Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair

PACIFIC COAST SURGICAL ASSOCIATION Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair For decades, the standard of care for a paraesophageal hiatal hernia (PEH) was surgical repair after diagnosis, irrespective of symptoms. This standard of care was based on the reported high risk of acute gastric volvulus, strangulation, bleeding, or obstruction associated with untreated PEH and on the high mortality associated with emergency repair.1,2 A paradigm shift occurred in 2002, when Stylopoulos et al,3 using Markov analysis, found that watchful waiting was superior to elective repair for patients older than 65 years of age with a minimally symptomatic PEH. As a result, many patients with a PEH deferred surgery and opted for watchful waiting. A predictable consequence of watchful waiting has been an increase in the number of patients presenting with an acute PEH, sometimes with catastrophic outcomes.4 We characterized outcomes of emergency PEH repair in the modern era compared with elective repair using data from the American College of Surgeons National Surgical Quality Improvement Program. Methods | We reviewed all PEH repairs reported to the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012. Inclusion criteria were an age of 18 years or older at the time of surgery, an International Classification of Diseases, Ninth Revision (ICD-9) primary diagnosis code of diaphragmatic hernia (ie, ICD-9 code 551.3, 552.3, or 553.3), and a primary Current Procedural Terminology code indicating repair, as described by Mungo et al.5 Demographic data, comorbidities, and preoperative laboratory values were reviewed. The primary outcome was 30-day mortality. Secondary outcomes were hospital length of stay and serious morbidity (defined as return to the operating room, cardiac complication, sepsis, shock, ventilation >48 hours, unplanned reintubation, or cerebrovascular accident or stroke). Because this research involves only deidentified patient information, it did not require institutional review board approval from the University of California, San Francisco. Predictors of serious morbidity and 30-day mortality were identified in univariate logistic regression. Multivariate predictors were identified using backward-stepwise logistic regression. Statistical significance was defined as P < .05.