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Case Reports and Images in Surgery

 
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Clinical Image
 
Acute diaphragmatic hernia post-esophagectomy
M. G. Houston1, J. A. Kennedy2
1MB BCh BAO MRCSEd, Specialty Registrar, Upper GI surgery unit, Belfast City Hospital, Belfast, County Antrim, United Kingdom.
2MD FRCS FRCSI,Consultant General and Upper GI Surgeon, Upper GI surgery unit, Belfast City Hospital, Belfast, County Antrim, United Kingdom.

Article ID: 100026Z12MH2016
doi:10.5348/Z12-2016-26-CR-18

Address correspondence to:
MG Houston
Belfast City Hospital, Lisburn Road
Belfast, County Antrim
United Kingdom, BT9 7AB

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Houston MG, Kennedy JA. Acute diaphragmatic hernia post-esophagectomy. J Case Rep Images Surg 2016;2:67–69.


Case Report

A 63-year-old male with a history of ischemic heart disease and hypertension presented with dysphagia. He was a smoker of 40 cigarettes a day and had a previous history of alcohol abuse. At endoscopy, he was found to have a tumor beginning at 38 cm from the incisors and affecting the esophagogastric junction. Pathology confirmed adenocarcinoma. Subsequent staging with PET CT scan showed a cT3N1Mx tumor. Following discussion by the multidisciplinary team, he proceeded to neoadjuvant therapy with epirubicin, cisplatin and capecitabine (ECX). The patient could only tolerate two cycles of ECX due to dehydration and weight loss. He was fed enterally with a nasogastric tube and repeat PET-CT scan showed stable disease. Following a period of nutritional support, the patient proceeded to surgery.

The patient underwent a Lewis Tanner esophagectomy. The stomach was mobilized via midline laparotomy, with preservation of the right gastroepiploic artery. Esophageal dissection, esophagogastric resection and anastomosis of the gastric conduit to the proximal esophagus was completed via a right thoracotomy. The patient was transferred to the intensive therapy unit for postoperative care. He required intravenous fluid and inotropic support in the immediate postoperative period, however, inotropes were no longer required by day one postoperatively. A chest X-ray taken on day-one post-operatively shows apical and basal chest drains in situ in the right hemithorax with a small residual pneumothorax. There is a small pleural effusion in the left hemithorax (Figure 1).

On the third postoperative day, the patient became hemodynamically unstable and was hypotensive. Noradrenaline was restarted and phenylephrine boluses given to maintain blood pressure and urinary output. A repeat chest X-ray demonstrated an acute diaphragmatic hernia, with colon visible in the left chest (Figure 2). The patient proceeded to re-laparotomy. At operation, the transverse colon and omentum, which were both viable, were reduced into the abdominal cavity and the hiatus repaired primarily. A 70-cm segment of small bowel beginning at 50-cm from the duodenojejunal flexure was found to be ischemic; this was resected and an end jejunostomy and mucus fistula fashioned. The patient returned to the intensive care unit (ICU) and made a complete recovery. He is currently being treated in an intestinal failure unit and is awaiting restoration of gastrointestinal continuity.


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Figure 1: Chest X-ray taken on the first postoperative day. An apical and basal chest drain is in situ in the right hemithorax, which has a small residual pneumothorax. There is a small pleural effusion in the left hemithorax.



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Figure 2: Chest X-ray taken on the third postoperative day. There is an acute diaphragmatic hernia with colon visible in the left hemithorax. Note the apical drain in the right hemithorax. The pneumothorax has increased slightly in size and there is new surgical emphysema of the chest wall.


Discussion

Symptomatic post-esophagectomy diaphragmatic herniation necessitating repair is rare. A large case series by Price et al. [1] of 2,182 patients who had undergone esophagectomy found 15 patients (0.69%) required surgery for a symptomatic diaphragmatic hernia. The mean time of onset following esophagectomy was one year nine months; presentation in the immediate postoperative period, as in this case, is rarer still.

Although the number of patients requiring hernia repair is small, some studies have found that the incidence of post-esophagectomy may be higher than previously thought. Ganeshan et al. [2] and Crespin et al. [3] report occurrence rates of 15% and 14%, respectively. However, the consensus view in literature is that all patients who are symptomatic be offered repair.


Conclusion

In this case of a patient who was acutely unwell following of esophagectomy, a chest X-ray was sufficient to make diagnosis of acute diaphragmatic hernia the decision mandating re-laparotomy; further imaging was not necessary.


Keywords: Hernia, Oesophageal cancer, Oesophagecomy, Postoperative complications


References
  1. Price TN, Allen MS, Nichols FC 3rd, et al. Hiatal hernia after esophagectomy: analysis of 2,182 esophagectomies from a single institution. Ann Thorac Surg 2011 Dec;92(6):2041–5.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Ganeshan DM, Correa AM, Bhosale P, et al. Diaphragmatic hernia after esophagectomy in 440 patients with long-term follow-up. Ann Thorac Surg 2013 Oct;96(4):1138–45.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Crespin OM, Farjah F, Cuevas C, et al. Hiatal Herniation After Transhiatal Esophagectomy: an Underreported Complication. J Gastrointest Surg 2016 Feb;20(2):231–6.   [CrossRef]   [Pubmed]    Back to citation no. 3
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Author Contributions
M. G. Houston – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
J. A. Kennedy – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 M. G. Houston et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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