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Ivy ML, Farivar AS, Baison GN, Griffin C, Bograd AJ, White PT, Louie BE. Morbidity and Mortality After Anti-reflux and Hiatal Hernia Surgery Across a Spectrum of Ages. J Gastrointest Surg 2024:S1091-255X(24)00484-0. [PMID: 38821211 DOI: 10.1016/j.gassur.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/11/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Anti-reflux surgery (ARS) and hiatal hernia repair (HHR) are common surgeries with modest morbidity. Increasing age is a risk factor for complications; however, details regarding acute morbidity are lacking. We aim to describe the incidence and types of morbidities across the spectrum of ages. METHODS A total of 2342 consecutive cases were retrospectively reviewed from 2003-20 for 30-day complications. All complications were assessed using the Clavien-Dindo (CD) Grading System. Patients were divided into five age groups: ≤59 years, 60-69 years, 70-79 years, 80-89 years, and ≥90 years. RESULTS The number of cases per age group were: 1100 patients ≤59 years, 684 patients 60-69 years, 458 patients 70-79 years, 458 patients 80-89 years, and 6 patients ≥90 years. A total of 427 (18.2%) complications occurred, including 2 mortalities each in the 60-69 group and 70-79 group, for a mortality rate of 0.2%. The complication rate increased from 149 (13.5%) in patients ≤59 to 35 (35%) in patients ≥80 (p=0.006), with CD Grade 1 and 2 accounting for >70% of complications, except in patients ≥80 (57.1%). CD Grade 3a and 3b were higher in patients ≥80 years, 26.5% (p = 0.001) and 11.8% (p = 0.021), respectively. CD 4a and 4b complications were rare overall. CONCLUSIONS 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≤2). These data should help patients, referring physicians and surgeons counsel patients about the impact of increasing age in ARS and HHR.
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Affiliation(s)
- Megan L Ivy
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - George N Baison
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - Cassandra Griffin
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - Adam J Bograd
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - Peter T White
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Medical Center Cancer and Digestive Health Institutes, 1101 Madison St, Ste 900, Seattle, WA, 98104, United States.
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Liu DS, Wong DJ, Goh SK, Fayed A, Stevens S, Aly A, Bright T, Weinberg L, Watson DI. Quantifying Perioperative Risks for Antireflux and Hiatus Hernia Surgery: A Multicenter Cohort Study of 4301 Patients. Ann Surg 2024; 279:796-807. [PMID: 38318704 DOI: 10.1097/sla.0000000000006223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Using a comprehensive Australian cohort, we quantified the incidence and determined the independent predictors of intraoperative and postoperative complications associated with antireflux and hiatus hernia surgeries. In addition, we performed an in-depth analysis to understand the complication profiles associated with each independent risk factor. BACKGROUND Predicting perioperative risks for fundoplication and hiatus hernia repair will inform treatment decision-making, hospital resource allocation, and benchmarking. However, available risk calculators do not account for hernia anatomy or technical aspects of surgery in estimating perioperative risk. METHODS Retrospective analysis of all elective antireflux and hiatus hernia surgeries in 36 Australian hospitals over 10 years. Hierarchical multivariate logistic regression analyses were performed to determine the independent predictors of intraoperative and postoperative complications accounting for patient, surgical, anatomic, and perioperative factors. RESULTS A total of 4301 surgeries were analyzed. Of these, 1569 (36.5%) were large/giant hernias and 292 (6.8%) were revisional procedures. The incidence rates of intraoperative and postoperative complications were 12.6% and 13.3%, respectively. The Charlson Comorbidity Index, hernia size, revisional surgery, and baseline anticoagulant usage independently predicted both intraoperative and postoperative complications. These risk factors were associated with their own complication profiles. Finally, using risk matrices, we visualized the cumulative impact of these 4 risk factors on the development of intraoperative, overall postoperative, and major postoperative complications. CONCLUSIONS This study has improved our understanding of perioperative morbidity associated with antireflux and hiatus hernia surgery. Our findings group patients along a spectrum of perioperative risks that inform care at an individual and institutional level.
