Watchful Waiting versus Elective Laparoscopic Repair for Minimally Symptomatic Paraesophageal Hernias: A Cost-Effectiveness Analysis

Ellen H Morrow, MD, Jennwood Chen, MD, Richard Nelson, PhD, Raminder Nirula, MD, MPH, Robert Glasgow, MD. University of Utah

Introduction: In this study, we aimed to evaluate the management strategies of watchful waiting versus elective laparoscopic hernia repair for minimally symptomatic paraesophageal hernias (PEH). The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis performed in 2002 that only compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the morbidity and mortality associated with elective laparoscopic hernia repair have decreased. Furthermore, a cost-effectiveness study for PEH repair has not been reported.

Methods: A Markov decision model was developed (using Tree Age ™ software) to compare the strategies of watchful waiting and elective laparoscopic hernia repair for minimally symptomatic PEH in a hypothetical cohort of 60 year-old patients. Input variables such as probabilities and utilities were estimated from a pooled analysis of published studies. Cost data were obtained from Medicare. The model was run for 20 1-year cycles. Outcomes for the two strategies were cost and QALY’s. One-way sensitivity analysis was performed to examine the differential effects of individual variables on the outcome of the model.

Results: Elective laparoscopic hernia repair was dominated by the watchful waiting strategy with respect to cost and effectiveness. The variables which had the largest influence on the results were the probability of progressive symptoms leading to elective repair, and quality of life with a minimally symptomatic hernia.

Conclusion: Despite an improved safety profile for elective laparoscopic hernia repair, this study confirms that watchful waiting is the preferred approach for minimally symptomatic paraesophageal hernias.