Paraesophageal Hernia Repair Outcomes Using Minimally Invasive Approaches

Minimally invasive surgery (MIS) has facilitated improved outcomes for various gastrointestinal operations. Many studies have shown improved perioperative outcomes in paraesophageal hernia (PEH) repair with MIS approaches, but the optimal approach is still debated.¹ In addition, the extent to which MIS has been adopted on the national level for PEH repair is unknown. Consequently, our study aimed to identify trends in utilization and outcomes for the MIS management of PEH.

We performed a retrospective review of inpatient admissions for PEH repair extracted from the Nationwide Inpatient Sample, a 20% stratified sample of admissions from nonfederal hospitals participating in the Healthcare Cost and Utilization Project between 2002 and 2012. Variables collected included age, race, sex, in-hospital mortality, year of surgery, elective vs nonelective surgery, preoperative mortality risk score, hospital location and volume, and patient comorbidities. Identification of PEH repair was based on International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes (53.7-53.84, 54.21). The proportion of PEH repairs performed via MIS approach was examined over time. In-hospital morbidity was identified by secondary ICD-9-CM diagnosis codes and further classified into wound, bleeding, urinary, septic, respiratory, cardiac, intraoperative, and thromboembolic complications. This study was approved by the institutional review board of Oregon Health and Science University, and waiver of informed consent was granted. Patients were deidentified. Baseline differences between groups were adjusted for by using multivariate logistic regression models and outcomes compared between MIS and open surgery. A 2-sided P < .001 was considered statistically significant.

A total of 97 393 PEH repairs were extracted from the database. Baseline characteristics are shown in the Table. Between 2002 and 2012, the proportion of MIS repairs increased from 9.8% (542 of 5531) to 79.6% (14 190 of 178 266) (OR, 1.66; 95% CI, 1.61-1.71; P < .001). This increase was associated with decreased in-hospital mortality from 3.5% (196 of 5546) in 2002 to 1.2% (205 of 17 830) in 2012 (OR, 0.90; 95% CI, 0.87-0.93; P < .001), and decreased rates of any complication from 29.8% (1656 of 5552) to 20.6% (3675 of 17 830) over the study period (OR, 0.95; 95% CI, 0.95-0.97; P < .001). When compared with open procedures, MIS was associated with significantly decreased rates of intraoperative injury and in-hospital mortality (0.6% [263 of 41 684] vs 3.0% [1672 of 56 040]; P < .001) and decreased wound, bleeding, urinary, septic, respiratory, and cardiac complications (Figure). Mean length of stay (LOS) was significantly less for MIS compared with the open approach (4.2 days vs 8.5 days, P < .001). There was no difference in thromboembolic complications between MIS and open approaches (0.6% vs 1.5%; P = .12).

This large population-based study shows that MIS for the repair of PEH accounted for 80% (14 190 of 17 830) of the surgical treatments in 2012. Early criticism of the MIS approach included that it was associated with a high rate of hiatal hernia recurrence.^2,3 However, refined techniques have led to reduction in hiatal hernia recurrences⁴ and decreased postoperative complications and LOS. Most hiatal hernia recurrences after MIS PEH repair are asymptomatic and usually detected on radiologic imaging.^4,5 Studies have found that recurrences requiring reoperation after MIS repairs are low at 2.2% to 6%.^5,6 Regardless, a role remains for open PEH repairs in cases of multiple prior abdominal operations and acute strangulation and in patients with an unstable condition.

Limitations include the use of retrospective, administrative data because coding may be driven by financial rather than clinical considerations. A single code for MIS PEH repair was introduced in October 2008. Prior to that time, MIS repairs may have been underreported as coding of the PEH repair and MIS procedure occurred separately. Despite this, our findings are consistent with prior reports of improved outcomes with MIS, and the data demonstrate widespread adoption of MIS for PEH repair on a national level.

Accepted for Publication: May 14, 2017.

Corresponding Author: James P. Dolan, MD, MCR, Division of Gastrointestinal and General Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR 97239 (dolanj@ohsu.edu).

Published Online: August 23, 2017. doi:10.1001/jamasurg.2017.2868

Author Contributions: Drs McLaren and Dolan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: McLaren, Hunter, Dolan.

Acquisition, analysis, or interpretation of data: McLaren, Hart, Dolan.

Drafting of the manuscript: McLaren, Dolan.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: McLaren, Hart.

Obtained funding: Dolan.

Administrative, technical, or material support: Dolan.

Study supervision: Hunter, Dolan.

Conflict of Interest Disclosures: None reported.

Funding/Support: The funding for this research was provided by the Oregon Clinical and Translational Research Institute and grant UL1TR000128 from the National Center for Advancing Translational Sciences of the National Institutes of Health (Dr Dolan).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This study was presented at the 2017 Pacific Coast Surgical Association Annual Meeting; February 18, 2017; Indian Wells, California.