Inpatient mortality analysis of paraesophageal hernia repair in octogenarians

Morbidity of emergent versus elective hiatal hernia repair: an analysis of the NIS database

BACKGROUND

Elective hiatal hernia repair (HHR) is associated with reduced morbidity compared to emergent HHR. However, few studies examine the specific factors contributing to morbidity in emergent HHR. This study uses the National Inpatient Sample (NIS) database to compare the morbidity of emergent versus non-emergent HHR and identify associated risk factors.

METHODS

Data from the NIS (2016-2021) were analyzed for all patients undergoing HHR. Health factors, including demographics, comorbidities, and operative details, were compared using chi-squared and T-tests. A multivariable logistic regression model was created to identify factors associated with morbidity, defined as postoperative complications such as sepsis, pneumonia, myocardial infarction, deep venous thrombosis (DVT), pulmonary embolism (PE), and others.

RESULTS

A total of 723,000 records existed with a hiatal hernia diagnosis code. Of these, 67,059 patients underwent HHR, with 61,586 (91.8%) undergoing non-emergent HHR. Emergent HHR was associated with increased morbidity (OR 3.95, 95% CI 1.0-1.05, p < 0.05). Risk factors for increased morbidity in both groups included hypertension and advanced age. Protective factors included female gender, GERD, and prior bariatric surgery. Diabetes increased morbidity in emergent HHR but not non-emergent HHR. Smoking, Medicare/Medicaid, mesh use, COPD, and history of DVT increased morbidity in elective HHR, but not emergent HHR. The robotic approach increased morbidity in non-emergent HHR but decreased it in emergent HHR.

CONCLUSION

Emergent HHR is associated with higher morbidity compared to non-emergent HHR. Risk factors like smoking, COPD, and DVT increase morbidity in non-emergent HHR, while female gender, GERD, and prior bariatric surgery are protective. The NIS database provides valuable insights into the morbidity associated with HHR and can guide surgical decision-making.

Acute paraesophageal hernia with gastric volvulus. Results of surgical treatment: a systematic review and meta-analysis

INTRODUCTION

Acute gastric volvulus (AGV), is an uncommon complication of large paraesophageal hernias (PEH), resulting in closed-loop obstruction that may lead to incarceration and strangulation. The aim of this study was to summarize the evidence on clinical characteristics, surgical treatment, postoperative complications (POC), recurrence, and 30-day mortality (30DM), in patients undergoing surgery for AGV secondary to PEH.

METHODS

A systematic review including studies on AGV secondary to PEH was conducted. Searches were performed in WoS, Embase, Medline, Scopus, BIREME-BV and SciELO. Primary outcomes included POC, 30DM and recurrence. Secondary outcomes comprised publication date, study origin and design, number of patients, volvulus type, hospital stay length, treatments; and methodological quality (MQ) of studies assessed using MInCir-T and MInCir-Pr2 scales. Descriptive statistics, weighted averages (WA), least squares logistic regression for comparisons, and meta-analysis of POC prevalence and HM were applied.

RESULTS

Of 1049 studies 171 met selection criteria, encompassing 15,178 patients. The WA age of patients was 75.3 ± 13.9 years, with 51.3% female. Most studies originated from USA (31.6%), with 52.6% published in the last decade. The WA of hospital stay was 7.9 ± 5.3 days. Among patients, 32.0% experienced POC, 7.6% required reinterventions and HM was 5.7%. MQ scores averaged 8.9 ± 2.3 (MInCir-T) and 13.4 ± 5.4 (MInCir-Pr2). When comparing 1990-2014 and 2015-2024 periods, there were significant differences in age, reinterventions, readmissions and recurrence rates.

CONCLUSIONS

Despite surgical and resuscitative advancements, AGV prognosis remains poor, with high POC rates, prolonged hospitalization and significant 30DM. These findings emphasize the importance of early diagnosis and timely intervention for acute PEH to improve surgical outcomes.

Comparison of Medical Research Abstracts Written by Surgical Trainees and Senior Surgeons or Generated by Large Language Models

Importance

Artificial intelligence (AI) has permeated academia, especially OpenAI Chat Generative Pretrained Transformer (ChatGPT), a large language model. However, little has been reported on its use in medical research.

Objective

To assess a chatbot's capability to generate and grade medical research abstracts.

Design, Setting, and Participants

In this cross-sectional study, ChatGPT versions 3.5 and 4.0 (referred to as chatbot 1 and chatbot 2) were coached to generate 10 abstracts by providing background literature, prompts, analyzed data for each topic, and 10 previously presented, unassociated abstracts to serve as models. The study was conducted between August 2023 and February 2024 (including data analysis).

