Postesophagectomy hiatal hernia: an uncommon complication after total minimally invasive surgery for esophageal cancer

Postesophagectomy hiatal hernia (PEHH) is an uncommon complication occurring in 0.3-4% of patients after esophagectomy. Its increasing incidence can be due to higher number of esophagectomies performed, as well as multimodal therapy improvements in esophageal cancer patients’ overall survival. Female gender, total minimally invasive (TMI) surgery, low Body Mass Index, extensive hiatal opening, and neoadjuvant therapy can be risk factors. PEHH is most commonly a left-sided hernia containing colon and/or small bowel. A high suspicion index is essential for diagnosis. Many patients are asymptomatic or mildly symptomatic, and patients can present months to years after esophagectomy. However, serious complications can occur, requiring emergent surgery. Symptomatic patients usually require surgical repair. PEHH repair can be accomplished by correcting he defect with simple non-absorbable suture or may require mesh reinforcement. Recurrences may be common after repair. We present the case of a PEHH in a 55-year-old male patient, mildly symptomatic, submitted to neoadjuvant chemoradiation therapy followed by a TMI Ivor-Lewis esophagectomy due to an esophageal cancer 2 years before. Patient has a left-sided hiatal hernia containing colon. He was submitted to an elective laparoscopic PEHH repair without mesh reinforcement. No consensus exists concerning incidence and risk factors due to great heterogeneity in published studies. TMI surgery, neoadjuvant therapy and lower BMI are associated with higher risk for PEHH. Diagnosis is clinically challenging. Generally, symptomatic patients are offered surgical repair, and TMI approaches are usually successful, but morbidity can occur in up to 35% of patients, with recurrences ranging from 13-29% of cases.