Nonoperative management of complicated hiatal hernia after transhiatal esophagectomy- case report.

INTRODUCTION: Hiatal hernia is rare after transhiatal esophagectomy occurring in less than 2% of patients [5]. Due to the rare incidence of hiatal hernias after transhiatal esophagectomy overlooking this differential in a symptomatic patient can be problematic. Patients can presents with recurrent pneumonia, complaints of reflux, and in the case presented small bowel obstructions. Surgery has been the mainstay of treatment for symptomatic hiatal hernias. This case report poses that nonoperative management is a viable treatment option for patients with complicated hiatal hernias after transhiatal esophagectomy. PRESENTATION OF CASE: We present the case of a mechanical small bowel obstruction occurring at the esophageal hiatus in a patient four years after transhiatal esophagectomy. The patient was successfully managed nonoperatively with resolution of small bowel obstruction and persistent hiatal hernia.
CONCLUSION: Hiatal hernias after transhiatal esophagectomy are a rare entity. Complications of these hernias with mechanical small bowel obstructions are even less described in the current literature. It is important to recognize hiatal hernias as a potential cause of obstructive symptoms after esophagectomy. While surgical intervention may be inevitable in certain population of patients. Initial nonoperative management is a viable treatment option and should be utilized in high risk operative patients.

Introduction

Hiatal hernia is rare after transhiatal esophagectomy occurring in less than 2% of patients [4]. Due to the rare incidence of hiatal hernias after transhiatal esophagectomy this can be neglected as a potential differential for symptomatic patients. Patients may presents with recurrent pneumonia, complaints of reflux, and in the case presented small bowel obstructions. Surgical adhesions at the esophageal hiatus as well as surgical reconstruction of the hiatus are thought to be protective against the development of hiatal hernias after esophagectomy. Small bowel obstructions within the hiatal hernia are rarely described in the current literature. This poses a complicated treatment plan for these patients especially if the patient is a poor surgical candidate due to comorbidites or malnourishment. Surgery has been the mainstay of treatment for symptomatic hiatal hernias. This case report poses that nonoperative management is a viable option for treating complicated hiatal hernias after transhiatal esophagostomy in select patients. It is of note that this case report has been reported in line with the SCARE criteria (see Fig. 1, Fig. 2).

Fig. 1

CT scan showing the herniation through the diaphragm.

Fig. 2

CT scan showing the herniation through the diaphragm.

Presentation of case

A 63 year old with past medical history of esophageal adenocarcinoma status post transhiatal esophagectomy completed in 2011, presented to the outpatient office with complaints of dysphagia in 2015. A barium swallow was performed which was consistent with aspiration secondary to oropharyngeal dysphagia. Given recurrent episodes of aspiration with accompanied pneumonia an elective jejunostomy tube was placed laparoscopically. At the time of the operation a hiatal hernia was noted. Surgical repair was not pursed secondary the wide mouth of the hernia defect without signs of ischemia or obstruction. Post operatively the patient was admitted to the hospital for enteral tube feed titration and need for rehabilitation placement due to weakness secondary to malnutrition. Trophic tube feeds were started on post-operative day (POD) #1 at half strength. Tube feeds were gradually advanced to goal on POD #4 at a goal rate of 80 cc/hr full strength. The patient began to have increasing abdominal pain as well as increased bilious drainage around the jejunostomy tube once tube feeds were at goal rate. was consistent with post-operative ileus vs. small bowel obstruction. The jejunostomy tube was placed to gravity drainage with 600 cc of bilious output. POD#7 return of bowel function was noted and tube feeds were thus restarted at 20 cc/hr at half strength. POD #8 the patient again complained of abdominal pain and had increase leakage around the J-tube. A CT with intravenous as well as omnipaque through the jejunostomy tube was obtained. CT reveled a left diaphragmatic hernia containing stomach, small and large intestine without signs of strangulation or ischemia. A mechanical small bowel obstruction was noted within the hernia sac. A transition point at the hiatus was noted with distal small bowel collapse, The patient also had small bilateral pleural effusions, moderate consolidation/collapse within both lower lobes, and small amount of free pelvic fluid without evidence of malignant recurrence. Nasogastric decompression was attempted however unsuccessful due to coiling of the tube within the surgical esophagus. The jejunomstomy tube remained to gravity with strict charting of 24 hour outputs. POD #9 bowel function was observed. Parental nutrition was started POD #10. POD #11 jejunostomy tube was clamped. Tube feeds were resumed on POD# 13 Goal tube feed rate was achieved on POD #20. The patient was discharged to a skilled nursing facility on POD #22, tolerating tube feeds at goal with appropriate bowel function.

