Ann Thorac Surg 2007;84:1852-1853. doi:10.1016/j.athoracsur.2007.08.006
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Steven DeMeester, MD
Department of Cardiothoracic Surgery, The University of Southern California, 1510 San Pablo St, No. 514, Los Angeles CA 90033
(Email: sdemeester{at}surgery.usc.edu).
Vallböhmer and colleagues [1] report 9 patients in whom intraabdominal organs herniated into the mediastinum or thoracic cavity after esophagectomy with gastric pull-up. No fixation of the stomach to the crura was performed, and in selected patients, the hiatus was narrowed with sutures when it was thought to be too wide. Symptoms were present in 6 of the 9 patients, and the hernia was found at a median time of 8 months after esophagectomy. Reoperation was performed in 7 patients (5 emergency and 2 elective) and consisted of reduction of the herniated bowel/organ into the abdomen and posterior repair of the hiatal defect (6 primary repairs and 1 with absorbable mesh). A concomitant bowel resection was necessary in 1 patient, and another required splenectomy. The authors recommend operative repair in all but the smallest asymptomatic hernias or if the patient has a short life expectancy. They also advise adjusting the size of the hiatus to approximate the graft to reduce the potential for this complication to occur.
Migration of abdominal organs through the enlarged hiatus after esophagectomy is a real entity, as pointed out in this article by Vallböhmer and colleagues. At our center, we routinely suture the graft, whether colon or stomach, to the left crus of the diaphragm to prevent herniation and redundancy of the graft (for colon grafts, primarily) or twisting of the graft in the mediastinum (for gastric pull-ups, primarily). It is also important to suture an enlarged hiatus closed to the point that it approximates the graft but not to the point that it compromises graft emptying.
Graft herniation can occur early in the postoperative period but is not always appreciated immediately. I have seen it more commonly after a colon interposition and now close the crura posterior to the graft with several figure-of-eight sutures and also suture the colon to the left crus at two or more locations. This effectively prevents herniation and reduces the likelihood of subsequent redundancy of the graft, because it can also get pulled up into the mediastinum if it has not been secured to the crura (Fig 1). Concerns expressed by Vallböhmer and colleagues about the potential for these sutures placed into the seromuscular layer of the stomach or colon graft to compromise the vascularity of the conduit are unfounded, in my opinion, and should not discourage their use.
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Fig 1. (A) Postoperative day 1 chest roentgenogram after esophagectomy with left colon interposition (mostly transverse colon based on left colic blood supply). (B) Postoperative day 2 chest roentgenogram in the same patient. Note the new air collection to the left of the hiatus representing herniated cecum and splenic flexure of the colon including the fresh colon-to-colon anastomosis. The colon herniated behind the colon graft, which was anastomosed to the antrum and had been sutured along the lateral edge of the left crus. The posterior crura had not been closed or sutured to the colon interposition, leaving the space through which the hernia occurred.
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As suggested by Vallböhmer and colleagues, I recommend surgical correction of a hernia identified in the early postoperative period, regardless of symptoms. However, if an asymptomatic hernia is found during a routine cancer follow-up, the necessity of repair is unclear. The finding by Vallböhmer and colleagues that bowel ischemia developed in a patient with hiatal herniation indicates that this is not a trivial matter, and that similar to other forms of hernia, severe complications can develop. The complexity of repair makes the old adage that an ounce of prevention is better than a pound of cure very apropos in this condition.
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References
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- Vallböhmer D, Hölscher AH, Herbold T, Gutschow C, Schröder W. Diaphragmatic hernia after conventional or laparoscopic-assisted transthoracic esophagectomy Ann Thorac Surg 2007;84:1847-1853.[Abstract/Free Full Text]
Related Article
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Diaphragmatic Hernia After Conventional or Laparoscopic-Assisted Transthoracic Esophagectomy
- Daniel Vallböhmer, Arnulf H. Hölscher, Till Herbold, Christian Gutschow, and Wolfgang Schröder
Ann. Thorac. Surg. 2007 84: 1847-1852.
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