Repair of symptomatic paraesophageal hernias in elderly (>70 years) patients results in sustained quality of life at 5 years and beyond

Morbidity and mortality after antireflux and hiatal hernia surgery across a spectrum of ages

BACKGROUND

Antireflux surgery (ARS) and hiatal hernia repair (HHR) are common surgical procedures with modest morbidity. Increasing age is a risk factor for complications; however, details regarding acute morbidity are lacking. This study aimed to describe the incidence rates and types of morbidities across the spectrum of ages.

METHODS

A total of 2342 consecutive cases were retrospectively reviewed from 2003 to 2020 for 30-day complications. All complications were assessed using the Clavien-Dindo (CD) grading system. Patients were divided into 5 age groups: ≤59, 60 to 69, 70 to 79, 80 to 89, and ≥90 years.

RESULTS

The numbers per age group were 1100 patients aged ≤59 years, 684 patients aged 60 to 69 years, 458 patients aged 70 to 79 years, 458 patients aged 80 to 89 years, and 6 patients aged ≥90 years. A total of 427 complications (18.2%) occurred, including 2 mortalities, each in the 60- to 69-year age group and the 70- to 79-year age group, for a mortality rate of 0.2%. The complication rate increased from 13.5% (149) in patients aged ≤59 years to 35.0% (35) in patients aged ≥80 years (P = .006), with CD grades I and II accounting for >70% of complications, except in patients aged ≥80 years (57.1%). CD grades IIIa and IIIb were higher in patients aged ≥80 years (26.5% [P = .001] and 11.8% [P = .021], respectively). CD grade IVa and IVb complications were rare overall.

CONCLUSION

There is a modest rate of morbidity that increases as patients age, regardless of hernia type, elective or primary surgery, with most being minor complications (CD grade≤II). Our data should help patients, referring physicians, and surgeons counsel patients regarding the effect of increasing age in ARS and HHR.

Could "Low Quality of Life" Rather Than "Significant Symptoms" Be Better Criteria for the Selection of Patients for the Repair of a Giant Hiatus Hernia?

Purpose Giant hiatus hernia (GHH) repair is undertaken electively in symptomatic patients, to prevent complications such as gastric volvulus and subsequent mortality. Advances in laparoscopy and perioperative care have reduced the risk of GHH repair, and improvement in quality of life (QoL) has become an important outcome measure. In our unit, we have been assessing QoL in all the operated as well as non-operated patients with GHH, using the "Quality of Life in Reflux and Dyspepsia" (QOLRAD) questionnaire. We sought to evaluate differences in QoL between patients who were managed conservatively for GHH and those who underwent GHH repair over a two-year period. Methods All patients seen in the Upper Gastrointestinal Tertiary Unit in Lancashire Teaching Hospitals NHS Trust with GHH between January 2015 and December 2022 were identified from a prospectively kept database. QOLRAD scores were analyzed and compared between conservatively and operatively managed patients using the Mann-Whitney U test. Demographic and operative outcome data were also collected. Results Eighty-seven patients with GHH were included. QoL of 51 patients improved significantly after elective surgery. Five out of 36 patients, who were initially treated conservatively, elected to have repair during their follow-up period. These 5 Patients had a lower initial QOLRAD score in comparison to those whose management remained conservative (2.72 vs 5.05, Mann Whitney U test p=0.034), and their QOLRAD scores also improved significantly after the operation. QOLRAD scores in conservatively managed patients remained stable over a two-year follow-up period. Conclusion Objectively calculated low QoL may be a more useful tool than subjective symptoms in selecting patients for elective repair of GHH.

The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes

BACKGROUND

Observation of paraesophageal hernias (PEHs) may lead to emergent surgery for hernia-related complications. This study evaluated urgent or emergent repair outcomes to quantify the possible sequelae of failed conservative PEH management.

METHODS

The impact of operative status (elective vs urgent or emergent) on perioperative mortality or major morbidity for patients who underwent hiatal hernia repair for a PEH diagnosis from 2012 to 2021 in the Society of Thoracic Surgery General Thoracic Surgery Database was evaluated with multivariable logistic regression models.