Discussion

Hiatal hernia occurring at the esophageal hiatus after esophagectomy occurs in 0.4–15% of patients [2]. The hernia rate is higher for minimally invasive esophagectomies than for transhiatal esophagectomies. It is hypothesized that adhesions from open surgery are responsible for the decreased hiatal hernia rate after transhiatal esophagectomy [1,2]. Secondary to the low incidence of hiatal hernia after transhiatal esophagectomy it can be easily missed when devising a differential for symptomatic patients. Diagnosing a diaphragmatic hernia in such patients can be enigmatic especially if complicated. CT scan is the best modality to detect hiatal hernias and possible complications such as ischemia, obstruction, as well as content within the hernia sac. If surgical intervention is pursued CT imaging can also assist with operative planning. Due to the concern for content incarceration or strangulation within the hiatal hernia it has been recommended that surgical repair considered [5]. Mortality rates associated with complicated hiatal hernias range from 20 to 80% if discovered late and only 10% if discovered early [3]. Surgical repair however, is accompanied by low mortality but has substantial morbidity [5]. The surgical risk of the patient must also be considered. Factors such as age, malignancy status, comorbidies, and nutritional status should be deliberated.

In this case the patient presented with hiatal hernia after transhiatal esophagostomy complicated by mechanical partial small bowel obstruction. It is unclear how long the hiatal hernia had been present due to lack of imaging prior to acute presentation in 2015. The transhiatal esophagectomy was completed 4 years prior to admission. The obstruction noted on CT scan did not show signs of perforation or obstruction. Nor did laboratory values indicate elevation in lactic acid or leukocytosis. Surgical intervention was discussed due to hiatal hernia complicated by small bowel obstruction. Potentially two pathologies that warrant surgical intervention for definitive treatment. However, the patient had cardiac comorbidities as well as a significant malnutrition component secondary to oropharyngeal dysphagia requiring supplemental enteral nutrition was of concern. In this case the patient was managed with nonoperative treatment with jejunostomy tube to gravity for decompression. A total of 5 days until complete resolution of the obstruction was noted.

When hiatal hernia after esophagostomy is accompanied by a mechanical small bowel obstruction this many times will further push the surgeon to operate. Mechanical obstruction is initially managed non-operatively however if symptoms do not improve within 48–72 hours it is recommended to pursue operative management [6]. 80% of mechanical partial small bowel obstruction will resolve with conservative management with a 10–30% recurrence rate when caused by chronic adhesions [6]. Even with resolution of the obstruction nonoperatively it has been recommended to electively repair the hiatal hernia to prevent recurrence. If the hiatal hernia were left untreated it has been associated with as high as 45% rate of severe complication that can become life threating [7]. This case poses that patients who are considered high risk operative candidates that nonoperative treatment of the hiatal hernia is a viable treatment option even in the face of obstruction. The surgeon does need to clinically evaluate the patient for further decompensation during the nonoperative period and be prepared to proceed to the operating room if the patients' health further declines or if ischemia or perforation arises. It is unclear at this time how long a lack of surgical intervention should be continued if the obstruction does not resolve in a high risk patient without deterioration of physical status. In this case the patient was managed for 5 days awaiting resolution of obstruction. It is of note that due to the delay of bowel function and slow titration of enteral feeding to goal total parental nutrition was utilized one week after jejunostomy tube placement and continued till enteral nutrition was at goal rate.

Conclusion

In summary, hiatal hernia is an infrequent complication after transhiatal esophagectomy. Although rare, it is important to keep this clinical entity in mind as it can be associated with serious complications. Surgical intervention may be appropriate in many cases of symptomatic hiatal hernias. However, in high risk patients nonoperative management is a viable initial treatment option even in the face of mechanical partial obstruction without perforation or ischemia. In this case we present the successful nonoperative management of a patient with mechanical small bowel obstruction related to a hiatal hernia after transhiatal esophagectomy lending to the feasibility of this treatment option without definitive repair of the hiatal hernia.

Ethical approval

Ethical Approval was waved for this case report. However consent was given by the patients family member.

Sources of funding

None.

Author contribution

Sepher Lalezari-literature review and editor of paper.

Courtney R. Hanak-author of case report and editor of paper.

Thomas Husted- Attending physician and editor of final paper.

Conflicts of interest

None.

Research registration number

Not required as this is a case report and not a study.

Guarantor

Courtney R. Hanak.

Sepher Lalezari.