Journal of Gastrointestinal Surgery

, Volume 22, Issue 12, pp 2029–2036 | Cite as

The Association of Body Mass Index with Postoperative Outcomes After Elective Paraesophageal Hernia Repair

  • Samuel Torres Landa
  • Jordana B. Cohen
  • Robert A. Swendiman
  • Chris Wirtalla
  • Daniel T. Dempsey
  • Kristoffel R. Dumon
Original Article



To evaluate the association between body mass index (BMI) and postoperative outcomes in elective paraesophageal hernia (PEH) repairs.


A retrospective review of patients who underwent elective PEH repair in the ACS NSQIP database (2005–2015) was performed. Patients were stratified into BMI groups (< 18.5, 18.5–24.9, 25.0–29.9, 30.0–34.9, 35–39.9, and ≥ 40.0 kg/m2) according to the World Health Organization classification criteria. A multivariable logistic regression model was developed to characterize the association between BMI class and outcomes, including readmission, reoperation, postoperative complications, and mortality.


The median (IQR) age of the 9641 patients who met inclusion criteria was 64 (55–72) and 72.7% were women. Across each BMI class, age, race, gender, type of procedure, frailty index, smoking, and ASA class varied (p < 0.05). Underweight patients (BMI < 18.5 kg/m2) had an increased risk of mortality (OR = 6.35, p < 0.05). Patients with a BMI 35–39.9 kg/m2 (OR = 0.65, p < 0.05) and ≥ 40 kg/m2 (OR = 0.36, p < 0.001) were associated with a decreased risk for readmissions.


Underweight patients have an increased risk for postoperative mortality after elective PEH repair. Higher BMI was associated with a diminished risk for readmission, but not for mortality, reoperations, or overall complications.


Paraesophageal hernia NSQIP Obesity Outcomes Body mass index Underweight 



We thank Joseph Giacolone, Dr. Robert Caskey, Dr. Ari D. Brooks, Dr. Octavia E. Pickett-Blakely, Dr. Noel N. Williams, MD, and Dr. Andrew Sinnamon for providing with insightful input to the study.


  1. 1.
    Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD, Committee SG. Guidelines for the management of hiatal hernia. Surgical endoscopy. 2013;27(12):4409–28.CrossRefGoogle Scholar
  2. 2.
    Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best practice & research Clinical gastroenterology. 2008;22(4):601–16.CrossRefGoogle Scholar
  3. 3.
    Kaplan JA, Schecter S, Lin MY, Rogers SJ, Carter JT. Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair. JAMA surgery. 2015;150(11):1094–6.CrossRefGoogle Scholar
  4. 4.
    McLaren PJ, Hart KD, Hunter JG, Dolan JP. Paraesophageal Hernia Repair Outcomes Using Minimally Invasive Approaches. JAMA surgery. 2017;152(12):1176–8.CrossRefGoogle Scholar
  5. 5.
    Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Annals of surgery. 2009;250(1):166–72.CrossRefGoogle Scholar
  6. 6.
    Augustin T, Schneider E, Alaedeen D, Kroh M, Aminian A, Reznick D, Walsh M, Brethauer S. Emergent Surgery Does Not Independently Predict 30-Day Mortality After Paraesophageal Hernia Repair: Results from the ACS NSQIP Database. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2015;19(12):2097–104.CrossRefGoogle Scholar
  7. 7.
    Jassim H, Seligman JT, Frelich M, Goldblatt M, Kastenmeier A, Wallace J, Zhao HS, Szabo A, Gould JC. A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample. Surgical endoscopy. 2014;28(12):3473–8.CrossRefGoogle Scholar
  8. 8.
    World Health Organization. The WHO Global Database on BMI. Geneva, Switzerland: BMI classification; 2018. Available at:
  9. 9.
    Chimukangara M, Frelich MJ, Bosler ME, Rein LE, Szabo A, Gould JC. The impact of frailty on outcomes of paraesophageal hernia repair. J Surg Res. 2016;202(2):259–66.CrossRefGoogle Scholar
  10. 10.
    Chimukangara M, Helm MC, Frelich MJ, Bosler ME, Rein LE, Szabo A, Gould JC. A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surgical endoscopy. 2017;31(6):2509–19.CrossRefGoogle Scholar
  11. 11.
    Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. Jama. 2007;298(17):2028–37.CrossRefGoogle Scholar
  12. 12.
    Menke H, Klein A, John KD, Junginger T. Predictive value of ASA classification for the assessment of the perioperative risk. Int Surg. 1993;78(3):266–70.PubMedGoogle Scholar
  13. 13.
    Valentijn TM, Galal W, Tjeertes EK, Hoeks SE, Verhagen HJ, Stolker RJ. The obesity paradox in the surgical population. Surgeon. 2013;11(3):169–76.CrossRefGoogle Scholar
  14. 14.
    Hannan EL, Zhong Y, Lahey SJ, Culliford AT, Gold JP, Smith CR, Higgins RS, Jordan D, Wechsler A. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv. 2011;4(5):569–76.CrossRefGoogle Scholar
  15. 15.
    Rockx MA, Fox SA, Stitt LW, Lehnhardt KR, McKenzie FN, Quantz MA, Menkis AH, Novick RJ. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? Can J Surg. 2004;47(1):34–8.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Andersen KK, Olsen TS. The obesity paradox in stroke: lower mortality and lower risk of readmission for recurrent stroke in obese stroke patients. International journal of stroke : official journal of the International Stroke Society. 2015;10(1):99–104.CrossRefGoogle Scholar
  17. 17.
    Aly A, Munt J, Jamieson GG, Ludemann R, Devitt PG, Watson DI. Laparoscopic repair of large hiatal hernias. Br J Surg. 2005;92(5):648–53.CrossRefGoogle Scholar
  18. 18.
    Paulus E, Merchant AM, Lin E. Management of paraesophageal hernias in patients with morbid obesity. Bariatric Times. 2011;8:8–13.Google Scholar
  19. 19.
    Shada AL, Stem M, Funk LM, Greenberg JA, Lidor AO. Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;14(1):8–13.CrossRefGoogle Scholar
  20. 20.
    Gagner M. Comment on: concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;14(1):14–5.CrossRefGoogle Scholar
  21. 21.
    Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data. Journal of the American College of Surgeons. 2018;226(2):173–81 e8.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Samuel Torres Landa
    • 1
  • Jordana B. Cohen
    • 2
    • 3
  • Robert A. Swendiman
    • 1
  • Chris Wirtalla
    • 1
  • Daniel T. Dempsey
    • 1
  • Kristoffel R. Dumon
    • 1
  1. 1.Department of Surgery, Division of Gastrointestinal SurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Center for Clinical Epidemiology and Biostatistics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations