Introduction:
Hiatal Hernia after esophagectomy for cancer represents a potentially life-threatening long-term complication of which pathogenesis is unclear. However, it is well-known that its incidence is higher after minimally-invasive procedures. Aim of this single-center controlled cohort-study was to compare the incidence of hiatal hernia after open vs minimally-invasive esophagectomy (MIE), and to identify specific risk factors associated with its occurrence. Furthermore, the objective was to validate our hypothesis that the remaining omentum after MIE has a key role in the development of a post-esophagectomy hiatal hernia.
Methods:
Our prospectively maintained database was retrospectively queried for patients who underwent transthoracic esophagectomy (Ivor Lewis or McKeown) for cancer over a 15 years period. Groups were defined according to the procedure (open = omentectomy vs. minimally-invasive = non-omentectomy). Minimally-invasive procedures were performed both laparoscopic and robotically- 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 hiatal hernia after esophagectomy were analyzed.
Results:
A total of 897 patients were included. A hiatal hernia was registered in 1/490 (0.2%) in the open and in 21/407 (5.16%) of the 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 hiatal hernia 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. All patients underwent an omentectomy in the open, and none in the minimally-invasive group.
Conclusions:
In our cohort, hiatal hernia was significantly lower in patients who underwent open esophagectomy compared to MIE. Omentectomy might play a key role in the prevention of post-esophagectomy hiatal hernia and should thus be considered also during minimally-invasive procedures. However, further multicentric and randomized studies are needed.
