Paraesophageal hernia repair in the emergency setting: Is laparoscopy with the addition of a fundoplication the new gold standard?

Michael Klinginsmith, BS, Jennifer Jolley, MD, Daniel Lomelin, MPH, Crystal Krause, PhD, Jace Heiden, BS, Dmitry Oleynikov, MD. University of Nebraska Medical Center (UNMC/UNO)

Introduction: The surgical management of paraesophageal hernias (PEH) has evolved in the past few decades. Laparoscopic repair with a fundoplication is currently the preferred strategy in elective situations, but emergencies are still being done open at many institutions typically without an anti-reflux (AR) procedure. The aim of this study is to identify the current surgical practice of PEH repair in urgent and emergent settings and to investigate how patient characteristics influence the use of adjunctive techniques such as an AR procedure or gastrostomy tube (GT) placement.

Methods: This study utilized the University HealthSystem Consortium (UHC) database – a collaboration of data from over 200 hospitals. Specific patient information during October 2010 through June 2014 was retrieved from the UHC’s Clinical Data Base/Resource Manager using the International Classification of Disease 9 (ICD9) diagnosis codes for paraesophageal hernia (PEH) and other study-related procedures. Chi-squared and paired t-tests were applied to evaluate significance in all categorical variables using an alpha value of 0.05.

Results: A total of 7,950 patients over age 18 underwent surgical intervention for PEH from October 2010 to June 2014. Of these, 84.7% were performed laparoscopically versus 15.3% open. Patients deemed urgent/extreme upon admission accounted for 24.6% of the sample population, and almost 70% of those urgent/emergent cases were completed laparoscopically (Table 1). The group of open paraesophageal hernia repairs (OHR) demonstrated a higher proportion of urgent/emergent cases but only accounted for 30% of the total emergencies. With regard to the use of additional procedures, laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9% in LHR vs. 26.3% in OHR). Almost 90% of the elective PEH repairs shown here were accomplished via laparoscopy; and, overall, elective cases were more commonly associated with AR procedures compared to emergencies which frequently only incorporated GT placement (Table 1).

Conclusion: This study demonstrates that laparoscopic repair of PEH has become an accepted strategy in emergencies. When the open technique is used, it is often reserved for emergent surgeries and less commonly includes an AR procedure. In elective PEH repair, laparoscopy with an anti-reflux procedure is clearly the standard of care. These results indicate that the decision to perform an open or laparoscopic PEH repair, with or without an AR procedure or GT, may be based more on the physician’s skill set and surgical practices than the patient’s condition. Long term studies are needed to determine the functional outcomes of these strategies.

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