O50 diaphragmatic hernia after ivor-lewis oesophagectomy: analysis of risk factors and surgical repair results

Abstract Backgrounds and aim oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (PODH) represents a potentially life-threatening complication with an underestimated occurrence rate and unclear related risk factors. Aim of this study was to identify possible risk factors of PODH and results of surgical treatment from experience of two tertiary referral centers. Methods all patients affected by a clinically resectable oesophageal cancer (any T, any N and M0) and submitted to Ivor-Lewis oesophagectomy, regardless of technique (open, hybrid or totally minimally invasive) between 1997 and 2017 at our Institutions were selected for this study. Demographic, clinical pre, intra, post-operative, and follow-up data were prospectively collected in an electronic database. A retrospective analysis was conducted in order to evaluate the incidence of PODH, associated risk factors and surgical repair results. Results 414 patients underwent Ivor-Lewis oesophagectomy for cancer in the study period and 22 (5.3%) developed PODH at a median follow-up time of 16 months (6 - 177). Surgical repair was mainly conducted by laparoscopic approach (77%) with a conversion rate of 24%. Postoperative morbidity was 22.7% and mortality 4.5%. Median postoperative hospital stay was 6 days (2 - 95). 3 recurrences (13.6%) occurred at a median follow-up time of 10.1 months. A wide univariate analysis identified statistically significant associations between PODH occurrence and the administration of preoperative chemoradiation, a complete pathological response (CPR) and a harvested lymph-nodes number (HLN) larger than 33 (p-value 0.016, 0.001 and 0.024 respectively). A significant association with a large HLN number was confirmed by the multivariable analysis (0.026) along with CPR which could however be considered as a longer survival-related bias. Conclusions The minimally invasive surgery and the neoadjuvant chemoradiation, in contrast to results of other authors, in our experience are not associated with PODH development, while a HLN number larger than 33 resulted to be an independent risk factor, probably mirroring the extent of surgical demolition in oesophagectomy. Surgical repair can be safely and effectively performed trough laparoscopy but recurrences can frequently occur.