Repair of Symptomatic Paraesophageal Hernias in Elderly (>70 Years) Patients Results in Sustained Quality of Life at 5 or More Years

Oleg V Merzlikin, MD, Brian E Louie, MD, Alexander S Farivar, MD, Dale Shultz, Ralph W Aye, MD. Swedish Medical Center

Introduction:  Paraesophageal hernias (PEH) involve herniation of stomach and/or other viscera into the mediastinum resulting in symptoms that reduce quality of life (QOL).  Surgical repair in the elderly has low morbidity and results in significant improvement in QOL in the short term.  There is a paucity of long-term data detailing the outcomes. Without this data, patients or their physicians may eschew surgery due to advanced age, concerns about comorbidities, and life expectancy despite reduced QOL.   We evaluated the long-term QOL in elderly patients at least 5 years after repair.

Materials and Methods: We performed a retrospective chart review of consecutive patients 70 or greater who underwent PEH repair between 2003-2010. The PEH was required to be 5+ cm in axial length with a paraesophageal component. Quality of life was assessed preoperatively, at 12-24 months and at 5+ years using QOLRAD, GERD-HRQL and a dysphagia score.

Results: A total 73 patients underwent surgical repair.  Five patients were lost to follow up leaving 68 patients for analysis including 27 (40%) males and 41 (60%) females. Median age at repair was 77.6 years (IQR 73.1-82.3). There were two 90-day mortalities (2.4%), with one occurring within 30 days of surgery.

Overall, QOLRAD improved from 5.0 to 6.9 (p=0.002), GERD-HRQL improved from 13 to 2 (p=0.0003) and dysphagia improved from 12 to 45 (p=0.01) at a median follow up of 6.4 years.

During follow up, 22 (30%) patients died at a rate similar to the population. Deceased patients lived a median of 4 years (IQR 1.4-5.3) after repair with a median age at repair of 80.2 years (IQR 76.6-84.9). At a median follow up of 1.6 years, this group reported QOLRAD improved from 5.9 to 7.0 (p=0.05), GERD-HRQL improved from 14 to 4 (p=0.03) and dysphagia improved from 17 to 34 (p=0.02).

In the surviving 46 patients median follow up was 7.4 years (IQR 6.7-8.76). There were 7 recurrences.  From pre-operative to short term to long term, QOLRAD improved from 4.4 to 7.0 to 7.0 (p=0.01); GERD-HRQL improved from 11.5 to 3 to 1 (p=0.0002) and dysphagia improved from 12 to 18 to 45 (p=0.01)

Conclusions:  In elderly patients, surgical repair of a symptomatic PEH results in sustained improvement in quality of life.  Ninety-day mortality was low and patients who died in follow up survived 4 years after surgery with good quality of life.  These results justify surgical repair of symptomatic PEH in the elderly.