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Looking Beyond Age and Co-morbidities as Predictors of Outcomes in Paraesophageal Hernia Repair

  • 2008 ssat poster presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes.

Methods

We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)).

Results

Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference.

Conclusions

While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.

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References

  1. Diaz S, Brunt LM, Klingensmith ME, et al. Laparoscopic paraesophageal hernia repair, challenging operation: medium-term outcome of 116 patients. J Gastrointest Surg 2003;7(1):59–66. doi:10.1016/S1091-255X(02)00151-8.

    Article  PubMed  Google Scholar 

  2. Gangopadhyay N, Perrone JM, Soper NJ, Matthews BD, Eagon JC, Klingensmith ME, et al. Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients. Surgery 2006;140(4):491–498. doi:10.1016/j.surg.2006.07.001.

    Article  PubMed  Google Scholar 

  3. Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg 1997;1:221–228. doi:10.1016/S1091-255X(97)80113-8.

    Article  PubMed  CAS  Google Scholar 

  4. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002;236(4):492–500. doi:10.1097/00000658-200210000-00012.

    Article  PubMed  Google Scholar 

  5. Lal D, Pelligrini C, Oelschalager B. Laparoscopic repair of paraesopageal hernia. Surg Clin North Am 2005;85:105–118. doi:10.1016/j.suc.2004.09.008.

    Article  PubMed  Google Scholar 

  6. Andujar JJ, Papasavas PK, Birdas T, et al. Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc 2004;18:444–447. doi:10.1007/s00464-003-8823-4.

    Article  PubMed  CAS  Google Scholar 

  7. Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 2002;16:745–749. doi:10.1007/s00464-001-8194-7.

    Article  PubMed  CAS  Google Scholar 

  8. Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of repair of paraesophageal hernia. Ann Surg 1998;228:528–535. doi:10.1097/00000658-199810000-00009.

    Article  PubMed  CAS  Google Scholar 

  9. Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication. Am J Surg 1999;177:359–363. doi:10.1016/S0002-9610(99)00062-8.

    Article  PubMed  CAS  Google Scholar 

  10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383. doi:10.1016/0021-9681(87)90171-8.

    Article  PubMed  CAS  Google Scholar 

  11. Lin E, Smith CD. Paraesophageal hiatal hernias. In Jones D, Soper NA, eds. Principals of laparoscopic surgery. New York: Marcel Dekker, 2004, pp 243–258.

    Google Scholar 

  12. Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ. Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective? Surg Endosc 1999;13:838–842. doi:10.1007/s004649901116.

    Article  PubMed  CAS  Google Scholar 

  13. Flum DR, Koepsell T, Heagerty P, Pelligrini CA. The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992–1997. J Am Coll Surg 2002;195(5):611–618. doi:10.1016/S1072-7515(02)01490-4.

    Article  PubMed  Google Scholar 

  14. Deschamps C, Allen MS, Trastek VF, Johnson JO, Pairolero PC. Early experience and learning curve associated with laparoscopic Nissen fundoplication. J Thorac Cardiovasc Surg 1998;115(2):281–284. doi:10.1016/S0022-5223(98)70270-3.

    Article  PubMed  CAS  Google Scholar 

  15. Voitk A, Joffe J, Alvarez C, Rosenthal G. Factors contributing to laparoscopic failure during the learning curve for laparoscopic Nissen fundoplication in a community hospital. J Laparoendosc Adv Surg Tech A 1999;9(3):243–248.

    Article  PubMed  CAS  Google Scholar 

  16. Luostarinen ME, Isolauri JO. Surgical experience improves the long-term results of Nissen fundoplication. Scand J Gastroenterol 1999;34(2):117–120. doi:10.1080/00365529950172943.

    Article  PubMed  CAS  Google Scholar 

  17. Tekkis PP, Senagore AJ, Delaney CP, Fazio VW. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 2005;242(1):83–91. doi:10.1097/01.sla.0000167857.14690.68.

    Article  PubMed  Google Scholar 

  18. Goitein D, Mintz Y, Gross D, Reissman P. Laparoscopic adrenalectomy: ascending the learning curve. Surg Endosc 2004;18(5):771–773. doi:10.1007/s00464-003-8830-5.

    Article  PubMed  CAS  Google Scholar 

  19. Schauer P, Ikramuddin S, Hamad G, Gourash W. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 2003;17(2):212–215. doi:10.1007/s00464-002-8857-z.

    Article  PubMed  CAS  Google Scholar 

  20. Pierre AF, Luketich JD, Fernando HC, et al. Results of laparoscopic repair of giant Paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg 2002;74:1909–1915. doi:10.1016/S0003-4975(02)04088-2.

    Article  PubMed  Google Scholar 

  21. Finks JF, Wei Y, Birkmeyer JD. The rise and fall of antireflux surgery in the United States. Surg Endosc 2006;20:1698–1701. doi:10.1007/s00464-006-0042-3.

    Article  PubMed  Google Scholar 

  22. Eskes T, Haanen C. Why do women live longer than men? Eur J Obstet Gynecol Reprod Biol 2007;133:126–133. doi:10.1016/j.ejogrb.2007.01.006.

    Article  PubMed  Google Scholar 

  23. Nguyen NT, Luketich JD, Friedman DV, Ikramuddin S, Schauer PR. Pulmonary embolism following laparoscopic antireflux surgery: a case report and review of the literature. JSLS 1999;3(2):149–153.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 610, Baltimore, MD, 21287, USA

    Anirban Gupta, David Chang, Kimberley E. Steele, Michael A. Schweitzer, Jerome Lyn-Sue & Anne O. Lidor

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  1. Anirban Gupta
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  2. David Chang
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  3. Kimberley E. Steele
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  4. Michael A. Schweitzer
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  5. Jerome Lyn-Sue
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  6. Anne O. Lidor
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Correspondence to Anne O. Lidor.

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Gupta, A., Chang, D., Steele, K.E. et al. Looking Beyond Age and Co-morbidities as Predictors of Outcomes in Paraesophageal Hernia Repair. J Gastrointest Surg 12, 2119–2124 (2008). https://doi.org/10.1007/s11605-008-0685-6

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  • DOI: https://doi.org/10.1007/s11605-008-0685-6

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