Background: Given our aging population, patients with an intrathoracic stomach are an increasing clinical problem. The benefits of elective repair, risks of watchful waiting and the morbidity of emergent presentation are debated. As such, the timing of repair remains controversial, and most reports do not delineate emergent vs. elective presentations. The aim of the study was to compare the morbidity and mortality of elective and acute repair. Methods: 127 patients undergoing repair of an intrathoracic stomach from 2000-2006 were retrospectively reviewed. Surgical repair was elective in 104 and urgent in 23 patients presenting with ischemia, obstruction or GI bleeding. The approach was laparoscopic in 75, open transabdominal in 39, and transthoracic in 13. The majority of patients presenting acutely (17/23) had open transabdominal repair, while majority of elective repairs were laparoscopic (69/104). A fundoplication was added in 120 cases. Mean follow-up was 9.1 months (range 1-86). Outcome measures included perioperative complications, postoperative morbidity and mortality. Complications were graded via the classification reported by Clavien into major (III, IV & V) and minor (I, II). Factors associated with acute presentation were assessed via logistic regression.Results: Patients presenting acutely were older (79 vs. 65 years, p<.001) and had higher prevalence of at least one cardiopulmonary comorbidity (56% vs. 20%, p<.001). They suffered significantly greater mortality (22% vs. 1%, p<.001; all due to sepsis), major (30% vs. 3%, p<.001) and minor (43% vs. 19%, p<.05) complications than those with elective repair. On univariate logistic regression, urgent admission was strongly associated with in-hospital death, major complications, admission to ICU, return to OR, and minor complications (Table). Postoperative length of stay was also greater following acute presentation (median 9 vs. 4 days, p<.0001).Conclusion: Urgent surgical repair of an 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.

Complication	Odds Ratio	95% CI	P-Value (Wald χ2)
In-hospital Death	28.61	(3.16, 259.41)	0.003
Postoperative Major Complication	14.73	(3.45, 62.90)	0.001
ICU Admission	14.17	(2.55, 78.69)	0.003
Return to Operating Room	7.65	(1.20, 48.77)	0.031
Postoperative Minor Complication	3.23	(1.24, 8.42)	0.016
Intraoperative Complication	1.94	(.67, 5.67)	0.225

Acute vs. Elective Presentation