Mediastinal herniation of the biliary tract leading to bile duct obstruction following oesophagectomy

Abstract

Surgical management of oesophageal and gastro-oesophageal junction malignancies is one of the most challenging situations confronting the surgeon. Attaining a complete circumferential resection margin of lower-third oesophageal and gastro-oesophageal junction locally advanced carcinomas requires en-bloc resection of the hiatus and all the peri-oesophageal tissue and pleura. This results in an increased risk of herniation of the abdominal organs through the enlarged hiatus, which carries significant risk of morbidity and mortality. The incidence of this complication is higher than has been reported. Surgical management of symptomatic hernias is the standard treatment while criteria for managing asymptomatic hernias are less clear. We report a rare case of a late mediastinal herniation of the pancreas and bile duct, leading to obstructive jaundice following oesophagectomy which was treated successfully in our unit.

Case of Delayed Transhiatal Pancreatic Herniation After Esophagectomy

“…Herniation of the pancreas into the mediastinum after esophagectomy is extremely rare with only 4 cases reported in the literature. [1][2][3][4] In 1 case, the patient required emergent exploratory laparotomy secondary to bile duct obstruction. 4 The rest were asymptomatic.…”

“…[1][2][3][4] In 1 case, the patient required emergent exploratory laparotomy secondary to bile duct obstruction. 4 The rest were asymptomatic. [1][2][3] The mechanism of pancreatic herniation into the mediastinum is believed to be secondary to stretching of the transverse mesocolon, which connects the inferior aspect of the pancreas to the transverse colon.…”

“…Some authors suggest surgical revision in all symptomatic patients without a poor prognosis because of potentially catastrophic consequences of hernia enlargement. 1,4 However, despite hiatal hernia revision, recurrence of the hiatal hernia can be observed in up to 30% of patients. 1…”