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Is Hiatal Herniation After Transhiatal Esophagectomy an Underreported Complication?
Oscar M. Crespin*1, Farhood Farjah1, Carlos Cuevas2, Analisa Armstrong1, Bryan T. Kim3, ANA V. Martin1, Carlos a. Pellegrini1, Brant Oelchlanger1
1Surgery, University of Washington Medical Center, Seattle, WA; 2Radiology, University of Washington, Seattle, WA; 3University of Washington, Seattle, WA
Introduction:
Although hiatal herniation after esophagectomy (HHAE) is often considered an acute complication, improved patient survival as a result of early detection and multi-modality treatment has led to an increasing number of reports of late presentation of HHAE. The aims of this study were to describe the overall incidence and presentation of hiatal hernias after transhiatal esophagectomy (THE).
Methods:
A retrospective cohort study (2004-2013) was performed of esophageal cancer patients who underwent THE. An expert radiologist independently reviewed all available post-operative computed tomography imaging to determine the presence or absence of HHAE regardless of the original radiology report. A time-to-event competing risk analysis was performed to estimate the cumulative incidence of HHAE.
Results:
There were 192 patients with THE during this period: median age 63, 83% men, median body mass index 26, 24% prior history of abdominal hernia, 83% stage II-III, and 67% induction therapy. The two-year cumulative incidence of HHAE was 14% (n=22). The median time to hiatal hernia detection was 7.5 months. The Table summarizes the outcomes. Half (n=11) were not detected and reported by the radiologist when screening for cancer recurrence. All symptomatic patients underwent hiatal hernia surgical repair 4% (n=7). There was one recurrence in the open group, no deaths in either repair groups.
Conclusion:
Hiatal herniation after THE is higher than expected (14% in our cohort). Moreover, the incidence may be underreported since most occurrences appear to be asymptomatic and found incidentally on surveillance imaging.
Table
| HH detection relative to THE | Hiatal Hernia
(detected initially)
| Hiatal Hernia
(detected during the study)
| Symptomatic | Open repair | Laparoscopic repair | | Acute (<3 months) (n=5) | 2 | 3 | 2 | 2 | 0 | | Late (3-97 months) (n=17) | 9 | 8 | 5 | 2 | 3 | | Total= 22 | 11 | 11 | 7 | 4 | 3 |
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