Esophageal Adenocarcinoma: Impact of a Large Hiatal Hernia on Outcomes After Surgery

Ann Surg. 2016 Nov;264(5):862-870. doi: 10.1097/SLA.0000000000001769.

Abstract

Objective: To evaluate complete tumor resection rate (primary objective), 30-day postoperative outcomes, and survival (secondary objectives) in patients with a hiatal hernia (HH) ≥5 cm (HH group) compared with those who did not have a HH or presented with a HH <5 cm (control group).

Background: HH is a risk factor for esophageal and junctional adenocarcinoma (EGJA). Its impact on the outcomes after EGJA surgery is unknown.

Methods: Among 367 patients who underwent surgery for EGJA, a HH was searched for on computerized tomography scan and barium swallow, with comparison between the HH (n = 42) and control (n = 325) groups.

Results: In the HH group, EGJAs exhibited higher rates of incomplete resection (50.0% vs 4.0%; P < 0.001), of pN3 stages (28.5% vs 10.1%; P = 0.002), and lower median survival (20.9 vs 41.0 mos; P = 0.001). After adjustment, a HH ≥5 cm was a predictor of incomplete resection (odds ratio 21.0, 95% confidence interval 9.4-46.8, P < 0.001) and a poor prognostic factor (hazard ratio 1.6, 95% confidence interval 1.1-2.5, P = 0.025). In the HH group, 30-day mortality was significantly higher in patients who received neoadjuvant radiotherapy (20.0% vs 0%; P = 0.040), which was related to greater cardiac and pulmonary toxicity.

Conclusions: For the first time, we showed that a HH ≥5 cm is associated with a poor prognosis in patients who had surgery for EGJA, linked to greater incomplete resection and lymph node involvement. Neoadjuvant radiotherapy was associated with a significant toxicity in patients with a HH ≥5 cm.

MeSH terms

  • Adenocarcinoma / complications*
  • Adenocarcinoma / mortality
  • Adenocarcinoma / surgery*
  • Adult
  • Aged
  • Aged, 80 and over
  • Case-Control Studies
  • Combined Modality Therapy
  • Esophageal Neoplasms / complications*
  • Esophageal Neoplasms / mortality
  • Esophageal Neoplasms / surgery*
  • Esophagectomy*
  • Female
  • Hernia, Hiatal / complications*
  • Hospitalization
  • Humans
  • Male
  • Middle Aged
  • Neoplasm Staging
  • Survival Rate
  • Treatment Outcome
  • Young Adult

Supplementary concepts

  • Adenocarcinoma Of Esophagus