Prognostic factors for paraconduit hernia in adult patients post-esophagectomy for cancer: a systematic review

Paraconduit hiatal hernia (PCH) is a serious complication following esophagectomy with significant morbidity and mortality. We aimed to conduct a comprehensive review to describe the prognostic factors for PCH in adult patients following esophagectomy for esophageal or gastric cancer to better understand which patients at risk. A systematic search was carried out in Ovid MEDLINE, Embase and Web-of-Science, from inception to August-2024. All studies of adult patients assessing risk factors for radiologically-confirmed PCH following esophagectomy for upper gastrointestinal cancers were included. The data showed that a minimally-invasive esophagectomy was associated with a significant increase in risk of developing PCH (odds ratio [OR]: 4.29, 95% confidence interval [CI]: 1.09-16.87; P = 0.04), particularly following laparoscopic-abdominal approach (hazard ratio [HR]: 2.98, 95% CI: 1.60-5.55; P < 0.01), and a 203% increase following extensive lymphadenectomy (OR: 3.03, 95% CI: 1.14-8.05; P = 0.03). A prophylactic-cruroplasty was not found to be associated with this complication (P = 0.18). Neoadjuvant-chemotherapy and neoadjuvant-chemoradiotherapy (nCRT) were both found to be associated with an increased risk of PCH (HR: 1.56, 95% CI: 0.58-4.17, P < 0.01; HR: 4.27 95% CI: 1.70-10.76; P < 0.01). Tumors located at gastro-esophageal-junction (GOJ) were associated with the greatest risk (HR: 3.51, 95% CI: 1.91-6.45; P < 0.01). In terms of clinical risk factors, patients with body-mass index (BMI) <25 (OR: 2.00, 95% CI: 1.10-3.70; P = 0.03), a pre-operative hiatus hernia (HH) (HR: 1.72, 95% CI: 1.01-2.94; P < 0.05) and those who had previous hiatal-surgery (HR:3.68, 95% CI: 1.61-8.45; P < 0.01) were associated with increased risk of developing PCH. The current literature suggests an associative trend between patients with BMI less than 25; nCRT; laparoscopic resection; GOJ tumor location; previous HH or hiatal surgery, and developing a PCH post-operatively.