patients was discharged after 7 days from the surgery.

Figure 2 CT scan: recurrent DH with stomach and transverse colon ascended through a defect in the left hemi-diaphragm post-DH laparoscopic repair post-MIE. DH, diaphragmatic hernia; MIE, minimally invasive esophagectomy.

At 5 years CT scan follow-up we did not record any recurrence.

All procedures performed were in accordance with the ethical standards of the Helsinki Declaration as revised in 2013. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

DH is a rare but morbid complication of esophageal surgery, since 2007only 36 cases have been reported in the literature, they mainly deal with the herniation of small bowel, transverse colon and spleen in the left hemithorax (13). As a matter of fact, in our case, we observed the small bowel and transverse colon ascending into the left hemithorax.

Oor et al. (14), highlighted in their metanalysis a higher incidence of DH following MIE (4.5%) as compared with open procedures (1%). When it occurs as an early post-operative event, it is most likely due to the lack of peritoneal adhesion, mostly during MIE (15,16), while if it occurs later in the post-operative course, other factors might be involved, such as a progressive hiatal dilatation, an increased abdominal pressure and the negative intrathoracic one (17,18).

Moreover, we have very limited information about the possible predictive factors for DH, some of the factors predisposing post-esophagectomy patients to DH could be female sex, Body mass index (BMI) <25 kg/m² and extended hiatal opening (19,20).

DH is characterized by a very wide spectrum of clinical presentation, most of the patients are asymptomatic, others present totally unspecific symptoms, and a minority of them show gastrointestinal or respiratory manifestation depending of the content of the DH, this usually leads to a delated diagnosis with a significant growth of DH related complications, such as ischemia or perforation (21). Furthermore, CT scan should be considered as the gold standard technique for diagnosing this disease (12). The patient presented to our observation 3 years after MIE, got a non-specific abdominal pain with vomiting and was diagnosed with DH after undergoing a CT scan of the abdomen and the thorax.

To the best of our knowledge, nowadays a standardized treatment protocol of DH is lacking (22). Some authors advocate a surgical repair even for asymptomatic patients (21,23), while others such as Erkmen et al. (24) suggest a surgical treatment of post-esophagectomy DH only for symptomatic patients, with an active observation of asymptomatic ones with CT scan every 6 months. In general, we can state that as surgery risks for patients underwent to esophagectomy are higher than in the general population only symptomatic DH should undergo a surgical repair (25), even if Brenkman et al. (22), demonstrated in their series that a conservative management was successful even in the 90% of their symptomatic patients, and stated that whether to perform surgery depends on the severity of symptoms, prognosis and patient fitness.

A general consensus is lacking even concerning the most appropriate surgical technique to repair the DH, primarily repairing the diaphragm defect with a direct suture of the pillars is effective in most cases, as in our, avoiding the risk of visceral erosion linked to the use of a mesh (8); whereas some surgeons such as Narayanan et al. (26), prefer the employ of a biologic mesh advocating effective results, or even Müller-Stich et al. (27) favour the use of a mesh in the absence of ischemia or perforation signs, with a significant diminution of recurrences .

Nevertheless, studies showing the superiority of one or the other approach are few, but Watson et al. (28) demonstrated in their work that there were no significant differences between the 2 techniques in terms of clinical outcome nor recurrence rate. In our experience of recurrence, we adopt an open surgical approach, in order to promote the adhesion formation and reduce further recurrences, along with the positioning of a dual mesh prothesis on the defect placed in the left hemidiaphragm and we did not record any further recurrences or post-operative complication.

However, given the increasing incidence of DH with MIE, the best conduct should ideally aim to prevent this post-operative complication. Several approach to reduce the risk of DH during MIE have been proposed, among those we number limiting the hiatal size by living the crura intact, closing anteriorly the hiatus, securing the stomach to the hiatus, suturing the conduit to the crura, preserving the peritoneal lining and relaxing incision in the left hemi-diaphragm (7). From our point of view, given our experience even if little, a good strategy aiming to prevent DH post-MIE occurrence, could be a minimal opening of the hiatus, with a laparoscopic transabdominal approach and if further mobilization of the esophagus is necessary a right lateral approach, with the incision of the right hemidiaphragm, should be preferred.

Conclusions

The above mentioned case demonstrates as the transabdominal laparoscopic approach, with direct suture of the diaphragmatic defect, seems to be safe and effective for repair of giant DH after MIE.

Moreover, as the DH could lead to high morbidity and mortality rate after MIE and it is supposed to be seen more and more frequently, given the rise in survival expectancy of patients affected by EC, we should pay more attention to this post-operative complication and to the possible prevention techniques.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Nadia Russolillo) for the series “Amplifying the voices of women surgeon scientists” published in Laparoscopic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ls.amegroups.com/article/view/ls-20-134/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/ls-20-134/coif). The series “Amplifying the voices of women surgeon scientists” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the Helsinki Declaration as revised in 2013. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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