INTRODUCTION Patients undergoing paraesophageal hernia (PEH) repair are typically older with more comorbidities than patients undergoing antireflux operations for gastroesophageal reflux disease (GERD) and these factors are thought to contribute to worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes. METHODS We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001-2005). Patients undergoing any abdominal anti-reflux operation with or without PEH repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with GERD or PEH, emergency admissions, and age < 18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed, one adjusting for pre-treatment variables (age, gender, race, comorbidities, hospital teaching status and volume of antireflux surgery, calendar year), and the second adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax (PTX), hemorrhage, cardiac, pulmonary, and thromboembolic events (VTE)).
Results: Of the 23,458 patients, 6706 patients had PEH. Of 88 total deaths, 50 were in the PEH group (0.75%). PEH patients are older (60.4 vs 49.1, p<0.001) and have significantly more comorbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. (Table) Further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients. Adjustment for cardiac complications or PTX does not eliminate the difference.
Conclusions: Although PEH patients have worse post-operative outcomes than GERD patients, age and comorbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of VTE. Additionally, the impact of hemorrhagic complications underscores the importance of experienced surgeons.

Complications		OR: PEH vs GER(95% CI)	p-value
Mortality		1.81 (1.06-3.09)	0.030
Technical	Esophageal laceration	2.00 (1.29-3.10)	0.002
	Splenectomy	1.44 (1.03-2.01)	0.033
	Pneumothorax	2.45 (1.64-3.65)	0.000
	Hemorrhage	1.53 (1.22-1.92)	0.000
Peri-op	Pulmonary	1.48 (1.26-1.75)	0.000
	Cardiac	2.11 (1.43-3.11)	0.000
	Thromboembolic	2.34 (1.29-4.23)	0.005