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Affiliation(s)
- David S Liu
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Surgery, The University of Melbourne, Austin Precinct, Austin Health, Victoria, Australia
| | - Darren J Wong
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Victoria, Australia
| | - Su Kah Goh
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
| | - Aly Fayed
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
| | - Sean Stevens
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
| | - Ahmad Aly
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, The University of Melbourne, Austin Precinct, Austin Health, Victoria, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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Shirakabe K, Ozawa N, Mochizuki Y, Mizokami K. Small Bowel Obstruction Caused by Type IV Hiatal Hernia. Case Rep Surg 2024; 2024:8837649. [PMID: 38415215 PMCID: PMC10898948 DOI: 10.1155/2024/8837649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024] Open
Abstract
Type IV hiatal hernia of the esophagus is characterized by herniation of the stomach and associated organs, such as the spleen, large and small bowel, and pancreas, through the esophageal hiatus. It is a relatively rare form of hiatal hernia that sometimes requires emergency surgery due to gastric incarceration, volvulus, and strangulation. Of these, small bowel obstruction is extremely rare and requires surgery. We report the case of an 83-year-old woman who was admitted to the hospital for small bowel obstruction caused by an ileum that had incarcerated the esophageal hiatus; emergency laparoscopic surgery was performed.
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Affiliation(s)
- Katsudai Shirakabe
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu City, Chiba, Japan
| | - Naoya Ozawa
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu City, Chiba, Japan
| | - Yoshihiro Mochizuki
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu City, Chiba, Japan
| | - Ken Mizokami
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu City, Chiba, Japan
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Khoma O, Wong NLJ, Mugino M, Khoma MJ, Van der Wall H, Falk GL. Dyspnoea improves following composite repair of giant paraoesophageal hernia. Ann R Coll Surg Engl 2022. [DOI: 10.1308/rcsann.2022.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- O Khoma
- University of Notre Dame, Chippendale, New South Wales, Australia
| | - NLJ Wong
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - M Mugino
- University of Notre Dame, Chippendale, New South Wales, Australia
| | - MJ Khoma
- Sydney Heartburn Clinic, Australia
| | - H Van der Wall
- University of Notre Dame, Chippendale, New South Wales, Australia
| | - GL Falk
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
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Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality. Surg Endosc 2021; 36:1407-1413. [PMID: 33712938 DOI: 10.1007/s00464-021-08425-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
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.
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Cheverie JN, Neki K, Lee AM, Li JZ, Dominguez-Profeta R, Matsuzaki T, Broderick RC, Jacobsen GR, Sandler BJ, Horgan S. Minimally Invasive Paraesophageal Hernia Repair in the Elderly: Is Age Really Just a Number? J Laparoendosc Adv Surg Tech A 2021; 32:111-117. [PMID: 33709788 DOI: 10.1089/lap.2020.0792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Joslin N Cheverie
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Kai Neki
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Arielle M Lee
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Rebeca Dominguez-Profeta
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Tokio Matsuzaki
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
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Perez SA, Reddy SB, Meister A, Pinjic E, Suzuki K, Litle VR. Venous thromboembolism in benign esophageal surgery patients: potential cost effectiveness of Caprini risk stratification. Surg Endosc 2021; 36:764-770. [PMID: 33492505 DOI: 10.1007/s00464-020-08269-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Caprini risk assessment model (RAM) stratifies surgical patients for prescription of post-discharge extended heparin prophylaxis to reduce post-operative venous thromboembolism (VTE) events. The average cost for treatment of a VTE event is $15,123. The 30-day post-operative VTE rate after benign esophageal procedures is < 0.8% per the Society of Thoracic Surgeons database. We hypothesized that the financial cost of selective extended prophylaxis in patients undergoing surgery for benign esophageal disease would exceed the cost of treating these rare events and therefore use of risk stratification for extended prophylaxis would not be beneficial. METHODS