Impact of obesity on the morbidity of laparoscopic paraesophageal hernia repair: Analysis using the NSQIP Database

Radu Pescarus, MD, Maria A Cassera, BS, Eran Shlomovitz, MD, Ahmed Sharata, MD, Kevin M Reavis, MD, Christy M Dunst, MD, Lee L Swanstrom, MD. Providence Cancer Center, Portland; The Oregon Clinic, Portland, Oregon.

The impact of obesity on outcomes after antireflux surgery is controversial. It is recognized, however, that obesity increases the risk of early recurrence (ROR) for other hernias such as inguinal and ventral and increases the morbidity risk of most surgeries. The impact of obesity on the morbidity of paraesophageal hernia (PEH) repairs has not been looked at. Our objective is to investigate the impact of obesity on post-operative outcomes after laparoscopic PEH repair in a large prospective database.

We analyzed data from a population based database of primary elective laparoscopic PEH repairs. Patients who underwent a laparoscopic PEH repair without mesh (CPT code 43281) and with mesh (CPT code 43282) were identified using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2005 through 2011. Pre-operative factors including age, American Society of Anesthesiology (ASA) classification ≥ 3, smoking and diabetes were assessed using bivariate analysis (Mann-Whitney and Fisher’s exact test). Multivariate regression analysis was used to compare 30 day outcomes including pulmonary complications, cardiac events, thromboembolism, sepsis, surgical site infections (SSI), post-operative length of stay and death.

A total of 2834 patients that underwent primary elective laparoscopic PEH repair were identified. Those who underwent an outpatient procedure (459 patients), underwent emergency surgery (57 patients), or who did not have height or weight data available (9 patients) were excluded. The remaining patients were divided into two groups based on calculated body mass index (BMI): group I (<25 BMI, normal weight) containing 437 patients, and group II (>25 BMI, overweight and obese) containing 1872 patients.

Compared to group I, group II was younger (60 vs 73 years median; p<0.001), with more diabetics (9% vs 5%; p=0.001) and with a greater female-to-male ratio (74% vs 67%; p=0.004). The 2 groups were similar in terms of smoking (p=0.576) and ASA class ≥ 3 (p=0.222).

The overall mortality in the study group was 0.7% with no significant difference between the 2 groups (p=0.523). The post-operative length of stay was 4.3±7.1 days for group I and 2.9±3.7 days for group II (p<0.001). The difference in length of stay remains significant even when comparing the patients having complications (p=0.523) in the 2 groups or the patients without complications (p<0.001) in the 2 groups. The increase in length of stay in the lower BMI group may be explained by the significantly greater number of the elderly in group I.

On multivariate regression analysis, group II patients experienced more deep and organ space SSI (p=0.023). Interestingly, superficial SSI (p=0.8), pulmonary (p=0.113), cardiac (p=0.605), septic (p=0.796) and thromboembolic (p=0.384) complications were not different between the two groups.

Our analysis of short-term post operative outcomes after laparoscopic PEH repair using NSQIP database shows no increase in mortality in overweight/obese patients in spite of the significant difference in age between the two cohorts. While deep and organ space SSI are more frequent in patients with BMI>25, all other analyzed morbidities appear to be equivalent.

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