Paraconduit Hernia in the Era of Minimally Invasive Esophagectomy: Underdiagnosed?

Background: There is a need to compare the proportions, risk factors, and natural histories of postesophagectomy paraconduit hernias in minimally invasive and open esophagectomies. Methods: This is a single-center, retrospective cohort study of esophageal cancer surgery performed between 2007 and 2017. Postesophagectomy paraconduit hernias were identified on cross-sectional imaging. Patient charts were reviewed to describe the management and natural history. Results: Between 2007 and 2017, 391 esophagectomies were performed. After exclusions, 347 patients remained, 135 of whom were total minimally invasive esophagectomies (MIEs) (39%). Postoperative paraconduit hernias developed in 10% of patients. Median time to diagnosis was 258 days. Of 135 MIEs, 20 had a paraconduit hernia (15%) compared with 16 of 212 open or hybrid esophagectomies (8%; P =.03). Hernias were symptomatic in 13 patients (36%) and asymptomatic in 23 (64%), which were detected radiographically. Repair was performed in 11 of 13 symptomatic patients (85%), compared with 3 of 23 asymptomatic patients (13%). In the asymptomatic group, only 1 required emergency repair (4.3%). There was a trend toward a greater proportion of symptomatic paraconduit hernias compared with asymptomatic patients (77% versus 43%; P =.08) in MIE patients. Factors associated with the development of paraconduit hernias on univariate analysis were younger age (P =.02) and not receiving neoadjuvant chemotherapy (P =.01) or neoadjuvant radiation (P =.03). Conclusions: Postesophagectomy paraconduit hernia is more common after totally minimally invasive esophagectomy compared with open or hybrid techniques. One third are symptomatic and the remainder are detected only radiographically. Repair of asymptomatic hernias consider the patient's cancer prognosis.