Rafik Sorial, Julio F. Fiore Jr, Jonathan Spicer, Melina Vassiliou, Gerald M Fried, Liane S Feldman, Lorenzo E Ferri, Lawrence Lee, Carmen L Mueller. McGill University Health Center
Introduction: Historically, surgery was offered to all patients with giant paraesophageal hernia to avoid the risks of gastric volvulus and incarceration. A paradigm shift occurred 15 years ago when decision-model analysis showed watchful waiting to be superior to elective laparoscopic repair (LPEHR) for elderly and minimally symptomatic patients due to high rates of morbidity and mortality with elective surgery. Recent reports suggest modern era outcomes have improved, such that elective repair may now be favorable for more patients. Furthermore, the morbidity of emergency surgery may still be significant.
The objectives of this study were to compare modern-era surgical outcomes after elective and emergency repair of giant paraesophageal hernias at a high volume tertiary care center.
Methods: A retrospective review was conducted of all Type II-IV paraesophageal hernia repairs performed between Jan 1, 2012-Sept 15, 2017. Type I hiatal hernias (HH), HHs after esophagectomy, and cases with planned simultaneous procedures other than cholecystectomy were excluded from the final analysis. Comparisons between groups were made using t-test for continuous variables and chi squared test for categorical variables. Multiple logistic regression was used to identify independent risk factors for morbidity.
Results: A total of 309 cases were reviewed of which 194 met inclusion criteria (17 emergency, 177 elective). Eight had Type II PEH, 141 had Type III, and 45 had Type IV. Emergency patients were older (78 (SD12.8) vs 70 (SD10.6) years; p=0.003), more comorbid (ASA ≥ 3: 94% vs 33%, p<0.0001), and more likely to undergo gastrostomy tube insertion (23.5% vs 0%, p=0.003). Mean length of stay was shorter in the elective group: 2 (SD2.8) vs. 11 (SD17.7) days, p<0.0001, and emergency patients were less likely to return directly to their original residence at discharge (70.6% vs 99.4%, p<0.0001). There were significantly more major complications (Clavien-Dindo score ≥3) in the emergency group (29.4% vs 5.6%, p=0.006). Type of PEH, conversion to open, operative time, blood loss, splenectomy, gastric perforation, 30-day ER visits, readmission and re-operation rates were similar between groups. There were no peri-operative deaths in either group. In the elective group, age was not an independent risk factor for complications (OR 1.05, 95%CI 0.98-1.12).
Conclusions: The incidence of major complications and mortality in this series were much lower than those previously reported for elective LPEHR, while morbidity after emergency repair remains high. The paradigm of watchful waiting for elderly and/or minimally symptomatic patients with giant PEH should be revisited.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87769
Program Number: P449
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster