Alexis Graham, MD, Miloslawa Stem, MS, Alisa Coker, MD, Gina Adrales, MD. Johns Hopkins Hospital
INTRODUCTION: Increased age, higher American Society of Anesthesiologists (ASA) score, and frailty are known risk factors for morbidity and mortality following paraesophageal hernia (PEH) repair. Understanding the effect of sex on outcomes may impact the approach to repair.
METHODS: A retrospective cohort study of ACS-NSQIP patients who underwent primary laparoscopic PEH repair between 2012-2016 was performed. Those undergoing concurrent bariatric and esophagectomy procedures were excluded. Primary outcomes included 30-day morbidity, mortality, readmission, and reoperation with patients stratified by sex (Table). Multivariable logistic regression analysis was used to identify risk factors for emergent repair and to assess the impact of sex on outcomes. Separate analyses were performed for elective and emergent cases.
RESULTS: Of the 15,596 patients who met study criteria, 71.3% were female(F) and 28.7% were male(M). Of these, 97.8% (n=15,429) underwent elective repair (97.9% F) and 2.2% (n=347) underwent emergent repair (67.4% F). Within the elective repair group, men were younger (age>65 years; 39.9 vs 50.3%), thinner (BMI>30; 37.2 vs 51.1%), and less healthy (ASA>3; 2.7% vs 1.9%) with an increased incidence of bleeding diathesis (2.3 vs 1.7%), longer operating times (min; 155±78 vs 142±69), and increased mortality (0.82 vs 0.48%), when compared to females, respectively. Significant risk factors for mortality included male sex (OR 1.86; 95%CI (1.20-2.89), p=0.006), COPD (OR 1.99 (1.11-3.57), p=0.021), bleeding diathesis (OR 3.34 (1.67-6.68); p=0.001), age >65y (3.6 (1.97-6.56), p<0.001), and ASA>3 (6.48 (3.05-13.78), p<0.001). There was no difference between sexes in morbidity, readmission, or reoperation.
Among the emergent group, baseline characteristics between sexes where comparable except for longer operative time in males (181±74 min) vs females (157±72 min). There was no significant difference in outcomes between sexes in the emergent group. Significant risk factors for emergent repair included age≥75 (OR 1.48, (1.02-2.15), p=0.039), ASA III and IV-V (OR 1.95, (1.48-2.56); OR 8.90, (5.85-13.55); respectively; both p<0.001), and bleeding diathesis (OR 2.85, (1.83-4.42), p<0.001).
Those with BMI>30 had a decreased mortality risk in the elective setting (OR 0.59 (0.36-0.96), p=0.034) and a decreased risk of needing emergent repair (OR 0.60 (0.44-0.81), p=0.001).
CONCLUSIONS: Male sex was a significant predictor of 30-day mortality in PEH repair independent of poor health. While higher BMI appears to be protective, it may correlate with female sex. Differences in fat distribution between sexes may contribute to longer operative times and subsequently greater morbidity in males.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95620
Program Number: P524
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster