Revisional Surgery After Esophagectomy: An Analysis of 43 Patients

Background Reflux and postprandial fullness are common after esophagectomy. On occasion, these symptoms have an anatomic basis that requires operative correction. Two such conditions are the following: (1) a diaphragmatic hernia in which bowel herniates into the chest; and (2) a redundant conduit that impairs gastric emptying. The recognition of these conditions and the results of operative correction are the subject of this analysis. Methods A retrospective review from 1995 to 2007 identified patients who developed either a diaphragmatic hernia or a redundant gastric conduit after esophagectomy. The presenting symptoms, operative approach, and outcomes after surgery were recorded. Results Forty-three patients (representing 4% of the esophagectomy volume in this time period) were identified with a diaphragmatic hernia (n = 21), redundant gastric conduit (n = 19), or both (n = 3). Mean time from esophagectomy to diagnosis was 32 months for diaphragmatic hernia and 18 months for redundant conduit. The majority of hernias occurred to the left of the gastric conduit. A mechanical obstruction to gastric emptying was noted in 54% of patients with a redundant conduit. Forty patients underwent revisional surgery (minimally invasive: 35; open: 5). The recurrence rate after repair of a diaphragmatic hernia was 29%. Symptoms improved in 85% of patients after revision of a redundant conduit. Conclusions A diaphragmatic hernia or redundant conduit may occur years after esophagectomy. Hernias almost always occur adjacent to the greater curve of the stomach. The development of a redundant conduit may be associated with a functional outflow obstruction. Surgical correction of these conditions can alleviate symptoms in the majority of patients.