Safety of Laparoscopic Paraesophageal Hernia Repair in Octogenarians

BACKGROUND
Paraesophageal hernias (PEH) most commonly afflict the elderly, carrying a 10-30% risk of complications including gastrointestinal hemorrhage, gastric volvulus and strangulation. Ninety percent of all PEH hernias in the United States are still being performed via open approach. As a result, due to their frequent accompanying comorbidities and resultant fears of perioperative morbidity, many elderly patients are often not referred for surgical repair. We hypothesized that laparoscopic PEH repair is safe and effective even in the very elderly.
METHODS
A retrospective chart review of patients ≥80 years old, undergoing PEH repair at a tertiary care center was performed. Both elective and urgent cases were reviewed, all of which were performed laparoscopically. Patient demographics, pre-operative symptoms, operative details, perioperative complications, 30-day mortality, and post-operative symptom resolution were analyzed.
RESULTS
Between 1998 and 2009, 59 consecutive patients, age 80 and older, underwent laparoscopic PEH repair. Mean age was 86.1 years (range: 82-90) with a marked female preponderance (1:3). Seventy-six percent of patients had at least 1 comorbidity. Most patients had multiple pre-operative symptoms including post-priandial pain or bloating (64%), dysphagia (40%), food regurgitation or vomiting (46%), shortness of breath (32%) and GERD (37%). There were 7 (11.8%) non-elective cases and 52 (88.1%) elective cases performed. Mean operative time was 193 minutes (range: 127-354) and there was one (1.7%) conversion to open operation. There were 5 (8.5%) intra-operative complications: 3 pneumothoraces, and 2 esophageal tears. Mean length of hospitalization was 2.7 days (range 2-20). There were 9 (15.2%) postoperative complications and 2 (3.4%) deaths (one myocardial infarction and one esophageal leak with sepsis). Follow up data was available for 90% of patients, of whom 89.4 % experienced complete or partial symptom resolution. CONCLUSION
Laparoscopic PEH repair may be performed safely even in octogenerians. In fact, perioperative morbidity and mortality rates of the laparoscopic approach found in this series are superior to traditional open repairs. Furthermore, laparoscopic PEH repair provided improvement in the vast majority of our patients. We believe our findings should encourage elective surgical evaluation even in very elderly patients and that age should not be viewed as a contraindication to PEH repair. The majority of these repairs should be performed laparoscopically to maximize patient benefit.


Session: Podium Presentation

Program Number: S099

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