Surgical Endoscopy

, Volume 32, Issue 2, pp 864–871 | Cite as

Approach to asymptomatic paraesophageal hernia: watchful waiting or elective laparoscopic hernia repair?

  • James J. Jung
  • David M. Naimark
  • Ramy Behman
  • Teodor P. Grantcharov



There is no consensus on whether asymptomatic paraesophageal hernia (PEH) should be operated. Some argue that surgery is necessary prophylaxis against potentially catastrophic consequences of acute complications in untreated PEH. Others reason that the acute complications are rare and emergent operations have relatively low mortality. In the laparoscopic era, elective operations have become safer and less morbid. However, recent studies report high incidence of recurrent hernia, some of which affect quality of life and require further interventions. In light of these new findings, we investigated whether asymptomatic PEH should receive elective laparoscopic hernia repair (ELHR) or watchful waiting (WW).


A Markov Monte Carlo microsimulation decision analysis model followed a hypothetical cohort of asymptomatic PEH patients who have predominantly female gender and normally distributed mean age of 62.5 years for the lifetime. Accrued health benefits expressed in quality-adjusted life months (QALM) were compared between two strategies: WW and ELHR. Two-dimensional simulations were performed to account for uncertainties in the model. Deterministic sensitivity analyses were performed to test key assumptions.


After considering both individual- and parameter-level uncertainties in the two-dimensional simulations, WW was the superior strategy in 82% of the simulations, accumulating mean 5 QALM more than ELHR (168 vs. 163). Our model was robust to deterministic sensitivity analyses and was internally validated, which supported the validity of our results.


Patients with asymptomatic PEH are more likely to achieve greater health outcomes if they undergo WW as initial treatment than ELHR.


Hiatal hernia Paraesophageal hernia Laparoscopic surgery Decision analysis Markov model 


Compliance with ethical standards


Dr. Grantcharov received grants from Ethicon Canada, Medtronic Canada, Olympus Canada, Takeda Canada, and Baxter Canada and owns intellectual properties from Surgical Safety Technologies Inc. Drs. Jung, Naimark, and Behman have no conflicts of interest or financial ties to disclose.

Supplementary material

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464_2017_5755_MOESM4_ESM.docx (39 kb)
Supplementary material 4 (DOCX 40 KB)


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of TorontoTorontoCanada
  2. 2.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada

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