Exposure

Abstract versions utilizing the same topic and data were written by a surgical trainee or a senior physician or generated by chatbot 1 and chatbot 2 for comparison. The 10 training abstracts were written by 8 surgical residents or fellows, edited by the same senior surgeon, at a high-volume hospital in the Southeastern US with an emphasis on outcomes-based research. Abstract comparison was then based on 10 abstracts written by 5 surgical trainees within the first 6 months of their research year, edited by the same senior author.

Main Outcomes and Measures

The primary outcome measurements were the abstract grades using 10- and 20-point scales and ranks (first to fourth). Abstract versions by chatbot 1, chatbot 2, junior residents, and the senior author were compared and judged by blinded surgeon-reviewers as well as both chatbot models. Five academic attending surgeons from Denmark, the UK, and the US, with extensive experience in surgical organizations, research, and abstract evaluation served as reviewers.

Results

Surgeon-reviewers were unable to differentiate between abstract versions. Each reviewer ranked an AI-generated version first at least once. Abstracts demonstrated no difference in their median (IQR) 10-point scores (resident, 7.0 [6.0-8.0]; senior author, 7.0 [6.0-8.0]; chatbot 1, 7.0 [6.0-8.0]; chatbot 2, 7.0 [6.0-8.0]; P = .61), 20-point scores (resident, 14.0 [12.0-7.0]; senior author, 15.0 [13.0-17.0]; chatbot 1, 14.0 [12.0-16.0]; chatbot 2, 14.0 [13.0-16.0]; P = .50), or rank (resident, 3.0 [1.0-4.0]; senior author, 2.0 [1.0-4.0]; chatbot 1, 3.0 [2.0-4.0]; chatbot 2, 2.0 [1.0-3.0]; P = .14). The abstract grades given by chatbot 1 were comparable to the surgeon-reviewers' grades. However, chatbot 2 graded more favorably than the surgeon-reviewers and chatbot 1. Median (IQR) chatbot 2-reviewer grades were higher than surgeon-reviewer grades of all 4 abstract versions (resident, 14.0 [12.0-17.0] vs 16.9 [16.0-17.5]; P = .02; senior author, 15.0 [13.0-17.0] vs 17.0 [16.5-18.0]; P = .03; chatbot 1, 14.0 [12.0-16.0] vs 17.8 [17.5-18.5]; P = .002; chatbot 2, 14.0 [13.0-16.0] vs 16.8 [14.5-18.0]; P = .04). When comparing the grades of the 2 chatbots, chatbot 2 gave higher median (IQR) grades for abstracts than chatbot 1 (resident, 14.0 [13.0-15.0] vs 16.9 [16.0-17.5]; P = .003; senior author, 13.5 [13.0-15.5] vs 17.0 [16.5-18.0]; P = .004; chatbot 1, 14.5 [13.0-15.0] vs 17.8 [17.5-18.5]; P = .003; chatbot 2, 14.0 [13.0-15.0] vs 16.8 [14.5-18.0]; P = .01).

Conclusions and Relevance

In this cross-sectional study, trained chatbots generated convincing medical abstracts, undifferentiable from resident or senior author drafts. Chatbot 1 graded abstracts similarly to surgeon-reviewers, while chatbot 2 was less stringent. These findings may assist surgeon-scientists in successfully implementing AI in medical research.

Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.

Defining surgical risk in octogenarians undergoing paraesophageal hernia repair

BACKGROUND

With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR).

METHODS

The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed.

RESULTS

From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001).

CONCLUSIONS

Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.

Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication

PURPOSE

Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates.

METHODOLOGY

A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model.

RESULTS

625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003).

CONCLUSION

In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.

Minimally Invasive Abdominal Repair of a Giant Paraesophageal Hiatal Hernia with Occupation of the Right Thorax in a 53-Year-Old Man

Paraesophageal giant hiatal hernia is a rare condition associated with serious complications if not treated surgically. There are no reports of the minimally invasive abdominal repair of a giant hiatal hernia of the stomach almost entirely occupying the right thoracic cavity. The most common clinical presentation includes pathological gastroesophageal reflux, dysphagia, chest pain, or respiratory symptoms such as chronic cough or dyspnoea. Chest computed tomography, upper gastrointestinal endoscopy, and high-resolution oesophageal manometry are used to indicate the best treatment. This article reports the minimally invasive abdominal repair of a case of paraesophageal giant hiatal hernia occupying the right thoracic cavity.

Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair

Introduction

Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.

Methods

A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.

Results

Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm³, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm², p < 0.001). In multivariate analysis, HSV increase of 100cm³ (OR 1.17 CI 1.02–1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.

Conclusions

Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Laparoscopic repair of giant hiatal hernia for elderly patients

Background

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.

