The effect of prophylactic cruroplasty on the incidence of hiatal herniation after robot-assisted minimally invasive esophagectomy (RAMIE)

BACKGROUND: Hiatal herniation (HH) following esophagectomy can cause severe complications and affect functional outcomes. This study assessed whether prophylactic cruroplasty during robot-assisted minimally invasive esophagectomy (RAMIE) reduces HH incidence.

METHODS: Patients undergoing curative RAMIE with cervical anastomosis for esophageal cancer at a high-volume center were included. Cruroplasty became routine in 2017 unless the hiatus was narrow. The primary outcome was HH incidence with versus without cruroplasty. Median follow-up was calculated using the reverse Kaplan-Meier method. Kaplan-Meier curves assessed HH-free survival and cumulative incidences up to 4 years, considering the time-dependent nature of HH. The log-rank test compared groups. Multivariable Cox regression evaluated the association between cruroplasty and HH, with hazard ratios (HR) and 95%-confidence interval (95%CI).

RESULTS: Between 2003 and 2023, 366 patients underwent RAMIE with cervical anastomosis. Median follow was 81 months (95%CI 71-91). In the cruroplasty group, 5 (5%) developed a HH (2 symptomatic, 3 asymptomatic), while 23 (9%) of patients without cruroplasty developed a HH (5 acute, 8 symptomatic, 10 asymptomatic). Most HHs were detected within 2 years (71%; n = 20). The 4-year cumulative incidence was 5.7% with cruroplasty and 11.1% without (P = 0.289). Imaging was performed in 77 of 101 patients (76%) with cruroplasty and 228 of 265 patients (86%) without cruroplasty. Cox regression revealed no significant association between cruroplasty and HH (HR 0.652, 95%CI 0.244-1.740).

CONCLUSION: Prophylactic cruroplasty may reduce HH in RAMIE with cervical anastomose, though it cannot always prevent HH. Further research is warranted to confirm these findings and evaluate its role in other types of esophagectomy.