Better now than later? A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample

John Seligman, BA, Maurice Page, MD, Matthew Frelich, MS, Matthew I Goldblatt, MD, Andrew Kastenmeier, MD, James Wallace, MD, PhD, Heather S Zhao, MS, Aniko Szabo, PhD, Jon C Gould, MD

Medical College of Wisconsin, Department of Surgery, Division of General Surgery

Background: As the population in the United States ages, the incidence of patients presenting for medical attention with a large and/or complex paraesophageal hernia (PEH) is increasing. The morbidity and mortality of the laparoscopic approach to the repair of these hernias is low, making elective repair of symptomatic hernias an option. Some patients with a known PEH may opt not to pursue elective surgery, only to present later with complications related to the hernia necessitating immediate surgery. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set.

Methods: The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006-2008). Primary outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair.

Results: A total of 8,462 records in the data, representing 41,723 patients in the United States undergoing PEH repair in the study interval were identified. Of these procedures, 74.2% were elective and overall, 42.4% were performed laparoscopically. Logistic modeling revealed that age (odds ratio estimate [OR] = 1.012), elective case status (OR = 0.679), a laparoscopic approach (OR = 0.451), and female sex (OR = 0.969) were independently associated with a lower probability of complications. Age (OR = 1.061), elective case status (OR = 0.310), and a laparoscopic approach (OR = 0.365) were independently associated with a lower probability of mortality.

Age Sex (%F) Race (%caucasian) Laparoscopic (%) Complication (%) Mortality (%)
Elective 61.3 69.7 88.5 47.7 16.5 0.37
Emergent 65.5 64.4 84 26.9 33.4 3.17
p-value <0.0001 <0.0001 0.156 <0.0001 <0.0001 <0.0001

Conclusions: Patients who present for emergent repair of PEH are older and more likely to be from an ethnic minority when compared to patients undergoing elective surgery. The need for emergent surgical repair of PEH is associated with a substantial increase in morbidity and mortality. Laparoscopic PEH repair, especially when performed electively, is associated with very low morbidity and mortality rates. Although the symptomatic nature of these hernias could not be determined from the current data set, we believe that this data supports a strategy involving elective laparoscopic repair of these hernias in patients who are of an acceptable operative risk.


Session: Poster Presentation

Program Number: P216

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