Methods

From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age <75). Interrupted non-absorbable suture was applied for crus closure and as an additional reinforcement, the mesh was fixed with absorbable tacks or medical glue. Procedure-related complications, score-based variation tendency of symptoms, gastrointestinal quality of life index (GIQLI), mortality, recurrence rate, hemoglobin, and the use of PPI were investigated.

Results

All patients underwent the procedure uneventfully. Dor fundoplication was used in 39 patients (62.9%) in the elderly group and 44 (50.0%) in the younger group and no case was converted to open. While the elderly group had a significantly higher percentage of ASA Class level 3 and cardiovascular and cerebrovascular diseases as compared to the younger group, the two groups had similar operative times, intraoperative blood loss, and percentage of intrathoracic stomach. Elderly group patients tended to have higher perioperative complications including pneumonia (3.2%) and atelectasis (3.2%) without statistical significance, as well as transfer to the intensive care unit compared, to younger patients (9.7% vs. 3.2%; P=0.144). The mean post-operative hospital stay was also significantly shorter in the younger group (2.8 days) compared with the elderly group (3.5 days; P=0.001). There was no mortality, recurrence, mesh-related complications such as visceral erosion, adhesion, or severe dysphagia during follow up in the two groups, and both groups demonstrated significant improvement in GIQLI scores and hemoglobin. The percentage of patients who needed PPI was also reduced in both groups.

Conclusions

Laparoscopic mesh repair of giant hiatal hernia for elderly patients is safe and effective when performed at experienced centers.

Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality

BACKGROUND

Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patients ≥ 65 years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reach ≤ 0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians.

METHODS

We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with age ≥ 65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR.

RESULTS

Patients age ≥ 65 had a higher 30-day mortality (0.5% vs 0.2%; p < 0.001). Subset analysis of patients age 65-80 and > 80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (p < 0.001). Independent predictors of mortality in patients ≥ 65 years were age > 80 (OR 5.23, p < 0.001) and COPD (OR 2.59, p = 0.04). Patients ≥ 65 had a slightly higher incidence of pneumonia (2% vs 1.2%; p < 0.001), unplanned intubation (0.8% vs 0.5%; p < 0.05), pulmonary embolism (0.7% vs 0.3%; p = 0.001), bleeding requiring transfusion (1% vs 0.5%; p < 0.05), and LOS (2.38 vs 1.86 days, p < 0.001) with no difference in sepsis, return to OR or readmission.

CONCLUSION

This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patients < 80 years toward elective repair of PEH.

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.

Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies

Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.

Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review

Background

Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature.

Methods

During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review.

Results

The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences.

Conclusion

Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.

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.

Failure to Rescue and Mortality Following Resection of Intracranial Neoplasms

BACKGROUND

There is growing recognition that perioperative complication rates are similar between hospitals, but mortality rates are lower at high-volume centers. This may be due to differences in the ability to rescue patients from major complications.

OBJECTIVE

To examine the relationship between hospital caseload and failure to rescue from complications following resection of intracranial neoplasms.

METHODS

We identified adults in the Nationwide Inpatient Sample diagnosed with glioma, meningioma, brain metastasis, or acoustic neuroma, who underwent surgical resection between 1998 and 2010. We stratified hospitals by low, intermediate, and high surgical volume tertiles and calculated failure to rescue rates (mortality in patients after a major complication).

RESULTS

A total of 550 054 patients were analyzed. Overall risk-adjusted complication rates were comparable between low- and medium-volume centers, and slightly lower at high-volume centers (15.3% [15.2, 15.5] vs 15.7% [15.5, 15.9] vs 14.3% [14.1, 14.6]). Risk-adjusted mortality decreased with increasing hospital surgical volume (10.3% [10.2, 10.5] vs 9.0% [8.9, 9.1] vs 7.1% [7.0, 7.2]). The overall risk-adjusted failure to rescue rate also decreased with increasing surgical volume (26.9% [26.3, 27.4] vs 24.8% [24.3, 25.3] vs 20.9% [20.5, 21.5]).

CONCLUSION

While complication rates were similar between high-volume and low-volume hospitals following craniotomy for tumor, mortality rates were substantially lower at high-volume centers. This appears to be due to the ability of high-volume hospitals to rescue patients from major perioperative complications.

Laparoscopic Paraesophageal Hernia Repair and Pulmonary Embolism

OBJECTIVE

Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study.

MATERIALS AND METHODS

Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed.

RESULTS

Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly.

CONCLUSIONS

Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.

Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy

Background:

There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

Methods:

This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4–9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both.

Results:

Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4–27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs.

Conclusion:

In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.

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.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Acute Vs. Elective Paraesophageal Hernia Repair: Endoscopic Gastric Decompression Allows Semi-Elective Surgery in a Majority of Acute Patients

BACKGROUND

Historically, patients presenting acutely with paraesophageal hernia and requiring urgent operation demonstrated inferior outcomes compared to patients undergoing elective repair.