All patients undergoing operations for benign esophageal pathology from July 2014 to May 2019 were reviewed. Patients designated as moderate or high risk for VTE were prescribed a 10- or 30-day post-operative course of extended prophylaxis with low-molecular weight heparin (LMWH). VTE and adverse bleeding events were recorded for the 60-day post-operative period. The cost of LMWH was provided by the institution pharmacy. RESULTS Records from 154 patients were eligible for review. Caprini RAM was used for all patients with the following distribution of risk categories: low = 64.9% (100/154); moderate = 31.8% (49/154); and high = 3.2% (5/154). The average cost of extended prophylaxis at discharge for the moderate-risk group was $121.23, while the high-risk group was $446.46. There were no 60-day VTE or adverse bleeding events recorded. CONCLUSIONS The majority of patients undergoing surgical therapy were at low risk of post-operative VTE event, with only 35% requiring extended VTE prophylaxis at time of discharge. When compared with the average cost of treatment for a VTE event, the cost of extended prophylaxis per patient in moderate or high-risk groups is substantially lower. In the era of cost-containment, risk stratification and extended prophylaxis may reduce healthcare costs and warrant future investigations.
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Affiliation(s)
- Sean A Perez
- School of Medicine, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Shriya B Reddy
- School of Medicine, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Amanda Meister
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Emma Pinjic
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Kei Suzuki
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Virginia R Litle
- Division of Thoracic Surgery, Department of Surgery, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA. .,Division of Thoracic Surgery, Department of Surgery, Boston University, 88 East Newton Street, Collamore Building, Suite 7380, Boston, MA, 02118, USA.
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El Lakis MA, Kaplan SJ, Hubka M, Mohiuddin K, Low DE. The Importance of Age on Short-Term Outcomes Associated With Repair of Giant Paraesophageal Hernias. Ann Thorac Surg 2017; 103:1700-1709. [DOI: 10.1016/j.athoracsur.2017.01.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 12/12/2022]
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Nomura T, Iwakiri K, Matsutani T, Hagiwara N, Fujita I, Nakamura Y, Kanazawa Y, Makino H, Kawami N, Miyashita M, Uchida E. Characteristics and Outcomes of Laparoscopic Surgery in Patients with Gastroesophageal Reflux and Related Disease: A Single Center Experience. J NIPPON MED SCH 2017; 84:25-31. [PMID: 28331141 DOI: 10.1272/jnms.84.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Laparoscopic anti-reflux surgery (LARS) is generally the treatment of choice for patients with gastroesophageal reflux disease (GERD). This report describes our experiences in performing LARS on patients with GERD, and focuses retrospectively on the pathophysiology of individual patients and the current status of Japanese patients who have undergone LARS. We demonstrate that patients with non-erosive reflux disease resistant to proton pump inhibitors (PPI-resistant NERD) and high-risk giant hernia, whom we are sometimes hesitant to treat surgically, can be safely and successfully treated with LARS (depending on the pathophysiology of individual patients). METHODS Between January 2007 and June 2015, 37 patients underwent LARS at Nippon Medical School Hospital. These patients were retrospectively subgrouped according to pathophysiology; 9 of them had PPI-resistant NERD (Group A), 19 had a giant hiatal hernia (Group B), and 9 had erosive esophagitis (Group N). Patient characteristics, intraoperative bleeding, operation duration, perioperative complications, and length of hospital stay were determined, along with symptomatic outcomes and patient satisfaction. RESULTS Patients in Group A were the youngest (average: 43.9 years), and those in Group B were the oldest (75.9 years) (P=0.002). The percentage of high-risk patients, as determined by performance status (P=0.047) and American Society of Anesthesiologists physical status classification (P=0.021), was highest in Group B, whereas the percentage of patients with mental disorders was highest in Group A (P=0.012). There were no significant differences among the groups in terms of intraoperative bleeding, surgery duration, or postoperative hospital stay. Thirty-three patients (89.2%), including all 19 in Group B, expressed excellent or good postoperative satisfaction levels. CONCLUSIONS The characteristics of the patients who underwent LARS at our hospital differed according to pathophysiology and from those in western countries. Satisfactory outcomes depended on the pathophysiology of individual patients.
