Kaplan JA, Schecter S, Lin MYC, Rogers SJ, Carter JT. Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair. JAMA Surg. 2015;150(11):1094-1096. doi:10.1001/jamasurg.2015.1867
For decades, the standard of care for a paraesophageal hiatal hernia (PEH) was surgical repair after diagnosis, irrespective of symptoms. This standard of care was based on the reported high risk of acute gastric volvulus, strangulation, bleeding, or obstruction associated with untreated PEH and on the high mortality associated with emergency repair.1,2 A paradigm shift occurred in 2002, when Stylopoulos et al,3 using Markov analysis, found that watchful waiting was superior to elective repair for patients older than 65 years of age with a minimally symptomatic PEH. As a result, many patients with a PEH deferred surgery and opted for watchful waiting. A predictable consequence of watchful waiting has been an increase in the number of patients presenting with an acute PEH, sometimes with catastrophic outcomes.4 We characterized outcomes of emergency PEH repair in the modern era compared with elective repair using data from the American College of Surgeons National Surgical Quality Improvement Program.
We reviewed all PEH repairs reported to the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012. Inclusion criteria were an age of 18 years or older at the time of surgery, an International Classification of Diseases, Ninth Revision (ICD-9) primary diagnosis code of diaphragmatic hernia (ie, ICD-9 code 551.3, 552.3, or 553.3), and a primary Current Procedural Terminology code indicating repair, as described by Mungo et al.5 Demographic data, comorbidities, and preoperative laboratory values were reviewed. The primary outcome was 30-day mortality. Secondary outcomes were hospital length of stay and serious morbidity (defined as return to the operating room, cardiac complication, sepsis, shock, ventilation >48 hours, unplanned reintubation, or cerebrovascular accident or stroke). Because this research involves only deidentified patient information, it did not require institutional review board approval from the University of California, San Francisco.
Predictors of serious morbidity and 30-day mortality were identified in univariate logistic regression. Multivariate predictors were identified using backward-stepwise logistic regression. Statistical significance was defined as P < .05.
Of 10 656 patients studied, 383 (3.6%) underwent an emergency PEH repair, and 10 273 (96.4%) underwent an elective PEH repair. Patients who underwent an emergency PEH repair were older, weighed less, and had more medical comorbidities (data not shown). On average, patients who underwent an emergency PEH repair were hospitalized 5 days longer than patients who underwent an elective PEH repair (mean [SD], 8  days vs 3  days; P < .001). The mortality rate was 5.5% for patients who underwent an emergency PEH repair and 0.65% for patients who underwent an elective PEH repair (P < .001). Serious morbidity occurred in 21.0% of patients who underwent an emergency PEH repair but only 5.2% of patients who underwent an elective PEH repair (P < .001). In multivariate analysis, emergency PEH repair did not predict mortality (Table 1) but did increase the odds of serious morbidity (Table 2). Patient frailty (advanced age, low serum albumin level, and dependent functional status) and the use of an open surgical approach were associated with both increased mortality and serious morbidity. Laparoscopic elective repair had the lowest mortality rate (0.46%).
In a large-scale national registry, emergency PEH repair was uncommon (3.6% of cases) but was associated with an unadjusted 9-fold increased odds of mortality and a 5-fold increased odds of serious morbidity. After adjustment for patient factors and operative technique, however, emergency PEH repair predicted serious morbidity but not mortality. These results reinforce the idea that the primary driver of surgical outcome was patient frailty, and, as such, frailty should be assessed whenever recommendations for PEH are being made.
We also found very low mortality and morbidity rates associated with elective laparoscopic PEH repair in the modern era. At the time of the Markov analysis in 2002, the mortality rate associated with elective PEH repair was 1.4%. Laparoscopic surgery and open surgery have become safer since then, with our study reporting less than half (0.6%) the mortality after elective repair than that in 2002 (and consistent with other reports5). The mortality and morbidity rates associated with laparoscopic PEH repair were on par with those associated with laparoscopic cholecystectomy.6 With such excellent short-term outcomes, elective laparoscopic repair should be weighed into treatment recommendations for patients with a PEH, particularly younger patients.
Corresponding Author: Jennifer A. Kaplan, MD, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, S-321, San Francisco, CA 94143-0470 (firstname.lastname@example.org).
Published Online: August 26, 2015. doi:10.1001/jamasurg.2015.1867.
Author Contributions: Dr Kaplan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kaplan, Rogers, Carter.
Acquisition, analysis, or interpretation of data: Kaplan, Schecter, Lin, Carter.
Drafting of the manuscript: Kaplan, Carter.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kaplan, Carter.
Administrative, technical, or material support: Lin, Carter.
Study supervision: Rogers, Carter.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 86th Annual Meeting of the Pacific Coast Surgical Association; February 20, 2015; Monterey, California.