METHODS

A prospective IRB-approved database was used to retrospectively review 570 consecutive patients undergoing paraesophageal hernia repair between 2000 and 2016.

RESULTS

Thirty-eight patients presented acutely (6.7%) and 532 electively. Acute presentation was associated with increased age (74 vs. 69 years) but similar age-adjusted Charlson comorbidity scores. A history of chest pain, intrathoracic stomach ≥75%, and mesoaxial rotation were more common in acute presentations. Emergency surgery was required in three patients (8%), and 35 patients were managed in a staged approach with guided decompression prior to semi-elective surgery. Acute presentation was associated with an increased hospital stay (5 (2-13) days vs. 4 (1-27) days, p = 0.001). There was no difference in postoperative Clavien-Dindo severity scores. One patient in the elective group died, and the overall mortality was 0.2%.

CONCLUSION

Our findings suggest that a majority of patients presenting with acute paraesophageal hernia can undergo a staged approach instead of urgent surgery with comparable outcomes to elective operations in high-volume centers. We suggest elective repair for patients presenting with a history of chest pain, intrathoracic stomach ≥75%, and a mesoaxial rotation.

Modern diagnosis and treatment of hiatal hernias

PURPOSE

Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias.

METHODS

A literature review of contemporary and latest studies with highest quality of evidence was completed. This information was examined and compiled in review format.

RESULTS

Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure. Repairs not amenable to key steps may undergo gastropexy and gastrostomy placement as an alternative procedure.

CONCLUSIONS

Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have reflux disease, an operative repair is required. A minimally invasive approach is safe and has improved outcomes.

Volume and outcomes relationship in laparoscopic diaphragmatic hernia repair

BACKGROUND

There is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that hospitals performing high case volume have improved outcomes compared to low-volume hospitals.

MATERIALS AND METHODS

We reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 for adults with the diagnosis of diaphragmatic hernia who underwent elective laparoscopic repair of diaphragmatic Hernia and/or Nissen fundoplication. Pediatric, emergent, and open cases were excluded. Main outcome measures included logistic regression analysis of factors predictive of in-hospital mortality and outcomes according to annual hospital case volume.

RESULTS

A total of 31,228 laparoscopic diaphragmatic hernia operations were analyzed. The overall in-hospital mortality was 0.14%. Risk factors for higher in-hospital mortality included renal failure (AOR: 6.26; 95% CI: 2.48-15.78; p < 0.001), age>60 years (AOR: 5.06; 95% CI: 2.38-10.76; p < 0.001), and CHF (AOR: 3.80; 95% CI: 1.39-10.38; p = 0.009) while an incremental increase in volume of 10 cases/year (AOR: 0.89; 95% CI: 0.81-0.98; p = 0.019) and diabetes (AOR: 0.34; 95% CI: 0.12-0.93; p = 0.036) decreases mortality. There was a small but significant inverse relationship between hospital case volume and mortality with a 10% reduction in adjusted odds of in-hospital mortality for every increase in 10 cases per year. Using 10 cases per year as the volume threshold, low-volume hospitals (≤10 cases/year) had almost a twofold higher mortality compared to high-volume hospitals (0.23 vs. 0.12%, respectively, p = 0.02).

CONCLUSIONS

There was a small but significant inverse relationship between the hospitals' case volume and mortality in laparoscopic diaphragmatic hernia repair.

Hiatal Hernia Repair with Novel Biological Graft Reinforcement

Background and Objectives:

Hiatal hernias are repaired laparoscopically with increasing use of reinforcement material. Both synthetic and biologically derived materials reduce the recurrence rate compared to primary crural repair. Synthetic mesh introduces complications, such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

Methods:

The 15 cases presented involved hiatal hernia repair with primary crural repair with UBM reinforcement and fundoplication. Patients were followed for an average of 3 years, and were assessed with upper gastrointestinal (GI) series, endoscopy, and assessments of subjective symptoms of gastroesophageal reflux disease (GERD).

Results:

Hernia diameters averaged 6 cm. Each repair was successful and completed laparoscopically. UBM exhibited favorable handling characteristics when placed as a horseshoe-type graft sutured to the crura. One patient underwent endoscopic balloon dilatation of a mild postoperative stenosis that resolved. No other complications occurred. In more than 3 years of follow-up, there have been no recurrences or long-term complications. GERD-health-related quality of life (HRQL) scores averaged 6 (range, 0–12, of a possible 50), indicating little reflux symptomatology. Follow-up upper GI series were obtained in 9 cases and showed intact repairs. An upper endoscopy was performed in 8 patients and showed no recurrences.

