Symptomatic diaphragmatic herniation following open and minimally invasive oesophagectomy: experience from a UK specialist unit.

BACKGROUND: The uptake of minimally invasive oesophagectomy (MIO) in the UK has increased dramatically in recent years. Post-oesophagectomy diaphragmatic hernias (PODHs) are rare, but may be influenced by the type of approach to resection. The aim of this study was to compare the incidence of symptomatic PODH following open and MIO in a UK specialist centre. METHODS: Consecutive patients undergoing oesophagectomy for malignant disease between 1996 and 2012 were included. A standardised, radical approach to the abdominal phase was employed, irrespective of the type of procedure undertaken. Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database. RESULTS: A total of 273 oesophagectomies were performed (205 open; 68 MIO). There were 62 hybrid MIOs (laparoscopic abdomen and thoracotomy) and six total MIOs. Seven patients required conversion and were analysed as part of the open cohort. Nine patients (13.2 %) developed a PODH in the MIO cohort compared with two patients (1.0 %) in the open cohort, (p < 0.001). Five patients developed hernias in the early post-operative period (days 2-10): all following MIO. Both PODHs in the open cohort occurred following transhiatal oesophagectomy. All PODHs were symptomatic and required surgical repair. CT thorax confirmed the diagnosis in 10 patients. Seven hernias were repaired laparoscopically, including two cases in the early post-operative period. PODHs were repaired using the following techniques: suture (n = 6), mesh reinforcement (n = 4) and omentopexy to the anterior abdominal wall without hiatal closure (n = 1). There were two recurrences (18 %). CONCLUSIONS: The incidence of symptomatic PODH may be higher following MIO compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and omentopexy to the abdominal wall may reduce the incidence of herniation.

The effect of centralisation on the outcomes of oesophagogastric surgery--a fifteen year audit.

INTRODUCTION: Centralisation of oesophagogastric (OG) resectional services has been proposed to improve patient outcomes in terms of perioperative mortality and long-term survival. Centralisation of services occurred in Gloucester 5 years ago. The aim of this paper is to assess if local patient outcomes have benefited from centralisation. METHODS: All oesophagogastric resections performed in our unit over a 15-year period (10-years pre-centralisation and 5-years post-centralisation) were assessed retrospectively. Patient demographics, pathological details and date of death were identified. Perioperative mortality (30 and 90 day) and estimated Kaplan-Meier survival was compared for cases performed pre- and post-centralisation of services. RESULTS: 456 resections for cancer were performed in the 15-year period; 234 of these were performed pre-centralisation (mean 23.4, range 13-31) and 222 were performed post-centralisation (mean 44.4, range 40-50). Median survival rates for gastric cancer were 1.1 years pre-centralisation and 1.5 years post-centralisation (p = 0.147) and median survival for oesophageal cancer improved from 1.1 years to 2.1 respectively (p = 0.028). Combined OG 30-day mortality rates improved from 10.3% pre-centralisation to 3.6% post-centralisation (p = 0.006, Fisher's exact test). DISCUSSION: Centralisation of OG services in Gloucester has resulted in twice as many resections being performed locally. Median survival for patients with oesophageal cancer has increased by 1 year and the 30-day mortality rate following resection has reduced by almost two thirds. Although other factors (such as improvements in oncological treatments, staging and critical care management over the 15-year time period) have undoubtedly had roles to play in these improvements, the results of this study support the policy of centralisation of upper GI cancer services.