Diaphragmatic herniation following total gastrectomy: review of the long-term experience of a tertiary institution

Langenbecks Arch Surg. 2019 Dec;404(8):993-998. doi: 10.1007/s00423-019-01842-6. Epub 2019 Nov 19.


Purpose: Diaphragmatic herniation (DH) is a rare but potentially fatal event after total gastrectomy (TG). Despite being life-threatening, risk factors for postoperative DH have yet to be elucidated. We conducted a retrospective analysis to identify clinical characteristics of patients developing DH after TG, along with a comprehensive review of the published literature.

Methods: Among 1361 consecutive patients undergoing TG for esophagogastric cancer between 1985 and 2013 in Toranomon Hospital, those requiring surgical intervention for postoperative DH were included. We also conducted a PubMed literature search on DH following TG.

Results: Five patients (four males, one female), with a median age of 68 at DH surgery, were identified. Intervals between TG and DH repair ranged from 2.9 to 189.0 (median, 78.1) months. Four patients had needed emergency surgery. Three patients had undergone open TG and two others laparoscopic TG, suggesting a significantly higher incidence of DH after laparoscopic TG (3/1302 vs. 2/59, p = 0.017). The diaphragmatic crus incision, creating the space for esophagojejunostomy, had been performed in all cases. The literature yielded seven relevant publications (16 patients). Intervals between TG and DH reduction ranged from 2 days to 36 months. All operations for DH had been carried out emergently.

Conclusion: The risk of DH persisted after TG. DH is potentially a very late complication of TG, presenting as a surgical emergency. Laparoscopic TG was suggested to be a risk factor for postgastrectomy DH. Incising the crus might also be a predictor of DH. Measures to prevent DH, e.g., appropriate closure of the crus, would be recommended in minimally invasive TG.

Keywords: Complication; Diaphragmatic hernia; Emergency; Esophagogastric junction cancer; Gastric cancer; Total gastrectomy.

Publication types

  • Review

MeSH terms

  • Aged
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Gastrectomy / adverse effects*
  • Gastrectomy / methods*
  • Hernia, Diaphragmatic / diagnostic imaging
  • Hernia, Diaphragmatic / etiology*
  • Hernia, Diaphragmatic / mortality
  • Hernia, Diaphragmatic / surgery
  • Herniorrhaphy / methods
  • Herniorrhaphy / mortality
  • Humans
  • Japan
  • Laparoscopy / adverse effects
  • Laparoscopy / methods*
  • Male
  • Middle Aged
  • Neoplasm Invasiveness / pathology
  • Neoplasm Staging
  • Open Abdomen Techniques / adverse effects
  • Open Abdomen Techniques / methods
  • Predictive Value of Tests
  • Reoperation
  • Retrospective Studies
  • Risk Assessment
  • Stomach Neoplasms / pathology
  • Stomach Neoplasms / surgery*
  • Survival Analysis
  • Tertiary Care Centers
  • Time Factors
  • Tomography, X-Ray Computed / methods
  • Treatment Outcome