Diaphragmatic herniation following oesophagectomy

Background: Intrathoracic herniation of abdominal viscera is a potentially life-threatening condition, especially when diagnosis is delayed. The aim of this study was to estimate its incidence following oesophageal resection and to define contributing factors that might influence its occurrence. Methods: All radiographic studies of the chest that were made during follow-up in a series of 218 patients who underwent oesophagectomy between 1993 and 1997 were reviewed. Results: Herniation of bowel alongside the oesophageal substitute was detected in nine patients (4 per cent). Four hernias occurred within the first week after operation and five were detected at late follow-up. Surgical treatment was indicated in six patients. Analysis of predisposing factors revealed that extended incision and partial resection of the diaphragm were associated with an increased risk of postoperative hernia formation (four of 29 following extended enlargement versus five of 189 after routine opening of the oesophageal hiatus; P = 0.02). Conclusion: Diaphragmatic herniation was found in 4 per cent of patients after oesophagectomy. After extended iatrogenic disruption of the normal hiatal anatomy, narrowing of the diaphragmatic opening may be indicated to avoid postoperative herniation of bowel into the chest. Awareness of its possible occurrence may help prevent the development of intestinal obstruction and strangulation.