International expert consensus on the management of paraconduit herniation after esophagectomy: results of a two-round Delphi survey.

AIMS: The management of Paraconduit Herniation after Esophagectomy (PCH) is controversial. This survey aims to identify recommended strategies for prevention and patient handling (including indication, preoperative work-up, technical-surgical details and follow-up) using the Delphi methodology. METHODS: We conducted a 2-round, 32-question, web-based International Delphi survey focusing on non-revisional, elective PCH in asymptomatic patients among surgical upper GI experts. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. RESULTS: Eighty-two surgeons with a median (IQR) experience of 17.5 (12-27) years from 19 countries across four continents (Europe, North America, Asia, Australia) participated in both Delphi rounds (response rate 43%). The annual median (IQR) individual and institutional caseload was 5 (5-5) and 5 (5-10) PCH surgeries, respectively. After Delphi round 2, strong expert consensus (> 75% agreement) was achieved for: (1) Preventive measures: avoiding opening the left pleura during index esophagectomy; (2) Indications for repair: prioritizing biologically younger (< 80 years) and tumor-free patients, complex multi-organ herniation, and radiographically enlarging PCH on surveillance, while explicitly discouraging repair for stable PCH or tumor recurrence; (3) Surgical approach: preferring laparoscopic or robotic-assisted laparoscopy with single-stitch suture hiatoplasty and gastropexy; and (4) Mesh use: utilizing biosynthetic absorbable mesh for high-risk selective cases (recurrent PCH, weak crura, large hiatal area) fixed with sutures, while explicitly discouraging the use of tacks. In contrast, many items from the questionnaire including surgical measures to prevent PCH and most technical details of mesh augmentation (material, shape, and placement) did not reach positive or negative concordance. CONCLUSIONS: This International Delphi survey represents the first expert-led process to identify recommended strategies for the management of PCH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.