Subhash Reddy, MD, Jonathan Grotts, MA, David Thoman, MD
Santa Barbara Cottage Hospital
Background:
Antireflux surgery and paraesophageal hernia repair are increasingly done in the elderly and those with multiple comorbidities. We sought to identify risk factors for adverse postoperative events after open or laparoscopic fundoplication by querying a large national database.
Methods:
Under the data use agreement for the American College of Surgeons National Surgical Quality Improvement (NSQIP) Program Public Use File, and with the institutional review board approval, we reviewed perioperative variables of patients who underwent fundoplication with or without paraesophageal hernia repair from 2006 to 2010. Patients who underwent a revision of a previous fundoplication or fundoplication for Heller myotomy as the principal procedure were excluded. The primary endpoint was mortality and secondary endpoints included post-operative adverse events. A multivariate model was used to control for pre-operative morbidity, age and BMI. Odds ratio, Chi square, logistic regression were performed using SPSS 2011.
Results:
Of 6,667 fundoplications analyzed, 5,571 (83.5%) were laparoscopic fundoplications and 1,725 paraesophageal hernia repairs. Overall, patients who had an open approach had more comorbidities than laparoscopic group. Using multivariate logistic regression preoperative variables likes Age > 70, and sepsis were independently associated with mortality, respiratory, urinary complications and transfusion requirements (P< 0.05), BMI >30 and steroids (P<0.05) were associated with wound infections. Laparoscopic procedure (p<0.05) showed protective effect for all post operative complications. Respiratory and cardiac comorbidities were not independently associated with postoperative adverse events (p> 0.05). Demographics and adverse events are summarized in the attached table.
| Variables |
Open (n=1096) |
Laparoscopic (n=5571) |
p value |
| Mean Age | 62.7 years | 55.4 years | 0.001 |
| Male | 410(37.4%) | 1999(35.8%) | 0.29 |
| Mean BMI | 29.1 | 29.7 | 0.001 |
| Mean Operation Time | 96 minutes | 75 minutes | 0.001 |
| Total Length of Stay | 5 days | 2 days | 0.001 |
| Wound Class- Contaminated | 34(3.1%) | 61(1.1%) | 0.001 |
| Postooperative Wound Infection | 86(7.8%) | 5491%) | 0.001 |
| Postoperative Respiratory events | 69(6.4%) | 75(1.3%) | 0.001 |
| Postoperative Cardiac events | 3 | 7 | 0.3 |
| Return to OR in 30 days | 52(4.7%) | 91(1.6%) | 0.001 |
| Blood Requring Transfusions | 21(1.9%) | 25(0.4%) | 0.001 |
| Mortality | 21(1.9%) | 17(0.3%) | 0.001 |
Conclusion:
Patients undergoing open fundoplication are of a higher acuity then patients undergoing laparoscopy. After controlling for risk factors, an open procedure does not result in higher mortality, but is associated with significantly increased morbidity.
Session: Podium Presentation
Program Number: S094