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

• Published in: Journal of gastrointestinal surgery 2018-02, Vol.22 (2), p.194-202
• Main Authors: Wirsching, Andrea, El Lakis, Moustapha A., Mohiuddin, Kamran, Pozzi, Agostino, Hubka, Michal, Low, Donald E.
• Format: Article
• Language: English
• Subjects: 2017 SSAT Plenary Presentation; Acute Disease; Aged; Aged, 80 and over; Chest Pain - etiology; Chest Pain - surgery; Decompression, Surgical - adverse effects; Elective surgery; Elective Surgical Procedures - adverse effects; Endoscopy, Gastrointestinal; Female; Gastroenterology; Gastrointestinal surgery; Hernia, Hiatal - complications; Hernia, Hiatal - surgery; Hernias; Herniorrhaphy - adverse effects; Humans; Length of Stay; Male; Medicine; Medicine & Public Health; Middle Aged; Patient Acuity; Postoperative Complications - etiology; Retrospective Studies; Stomach - surgery; Stomach Volvulus - etiology; Stomach Volvulus - surgery; Surgery
• ISSN: 1091-255X; 1873-4626
• DOI: 10.1007/s11605-017-3495-x

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.