RESULTS

Overall, 2082 (10.9%) of 19,122 patients with PEHs underwent urgent or emergent repair. Patients undergoing nonelective surgery were significantly older than patients undergoing elective surgery (median age, 73 years [interquartile range, 63-82 years] vs 66 years [interquartile range, 58-74 years]) and had a lower preoperative performance score (P < .001). Nonelective surgical procedures were more likely to be performed through the chest or by laparotomy rather than by laparoscopy (20% vs 11.4%; P < .001), and they were associated with longer hospitalizations (4 days vs 2 days; P < .001), higher operative mortality (4.5% vs 0.6%; P < .001), and higher major morbidity (27% vs 5.5%; P < .001). Nonelective surgery was a significant independent predictor of major morbidity in multivariable analysis (odds ratio, 2.06; P < .001). Patients more than the age of 80 years had higher operative mortality (4.3% vs 0.6%; P < 0.001) and major morbidity (19% vs 6.1%; P < .001) than younger patients overall, and these older patients more often had nonelective surgery (26% vs 8.6%; P < .001) CONCLUSIONS: The operative morbidity of PEH repair is significantly increased when surgery is nonelective, particularly for older patients. These results can inform the potential consequences of choosing watchful waiting vs elective PEH repair.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life

BACKGROUND

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression.

OBJECTIVE

To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms.

METHODS

Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used.

RESULTS

Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved.

CONCLUSIONS

LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Changes in Hemoglobin Levels in Patients with Hiatal Hernia and Anemia Demonstrates a Durable Resolution When Surgery Utilized

Objective:

To describe the patterns of care of patients presenting with anemia and a hiatal hernia and to document hemoglobin levels at each stage of care.

Background data:

Anemia may be associated with hiatal hernia. Current medical guidelines recommend iron supplements and proton pump inhibitors (PPIs) as initial steps, but not surgical repair is not routinely recommended despite evidence of cure.

Methods:

Retrospective review of patients with anemia and hiatal hernia who underwent surgical repair. Hemoglobin, PPI use, and symptoms were assessed at diagnosis, preoperatively, and postoperatively.

Results:

We identified 116 predominantly female patients with type 3 hernias with 52.6% (n = 61) having Cameron ulcers. At baseline, 24.1% (n = 28) were transfused, 52% (n = 60) started on iron supplements, 72% (n = 84) on PPIs, and 10% (n = 12) on H2-blockers. Referral to surgery occurred 454 days (IQR: 129-1332) after anemia diagnosis. The mean Hgb at diagnosis was 9.79 (range: 4.8-12.7) in females and 10.9 (range: 7.7-12.9) in males, increasing to 11.1 (range: 5.4-15) and 11.4 (range: 5.8-15.9) with medical management. After laparoscopic repair, it increased to 12.3 (range: 8.1-14.8) and 13.4 (range: 8.9-16.8) at short term follow up. This was sustained at 12.8 (range: 8.8-17.7) and 14.2 (8.1-17) long term. Medical management normalized Hgb in 36% (n = 40/111); whereas surgery normalized Hgb in 62% (n = 64/104) short term and 74% (n = 69/93) long term. Cameron’s ulcers were associated with normalization in 85% (38/45) but only 62% (n = 21/34) when not present.

Conclusion:

Anemia associated with a hiatal hernia improves with medication, but the addition of surgery normalizes Hgb, appears durable, allows cessation of medication, and improves quality of life.

Quality of life after giant hiatus hernia repair: A systematic review

BACKGROUND

Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH.

METHODOLOGY

A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded.

RESULTS

Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL.

CONCLUSION

Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

Minimally Invasive Paraesophageal Hernia Repair in the Elderly: Is Age Really Just a Number?

Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challenging operation with potential for dire complications. Advanced age and medical comorbidities may heighten perioperative risk and limit surgical candidacy, potentially refusing patients an opportunity toward symptom resolution. Given the increased prevalence in the elderly and associated surgical risks, we aim to assess age as an independent risk factor for perioperative morbidity and mortality after PEHR. Methods: A retrospective analysis using a prospectively maintained database assessed patients undergoing PEHR from 2007 to 2018. Patients were stratified by age: Group A (age <65 years), Group B (65≤ age <80 years), and Group C (age ≥80 years). Patient demographics, preoperative symptoms, postoperative outcomes, and mortality rate were analyzed. Barium esophagram was performed on symptomatic postsurgical patients. Recurrence was confirmed radiologically. Results: In total, 143 patients underwent laparoscopic (94.4%) or robotic-assisted (5.6%) PEHR. Average age per group was Group A (n = 49) 55.4 years (standard deviation [SD] ±8.91), Group B (n = 76) 71.4 years (SD ±4.40), and Group C (n = 17) 84.1 (years) (SD ±3.37). Group C had significantly higher rates of nonelective surgery (P = .018), preoperative weight loss (P = .014), hypertension (P = .031), ischemic heart disease (P = .001), and cancer (P = .039); preoperative body mass index was significantly lower (P = .048). Charlson comorbidity index differences between groups were significant (2.00 versus 3.61 versus 5.28, P < .001). Median follow-up was 426 days (6-3199). Symptom improvement was seen in 78.3% of patients. Recurrence and reoperation rates were not significantly different between groups. No differences were seen in mortality, length of stay, or postoperative complications between groups. Conclusions: PEHR in elderly patients proved to be safe and effective. Avoidance of emergent intervention may be achieved through a judicious elective approach to this anatomic problem. Symptom resolution and quality-of-life improvement can be safely achieved with surgical repair in this patient population, demonstrating that age is truly just a number for PEHR.

Age-related outcomes in laparoscopic hiatal hernia repair: Is there a "too old" for antireflux surgery?

BACKGROUND

Minimally invasive antireflux surgery has been shown to be safe and effective for the treatment of gastroesophageal reflux (GERD) in elderly patients. However, there is a paucity of data on the influence of advanced age on long-term quality of life (QoL) and perioperative outcomes after laparoscopic antireflux surgery (LARS).

METHOD

A retrospective study of patients undergoing LARS between February 2012 and June 2018 at a single institution was conducted. Patients were divided into four age categories. Perioperative data and quality of life (QOL) outcomes were collected and analyzed.

RESULTS

A total of 492 patients, with mean follow-up of 21 months post surgery, were included in the final analysis. Patients were divided into four age-determined subgroups (< 50:75, 50-65:179, 65-75:144, ≥ 75:94). Advancing age was associated with increasing likelihood of comorbid disease. Older patients were significantly more likely to require Collis gastroplasty (OR 2.09), or concurrent gastropexy (OR 3.20). Older surgical patients also demonstrated increased operative time (ß 6.29, p < .001), length of hospital stay (ß 0.56, p < .001) in addition to increased likelihood of intraoperative complications (OR 2.94, p = .003) and reoperations (OR 2.36, p < .05). However, postoperative QoL outcomes and complication rates were parallel among all age groups.

CONCLUSIONS

Among older patients, there is a greater risk of intraoperative complications, reoperation rates as well as longer operative time and LOS after LARS. However, a long-term QoL benefit is demonstrated among elderly patients who have undergone this procedure. Rather than serving as an exclusion criterion for surgical intervention, advanced age among chronic reflux patients should instead represent a comorbidity addressed in the planning stages of LARS.

Outcome of laparoscopic paraesophageal hernia repair in octogenarians: a registry-based, propensity score-matched comparison of 360 patients

Background

Paraesophageal hernias (PEH) tend to occur in elderly patients and the assumed higher morbidity of PEH repair may dissuade clinicians from seeking a surgical solution. On the other hand, the mortality rate for emergency repairs shows a sevenfold increase compared to elective repairs. This analysis evaluates the complication rates after elective PEH repair in patients 80 years and older in comparison with younger patients.

Methods

In total, 3209 patients with PEH were recorded in the Herniamed Registry between September 1, 2009 and January 5, 2018. Using propensity score matching, 360 matched pairs were formed for comparative analysis of general, intraoperative, and postoperative complication rates in both groups.

Results

Our analysis revealed a disadvantage in general complications (6.7% vs. 14.2%; p = 0.002) for patients ≥ 80 years old. No significant differences were found between the two groups for intraoperative (4.7% vs. 5.8%, p = 0.627) and postoperative complications (2.2% vs. 2.8%, p = 0.815) or for complication-related reoperations (1.7% vs. 2.2%, p = 0.791).

Conclusions

Despite a higher risk of general complications, PEH repair in octogenarians is not in itself associated with increased rates of intraoperative and postoperative complications or associated reoperations. Therefore, PEH repair can be safely offered to elderly patients with symptomatic PEH, if general medical risk factors are controlled.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-06619-4) contains supplementary material, which is available to authorized users.