Conclusion:

Surgeons may safely use laparoscopic fundoplication with UBM reinforcement for successful repair of hiatal hernias. In this series, repairs with UBM grafts have been durable at 3 years of follow-up and may serve as an alternative to synthetic mesh reinforcement of hiatal hernia repairs.

Laparoscopic paraesophageal hernia repair is safe in elderly patients

BACKGROUND

Paraesophageal hernias (PEHs) occur frequently in the elderly. Patients may not be referred for repair due to age or concern for high operative morbidity and mortality. The aim of this study was to compare outcomes of PEH repair based on age.

METHODS

Adult patients undergoing PEH repair between 2003 and 2012 at a tertiary referral center were included. Patients were divided by age (Y < 69, YO 70-79 and VO > 80). Body mass index (BMI), Charlson comorbidity index, operative time, estimated blood loss, length of stay, recurrence, Quality of Life in Reflux and Dyspepsia Questionnaire (QOLRAD) scores, morbidity and mortality were analyzed.

RESULTS

Two hundred and sixty-seven patients were included: Group Y N = 140 (median age 58.5); Group YO N = 82 (median age 75.0); and Group VO N = 45 (median age 83.0). Group Y had a significantly lower age-adjusted Charlson score compared to the older groups. Group VO had significantly lower BMIs compared to Groups Y and YO. Both groups had similar operative times, intraoperative blood loss and rates of Collis gastroplasty. Group Y had significantly less acute presentations compared to the elderly groups YO 12.2 %, p = 0.028, and VO 22.2 %, p = <0.001. Group Y had a smaller percentage of intrathoracic stomach (55.7 %) as compared to Groups YO (65.1 %; p = 0.001) and VO (74.3 %; p = < 0.001). There were no significant differences in mortalities between all three groups. The mean length of hospital stay was significantly shorter in Group Y (2.45) than in both Group YO (3.12; p = 0.001) and Group VO (5.13; p = <0.001). Major morbidity was significantly lower in the younger group 3.6 % when compared to Group VO (17.8 %; p = 0.001). All groups demonstrated significant improvement in QOLRAD scores.

CONCLUSION

The decision to perform laparoscopic paraesophageal hernia repair (LPEHR) in elderly patients remains challenging. LPEHR can be done safely and effectively in elderly patients at experienced centers.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis

INTRODUCTION

Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting.

METHODS

We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined.

RESULTS

Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair.

CONCLUSIONS

Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

The impact of frailty on outcomes of paraesophageal hernia repair

BACKGROUND

Frailty is a measure of physiological reserve that has been used to predict outcomes after surgical procedures in the elderly. We hypothesized that frailty would be associated with outcomes after paraesophageal hernia (PEH) repair.

METHODS

The National Surgical Quality Improvement Program database (2011-2013) was queried for International Classification of Diseases, Version 9 and Current Procedural Terminology codes associated with PEH repair in patients aged ≥ 60 y. A previously described modified frailty index (mFI), based on 11 clinical variables in National Surgical Quality Improvement Program was used to quantify frailty. Multivariate logistic regression was used to determine the relationship between frailty, complications, and mortality.

RESULTS

Of the 4434 PEH repairs that met inclusion criteria, 885 records were included in the final analysis (20%). Excluded patients were missing one or more variables in the mFI. The rate of complications that were Clavien-Dindo Grade ≥ 3 was 6.1%. Mortality was 0.9%. The readmission rate was 8.2%, and 10.9% of patients were discharged to a facility other than home. Relative to mFI scores of 0, 1, 2, and ≥3, the respective occurrence percentages were as follows; Grade ≥3 complication: 3.2%, 4.7%, 9.8%, and 23.3% (P < 0.0001; odds ratio [OR] 3.51; confidence interval [CI] 1.46-8.46); mortality: 0.0%, 0.9%, 1.8%, and 2.3% (P = 0.0974); discharge to facility other than home: 4.4%, 10.9%, 15.7%, and 31.7% (P < 0.0001; OR 4.07; CI 1.29-12.82); and readmission: 8.9%, 6.8%, 8.5%, and 16.3% (P = 0.1703; OR 1.01; CI 0.36-2.84). Complications and discharge destination were significantly correlated with the mFI.

CONCLUSIONS

Frailty, as assessed by the mFI, is correlated with postoperative complications and discharge to a facility other than home after PEH repair.

Emergent Surgery Does Not Independently Predict 30-Day Mortality After Paraesophageal Hernia Repair: Results from the ACS NSQIP Database

AIM

Patients undergoing emergency surgery for paraesophageal hernia (PEH) repair have a higher adjusted mortality risk based on Nationwide Inpatient Sample (NIS). We sought to examine this relationship in the National Surgical Quality Improvement Program (NSQIP), which adjusts for patient-level risk factors, including factors contributing to patient frailty.

