Thoracic herniation of abdominal contents post Oesophagectomy can present as an Emergency. Early recognition is vital and return to theatre may be necessary.
We present a case of a 71 yo male who presented with abdominal and chest pain 5 months following Oesophagectomy and had Emergency Post-Oesophagectomy Diaphragmatic hernia repair.
The patient presented to with bloating, nausea and vomiting, and epigastric pain to our Emergency Department, 5 months post Ivor-Lewis Oesophagectomy for distal oesophageal SCC post neoadjuvant chemoradiotherapy. CT abdomen revealed extensive Small Bowel herniation into the Left pleural cavity, associated with oedema, adjacent to the Gastric conduit, in Left hemithorax. Patient had an Emergency Laparotomy whereby the herniated oedematous 100 cm of Small Bowel was reduced into the peritoneal cavity, the diaphragmatic hernia was sutured with Ethibond with Gore BioA mesh reinforcement. The patient made an uneventful recovery.
Resection of hiatal muscles (or parts thereof) is vital for extracting the Gastric (or other) conduit from the abdomen into the chest. Left pleural breach intraoperatively predisposes patients to be at risk of herniation of abdominal contents into the thorax postoperatively. This usually involves Transverse colon or Small Bowel. Presenting symptoms may be vague including bloating, distension, early satiety, dyspnoea or chest pain. Early recognition and treatment is important. During PDH repair, posteriorly only the scar tissue overlying the Conduit is available for suturing, making the repair difficult and mesh reinforcement or bridging may be required.
Abdominal pain or bloating post-Oesophagectomy should be promptly assessed for Postoesophagectomy diaphragmatic hernia, which can be difficult to repair.