POHH is a rare but life-threatening complication of esophageal surgery. The first report of diaphragmatic hernia following esophagectomy was made by Terz et al. [9]. In the last decade, only 42 articles have been reported in the literature and they mainly deal with the herniation of the small bowel, transverse colon, and spleen in the left hemithorax. The hiatal hernia more often affects the left thoracic side [10]. Computerized tomography (CT) is the gold standard for diagnosis, allowing physicians to evaluate the size, location, and extent of a diaphragmatic hernia [11]. In our case, we observed the small bowel, descending and transverse colon herniating into the left hemithorax.
Diaphragmatic hernia can occur in acute or late period, with cases reported from 2 days of initial surgery to 12 years following surgery. Some are symptomatic and require immediate surgical repair, while others are repaired electively or treated conservatively, as shown in some studies [12, 13].
Brenkman et al. presented a treatment algorithm that also included a “wait-and-see” strategy for patients without symptoms. He also reported that conservative treatment was successful in 90% of their symptomatic patients [14].
Several studies have found that a significant percentage of POHH hernias may not cause any symptoms, which poses the question of whether a repair is always required [15, 16]. However, considering the relatively high incidence of urgent repairs (22%), the conservative approach must be evaluated against the risk of rapid progression, strangulation, and subsequent perforation, all of which can be fatal. After repair, the pooled morbidity rate is about 25%, but for urgent treatments, where the death rate is estimated to be between 8 and 20%, it may be significantly higher [10]).
After analyzing 2,182 esophagectomies performed between 1988 and 2009, Price et al. [13] discovered no difference in the incidence of diaphragmatic hernia between transhiatal and Ivor Lewis transthoracic esophagectomy, with rates of 0.83% and 0.92%, respectively. Additionally, Ganeshan et al. [17] discovered that 24% of patients with diaphragmatic hernias had underwent transhiatal esophagectomy, but only 12% of patients had Ivor-Lewis esophagectomy. According to Murad et al. [18] meta-analysis 2.6% POHH was reported after open esophagectomy and 6.3% after total minimally invasive esophagectomy including Ivor Lewis, McKeown, and transhiatal esophagectomies. Herein, Kent et al. [19] also reported that minimally invasive esophagectomy had a greater incidence of diaphragmatic hernia occurrence (2.8%) than the open method (0.8%) in 1,075 oesophagectomies.
One study found a correlation between neoadjuvant therapy and a higher risk of POHH [8]. Neoadjuvant treatment is associated with more advanced stage of the tumor and more thorough dissection at the level of the hiatus during the procedure, which may also be a factor in the observed incidence of POHH [5]. Another contributing factor may be poor wound healing following chemotherapy [21].
There is currently debate in the literature regarding the pathogenesis of diaphragmatic herniation following esophagectomy [16, 22]. The main factor that may contribute to a subsequent diaphragmatic herniation is likely the primary surgical approach and surgical manipulation of the hiatus [23]. The extensive manipulation of the hiatus during the transhiatal esophageal dissection has led the Hofstetters group to identify transhiatal resections as a risk factor [17]. Most European centers have given up on this strategy due to both oncologic outcomes and the above complications. Furthermore, diabetes, neoadjuvant medication, total number of harvested lymph nodes, reduced BMI (< 25 kg/m2), or severe weight loss following operation have been considered further risk factors [24].
Nowadays, there is currently no standardized POHH treatment procedure [14]. A mesh can be inserted to support the hiatal repair if only sutures are unable to provide a tension-free closure. Nonetheless, because of the concerns regarding the erosion into the gastric conduit and its vascular supply, especially with nonabsorbable mesh, their usage is still debatable [25]. Although long-term follow-up of these patients showed no difference in outcomes, historically, the use of prosthetic mesh repair in the general population was assumed to assure a considerable decrease in recurrence rates [26]. Three methods of repair, which are sutures, absorbable mesh, and nonabsorbable mesh examined in a recent randomized control study (N = 126). The results showed no statistically significant difference in the recurrence rates (23.1%, 30.8%, and 12.8%, respectively; P = 0.161) [27]. Omentoplasty, in which the omental pedicle is lateralized and tacked down to cover the hernia defect, and ligamentum teres hepatis mobilization, which helps support and buttress the hiatus, are other procedures used to improve the hiatal repair [28]. Although, the most crucial preventive measure is still a standardized esophagectomy with primary hiatoplasty of the hiatal hernia to reduce the incidence of POHH [15]. Suggestions for future research, potential advancements in surgical techniques for the prevention of post-esophagectomy hernia, and the development of standardized diagnostic and management protocols are being discussed.