METHODS

This is a retrospective analysis of the NSQIP from 2009 through 2011. A modified frailty index was created based on previously validated methodology.

RESULTS

Of 3498 patients with PEH repair, 175 (5 %) underwent emergent surgery. Older age, lower BMI, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), current dialysis, SIRS, and sepsis were significantly more common among emergent patients. These patients also had a poorer functional status, higher American Society of Anesthesiologists (ASA), and higher frailty scores and more likely to undergo open surgery. Postoperative complications were proportionally more common, and LOS was longer (8.5 vs. 3.4 days) among emergent patients (all p < 0.05). In univariate analysis, emergent patients demonstrated ten times greater mortality than the elective surgery group (8 vs. 0.8 %). On adjusted analysis, emergent surgery was no longer independently associated with mortality. Frailty score 2 or above and preoperative sepsis significantly predicted increased mortality while laparoscopic repair and BMI 25-50 and BMI ≥30 (vs. BMI <18.5) were significantly protective in the entire group of patients.

CONCLUSION

Increased mortality among patients undergoing emergent PEH repair may be related to severity of disease and other preoperative comorbid illness. Without an emergent indication, some of these patients likely would have been excluded as candidates for elective surgical intervention.

Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis

BACKGROUND

The development of minimally invasive operative techniques and improvement in postoperative care has made surgery a viable option to a greater number of elderly patients. Our objective was to evaluate the outcomes of laparoscopic and open foregut operation in relation to the patient age.

METHODS

Patients who underwent gastric fundoplication, paraesophageal hernia repair, and Heller myotomy were identified via the National Surgical Quality Improvement Program (NSQIP) database (2005-2011). Patient characteristics and outcomes were compared between five age groups (group I: ≤65 years, II: 65-69 years; III: 70-74 years; IV: 75-79 years; and V: ≥80 years). Multivariable logistic regression analysis was used to predict the impact of age and operative approach on the studied outcomes.

RESULTS

A total of 19,388 patients were identified. Advanced age was associated with increased rate of 30-day mortality, overall morbidity, serious morbidity, and extended length of stay, regardless of the operative approach. After we adjusted for other variables, advanced age was associated with increased odds of 30-day mortality compared with patients <65 years (III: odds ratio 2.70, 95% confidence interval 1.34-5.44, P = .01; IV: 2.80, 1.35-5.81, P = .01; V: 6.12, 3.41-10.99, P < .001).

CONCLUSION

Surgery for benign foregut disease in elderly patients carries a burden of mortality and morbidity that needs to be acknowledged.

A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample

BACKGROUND

As the life expectancy in the United States continues to increase, more elderly, sometimes frail patients present with sub-acute surgical conditions such as a symptomatic paraesophageal hernia (PEH). While the outcomes of PEH repair have improved largely due to the proliferation of laparoscopic surgery, there is still a defined rate of morbidity and mortality. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set.

METHODS

The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006-2008). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair.

RESULTS

A total of 8,462 records in the data, representing 41,723 patients in the US undergoing PEH repair in the study interval, were identified. Of these procedures, 74.2% was elective and 42.4% was laparoscopic. The overall complication and mortality rates were 20.8 and 1.1%, respectively. Emergent repair was associated with a higher rate of morbidity (33.4 vs. 16.5%, p < 0.001) and mortality (3.2 vs. 0.37%, p < 0.001) than elective repair. Emergent repair patients were more likely to be male, were older, and more likely to be minority. Logistic modeling revealed that younger age, elective case status, and a laparoscopic approach were independently associated with a lower probability of complications and mortality.

CONCLUSIONS

Patients undergoing emergent PEH repair in the United States tend to be older, more likely a racial minority, and less likely to undergo laparoscopic repair. Elective repair, younger age, and a laparoscopic approach are associated with improved outcomes. Considering all of the above, we recommend that patients consider elective repair with a surgeon experienced in the laparoscopic approach, especially when symptoms related to the hernia are present.

Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality

BACKGROUND

Large studies have documented the safety of laparoscopic paraesophageal hernia (PEH) repair in the general population. Even though this condition affects primarily the elderly, data on the short-term outcomes of this procedure on the oldest-old are lacking.

STUDY DESIGN

The NSQIP database was analyzed for all patients undergoing laparoscopic PEH repair in 2010 and 2011. Chi-square, Fisher's exact, and 2-tailed Student's t-test were used to compare baseline characteristics, morbidity, and mortality. Binary logistic regression was used to control for confounding variables. Odds ratios (OR) with 95% confidence intervals (CI) were reported when applicable.

