David M Parker, MD, FACS, Amrit A Rambhajan, MD, Anna R Ibele, MD, Kathleen Johanson, DO, Vladin Obradovic, MD, Jon D Gabrielsen, MD, FACS, Anthony T Petrick, MD, FACS
Geisinger Medical Center
Introduction: Acute incarceration of paraesophageal hernias (PEH) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open incisions. Our study was designed to evaluate the feasibility, safety and efficacy of laparoscopic repair (LPEHR) in patients with PEH and acute gastric volvulus.
Methods: We reviewed our prospectively maintained database and identified 269 patients undergoing an initial LPEHR at Geisinger Medical Center between January 2003 and January 2012. Patients were divided into group A (Acute), Group B (elective patients matched 1:3 to group A by age and comorbidity), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH undergoing urgent repair. The age, Charlson score, operative time, LOS, morbidity, mortality and recurrence rates were compared using the Wilcoxon rank sum test.
Results: Patients in each group were A (n=25), B (n=65) and C (n=242). Eight patients could not be matched due to high Charlson scores. Group A was similar to the matched group B, with no significant differences in age (73.2 vs 73.0, p=0.978), Charlson score (5.56 vs 4.83; p=0.371), BMI (29.6 vs 29.5; p=0.864) or mean operative time (182.9 vs 171.2 minutes; p=0.652). The LOS was significantly longer for the acute group (4.56 vs 2.72 days; p<0.001) and 20% of patients in A required an ICU stay compared to no ICU admissions in B (p<0.001). Group A had 4 major and 16 minor complications (88%) compared with overall morbidity of 17% in group B (p<0.001). However, the recurrence rate was similar between groups (4% vs 3%; p=0.858) at a mean follow up of 16.6 months (A) and 29.4 months (B; p=0.032) There were no mortalities in either group and all patients underwent successful laparoscopic repair.
When compared to all patients undergoing elective LPEHR, Group A was older (mean 73.3; range 54-91) compared to group C (mean 63,2; range 32-98) ( p=0.008) and had a higher Charlson score (5.56 vs 3.24; p<0.001). The groups had similar BMIs (29.6 vs 29.4; p=.998) and operative times (182.9 min. vs 175.7 min; p=.957). LOS was longer in the acute group A (4.6 vs 2.6 days; p<.001) and morbidity was significantly higher than group C (88.4% vs 16.7%; p<0.001). Both groups had a low recurrence rate (4% vs 4.6%; p=.891) at mean follow up of 16.6 and 24.1 months respectively (p=0.045). There was no significant difference in mortality (0% vs 0.8%; p=.648),
Conclusion: Historically patients presenting with acute symptoms related to PEH have required open repair associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS even when matched. However, the LOS remained shorter than reported for open repair and did not result in any mortality. The recurrence rates in all groups were low and comparable to elective repairs. We believe that laparoscopic repair of acute PEH is feasible, safe and effective when done in experienced centers.
Session: Podium Presentation
Program Number: S062
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