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Minimally Invasive Approach To Paraesophageal Hernia Repair Is Superior To Open, Even In The Emergent Setting: A Large National Database Analysis.

Salim Hosein, MD, Laura Flores, Priscila R Armijo, MD, Tyson Carlson, Dmitry Oleynikov, MD. University of Nebraska Medical Center

Introduction: We aimed to examine the utilization of various operative approaches to hiatal hernia repair (HHR) in elective and emergent/urgent (U) settings and to compare outcomes.

Methods: Vizient database was queried from 2015 to 2017 for adult patients with HHR using ICD codes. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robot-assisted (RHHR) groups, and further stratified by elective or U status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis was done using SPSS v.23.0.

Results: 9,171 adults underwent HHR during this period (OHHR: N=1,534; LHHR: N=6,796; RHHR: N=841). Overall, LHHR was the most frequently utilized approach (74.1%), followed by OHRR (16.7%) and then RHHR (9.2%). Table 1 demonstrates the utilization of each approach in both elective and U settings. OHHR approach was employed three times as frequently in U settings, compared to elective and 9.6% of elective, minor illness severity patients had OHHR. Overall analysis revealed that OHHR had longer average length of stay (LOS, 9.41 vs. <4 days, p<0.05) and higher post-operative complication rates (8.8% vs <3.8%, p<0.05), mortality (2.7% vs <0.5%) and mean direct costs ($27,842 vs <$10,407), when compared to both LHHR and RHHR. Further analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR in terms of complications (p<0.05), cost (p<0.001) and LOS (p<0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the U setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the U setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR in terms of LOS (p=0.002, p<0.0001) and cost (p=0.0133, p<0.001). In severe-extremely ill patients, despite being proportionately more utilized, OHHR was not superior to LHHR; in fact, complication, cost and mortality trends (all p>0.05) favored LHHR.

Conclusions: Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 95481

Program Number: P522

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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