RESULTS

A total of 2,681 patients undergoing laparoscopic PEH repair were identified. The mean (±SD) age of the cohort was 63 ± 14 years. We identified 313 patients (11.7%) aged 80 years and older. Using regression analysis, advanced age (OR 1.7, 95% CI 1.1 to 2.7, p = 0.009), American Society of Anesthesiologists class 3 or 4 (OR 1.4, 95% CI 1.0 to 2.1, p = 0.045), gastrostomy placement (OR 2.4, 95% CI 1.3 to 4.7, p = 0.007), and significant recent weight loss (OR 2.1, 95% CI 1.1 to 4.1, p = 0.037) were independently associated with development of overall morbidity. Mortality (1% vs 0.4%, p = 0.16) and serious morbidity (5.8% vs 3.7%, p = 0.083) were not significantly different between the older and younger groups. Minor morbidity was higher in the older group (8.3% vs 3.5%, OR 2.5, 95% CI 1.6 to 3.9, p < 0.001).

CONCLUSIONS

In an assessment of modern nationwide practice, laparoscopic PEH repair is performed with minimal morbidity and mortality. Elective repair in patients aged 80 years or older is not associated with significant differences in mortality or major morbidity compared with younger patients.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

Open versus laparoscopic hiatal hernia repair

Laparoscopic repair of paraesophageal hiatal hernia where only a portion of the stomach is in the chest, is associated with a lower mortality rate than open repair.

Background:

The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

Method:

The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality.

Results:

In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group.

Conclusion:

Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

[Hiatal hernias: why and how should they be surgically treated]

INTRODUCTION

There is controversy in the literature about the choice of expectant medical treatment versus surgical treatment of hiatal hernias, depending on the presence or absence of symptoms. This study presents the results obtained by our group, considering disease duration and postoperative results.

PATIENTS AND METHOD

A total of 121 patients were included and divided by age, disease duration, type of hiatal hernia and postoperative outcome.

RESULTS

In 32% of the patients younger than 70 years, symptom duration was longer than 11 years and 68% of those aged more than 71 years had long-term symptoms (p<.05). Type iv hernias (complex) and those with diameters measuring more than 16 cm were observed in the group with longer symptom duration. Complications were more frequent in the older age group, in those with longer symptom duration and in those with type iv complex hernias. There was no postoperative mortality and only one patient (0.8%) with a type iii hernia and severe oesophagitis required reoperation.

CONCLUSION

We recommend that patients with hiatal hernia undergo surgery at diagnosis to avoid complications and risks. Older patients should not be excluded from surgical indication but should undergo a complete multidisciplinary evaluation to avoid complications and postoperative mortality.

A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair

OBJECTIVE

In the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality.

METHODS

We assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed.

RESULTS

Urgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were pulmonary complications (n = 199; 20%). A 4-covariate prediction model consisting of age 80 years or more, urgency of operation, and 2 Charlson comorbidity index variables (congestive heart failure and pulmonary disease) provided discriminatory accuracy for postoperative mortality of 88%. A 5-covariate model (sex, age by decade, urgency of operation, congestive heart failure, and pulmonary disease) for major postoperative morbidity was 68% predictive.

CONCLUSIONS

Predictive models using pretreatment patient characteristics can accurately predict mortality and major morbidity after giant paraesophageal hernia repair. After prospective validation, these models could provide patient-specific risk prediction, tailored for individual patient characteristics, and contribute to decision-making regarding surgical intervention.

Surgical management of emergency and elective giant paraesophageal hiatus hernias

BACKGROUND

Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting.

SUBJECTS AND METHODS

Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed.

RESULTS

Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184).

CONCLUSIONS

This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.

Failure to Rescue As a Source of Variation in Hospital Mortality for Ovarian Cancer

Purpose

Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer.

Patients and Methods

The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and “failure to rescue” rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared.

Results

We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital.

Conclusion

Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.

Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair

BACKGROUND

We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia.

METHODS

Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms.

RESULTS

The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n=10), III (n=206), and IV (n=54), and the percent intrathoracic stomach was less than 50% (n=33), 50% to 74% (n=86), 75% to 99% (n=55), and 100% (n=96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p=0.005) and dyspnea (type IV; p=0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p=0.04); higher percent intrathoracic stomach with early satiety (p=0.02), decreased meal size (p=0.007), and dyspnea (p<0.001); and 50% to 74% intrathoracic stomach with anemia (p=0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%).

CONCLUSIONS

Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair.

Wait only to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes

INTRODUCTION

Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes.

METHODS

From the 2005-2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities.

RESULTS

Of 224 patients, 149 (67%) were early and 75 (33%) were interval, with mean 3.6 days. Repairs were 89% transabdominal, 9% included fundoplication, and 18% gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31% (p = 0.2) and mortality 5.4 versus 4% (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13%, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80% reduction in sepsis (95% confidence interval (CI), 0.05-0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups.