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Affiliation(s)
- Tsutomu Nomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
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Tam V, Luketich JD, Winger DG, Sarkaria IS, Levy RM, Christie NA, Awais O, Shende MR, Nason KS. Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis. J Gastrointest Surg 2017; 21:137-145. [PMID: 27492355 PMCID: PMC5209749 DOI: 10.1007/s11605-016-3231-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/26/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Vernissia Tam
- University of Pittsburgh Department of General Surgery, Pittsburgh, PA
| | | | - Daniel G. Winger
- University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, PA
| | | | - Ryan M. Levy
- Department of Cardiothoracic Surgery, Pittsburgh, PA
| | | | - Omar Awais
- Department of Cardiothoracic Surgery, Pittsburgh, PA
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Bonrath EM, Grantcharov TP. Contemporary management of paraesophaegeal hernias: establishing a European expert consensus. Surg Endosc 2014; 29:2180-95. [PMID: 25361649 DOI: 10.1007/s00464-014-3918-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/22/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology. METHODS A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach's α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed "undecided/controversial". RESULTS Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most "undecided/controversial" items were follow-up, postoperative care and surgical technique. CONCLUSIONS This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.
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Affiliation(s)
- E M Bonrath
- University of Toronto, 30 Bond Street, Toronto, ON, M5B1W8, Canada,
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12
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Jassim H, Seligman JT, Frelich M, Goldblatt M, Kastenmeier A, Wallace J, Zhao HS, Szabo A, Gould JC. A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample. Surg Endosc 2014; 28:3473-8. [PMID: 24939163 DOI: 10.1007/s00464-014-3626-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 05/16/2014] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Hassanain Jassim
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA
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Abstract
Gastroesophageal reflux disease is a common disorder in all patients but a particular problem in the elderly, for whom the disease often presents with advanced mucosal damage and other complications. Symptoms are also not as reliable an indication of disease severity in older patients. Likewise, therapy is more difficult because of potential side effects and drug interactions.
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Affiliation(s)
- Sami R Achem
- Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Kenneth R DeVault
- Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, FL, USA.
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Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality. J Am Coll Surg 2014; 218:1187-92. [PMID: 24698486 DOI: 10.1016/j.jamcollsurg.2013.12.058] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/10/2013] [Accepted: 12/17/2013] [Indexed: 02/07/2023]
Abstract
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.
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Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD. Guidelines for the management of hiatal hernia. Surg Endosc 2013; 27:4409-28. [PMID: 24018762 DOI: 10.1007/s00464-013-3173-3] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 08/02/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Geoffrey Paul Kohn
- Department of Surgery, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia,
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Ballian N, Luketich JD, Levy RM, Awais O, Winger D, Weksler B, Landreneau RJ, Nason KS. A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2013; 145:721-9. [PMID: 23312974 DOI: 10.1016/j.jtcvs.2012.12.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 10/10/2012] [Accepted: 12/10/2012] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Nikiforos Ballian
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburg, PA, USA
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Lidor AO, Chang DC, Feinberg RL, Steele KE, Schweitzer MA, Franco MM. Morbidity and mortality associated with antireflux surgery with or without paraesophogeal hernia: a large ACS NSQIP analysis. Surg Endosc 2011; 25:3101-8. [DOI: 10.1007/s00464-011-1676-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 03/11/2011] [Indexed: 01/09/2023]
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