Lindsey N Clark, MD, Melissa C Helm, BS, Jon C Gould, MD. Medical College of Wisconsin
Introduction: Patients who undergo surgery to repair a paraesophageal hernia may suffer from primarily gastroesophageal reflux (GERD) symptoms, obstructive symptoms related to the paraesophageal hernia (early satiety, dysphagia, or postprandial epigastric pain), or both kinds of symptoms. Some patients with obstructive symptoms need to dramatically modify their diet; many unintentionally lose a significant amount of weight prior to surgery. A subset of patients will develop Cameron’s erosions related to compression and partial volvulus of the herniated stomach that can cause anemia. Given the heterogeneous nature of patients who ultimately undergo surgery to correct a paraesophageal hernia, we sought to determine if patients with anemia or hypoalbuminemia suffered from increased morbidity or mortality following repair.
Methods: The American College of Surgeons National Surgical Quality Improvement Program datasets from 2011-2015 were used to identify patients undergoing laparoscopic, open, thoracic or thoracoabdominal paraesophageal hernia repair. Malnutrition was defined as preoperative albumin <3.5g/dL. Preoperative anemia was defined as hematocrit less than 36% for females and 39% for males, based on the World Health Organization definition. All outcomes were within thirty days. Binary logistic regression was used to evaluate if preoperative anemia or malnutrition was predictive of morbidity and mortality.
Results: A total of 15,105 patients met inclusion criteria; 70.9% female, median age 63. Of these patients, 7,943 had a known preoperative albumin; mean 3.9g/dL. 3.9% suffered from malnutrition. There were 13,139 patients with a known preoperative hematocrit; mean for female patients was 38.6%, mean for male patients was 41.4%. Anemic patients comprised 23.1% of the study population. Both anemia and malnutrition were associated with higher rates of complications, readmissions, reoperations and mortality (Table 1). Average postoperative length of stay was 6.1 days when malnourished and 3.1 days in those not malnourished (p<0.0001). Length of stay was found to differ in anemic patients although to a lesser degree: 4.1 days in anemic patients compared to 2.8 days in nonanemic patients (p<0.0001). Logistic regression showed greatest increase risk in myocardial infarction when anemic (Figure 1) and mortality when malnourished (Figure 2).
Conclusion: Malnutrition and anemia increase patient risk when undergoing paraesophageal hernia repair. There is an increase in morbidity and mortality as well as longer length of stay. Based on these findings, surgeons can target nutritional deficits to optimize patient outcomes. This information also is useful for setting realistic expectations when educating patients preoperatively regarding risks of repair.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85249
Program Number: S129
Presentation Session: ERAS Session
Presentation Type: Podium