CONCLUSIONS

Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.

Laparoscopic repair of esophageal hiatal hernia: an analysis of 129 cases

AIM: To evaluate the clinical effects of two different laparoscopic procedures in the management of esophageal hiatal hernia.

METHODS: The clinical data for 129 patients who underwent laparoscopic surgery for esophageal hiatal hernia from March 2001 to February 2009 at our hospital were retrospectively analyzed. All patients were divided into two groups based on the laparoscopic procedure used: Nissen group (360° fundoplication, n = 53) or Dor group (anterior 180° fundoplication, n = 76).

RESULTS: All operations were performed smoothly. No death occurred. Thirty patients (16 in the Nissen group and 14 in the Dor group) developed dysphagia after surgery, and 21 of them relieved within four months. Three patients in the Nissen group received esophageal dilatation for persistent dysphagia. Six months later, six patients had recurrence. The satisfaction rate was 89.51%.

CONCLUSION: Laparoscopic repair of esophageal hiatal hernia is an effective way to treat hiatal hernia. Dor anterior 180° fundoplication can decrease the incidence of postoperative dysphagia, abdominal distension and other complications, which might be caused by the Nissen procedure because of tighter fundoplication and injuries of the branches of vagus.

Should elective repair of intrathoracic stomach be encouraged?

BACKGROUND

Given our aging population, patients with an intrathoracic stomach are an increasing clinical problem. The timing of repair remains controversial, and most reports do not delineate morbidity of emergent presentation. The aim of the study was to compare the morbidity and mortality of elective and emergent repair.

METHODS

Study population consisted of 127 patients retrospectively reviewed undergoing repair of intrathoracic stomach from 2000 to 2006. Repair was elective in 104 and emergent in 23 patients. Outcome measures included postoperative morbidity and mortality.

RESULTS

Patients presenting acutely were older (79 vs. 65 years, p < 0.0001) and had higher prevalence of at least one cardiopulmonary comorbidity (57% vs. 21%, p = 0.0014). They suffered greater mortality (22% vs. 1%, p = 0.0007), major (30% vs. 3%, p = 0.0003), and minor (43% vs. 19%, p = 0.0269) complications compared to elective repair. On multivariate analysis, emergent repair was a predictor of in-hospital mortality, major complications, readmission to intensive care unit, return to operating room, and length of stay.

CONCLUSION

Emergent surgical repair of intrathoracic stomach was associated with markedly higher mortality and morbidity than elective repair. Although patients undergoing urgent surgery were older and had more comorbidities than those having an elective procedure, these data suggest that elective repair should be considered in patients with suitable surgical risk.

In-hospital mortality after resection of biliary tract cancer in the United States

OBJECTIVE

To assess perioperative mortality following resection of biliary tract cancer within the U.S.

BACKGROUND

Resection remains the only curative treatment for biliary tract cancer. However, current data on operative mortality after surgical resections for biliary tract cancer are limited to small and single-center studies.

METHODS

Using the Nationwide Inpatient Sample 1998-2006, a cohort of patient-discharges was assembled with a diagnosis of biliary tract cancer, including intrahepatic bile duct, extrahepatic bile duct, and gall bladder cancers. Patients undergoing resection, including hepatic resection, bile duct resection, pancreaticoduodenectomy, and cholecystectomy, were retained. The primary outcome measure was in-hospital mortality. Categorical variables were analyzed by chi-square. Multivariable logistic regression was performed to identify independent predictors of in-hospital mortality following resection.

RESULTS

31 870 patient-discharges occurred for the diagnosis of biliary tract cancer, including 36.2% intrahepatic ductal, 26.7% extrahepatic ductal, and 31.1% gall bladder. Of the total, 18.6% underwent resection: mean age was 69.3 years (median 70.0); 60.8% were female; 73.7% were white. Overall inpatient surgical mortality was 5.6%. Independently predictive factors of mortality included patient age >/=50 (vs. <50; age 50-59 odds ratio [OR] 5.51, 95% confidence interval [CI] 1.70-17.93; age 60-69 OR 7.25, 95% CI 2.29-22.96; age >/= 70 OR 9.03, 95% CI 2.86-28.56), the presence of identified comorbidities (congestive heart failure, OR 3.67, 95% CI 2.61-5.16; renal failure, OR 4.72, 95% CI 2.97-7.49), and admission designated as emergent (vs. elective; OR 1.82, 95% CI 1.39-2.37).

CONCLUSION

Increased in-hospital mortality for patients undergoing biliary tract cancer resection corresponded to age, comorbidity, hospital volume, and emergent admission. Further study is warranted to utilize these observations in promoting early detection, diagnosis, and elective resection.