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Iron Deficiency Anemia Is a Common Presenting Issue With Giant Paraesophageal Hernia and Resolves Following Repair
Philip W. Carrott, Sheraz Markar*, Jean Hong, Donald Low
Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA

Giant Paraesophageal hiatal hernias (PEH) are most commonly associated with symptoms of chest pain, early satiety and GERD. However, Iron-deficiency anemia is an under-appreciated condition associated with giant PEH. The aim of this study was to evaluate the incidence of iron-deficiency anemia in a cohort of patients with giant PEH and assess the incidence of resolution associated with operative PEH repair.
Between 2000 and 2010, 270 patients underwent operative repair of PEH and were prospectively entered into an IRB-approved database. From this cohort, 123 (45.6%) patients demonstrated a pre-existing diagnosis of iron-deficiency anemia. 77 patients had a documented pre-operative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up Hb level at least 3 months following surgery and constituted the study population.

From the cohort of 77 patients with documented pre-operative iron-deficiency anemia, 72 (94%) underwent elective PEH repair, with a median age was 75 (range 39-91). Cameron erosions were endoscopically documented preoperatively in 25 patients (32%). The average preoperative Hb value was 11.8 (7.6 - 16). Postoperatively at 3 - 12 month follow-up, the average Hb level was 13.2 (10.7 - 17), and at more than 1 year follow-up it was 13.6 (9.2 - 17.2) (P < 0.05). Furthermore 90% of patients had a rise in post-operative hemoglobin level by at least 1g/dL. Anemia was fully resolved postoperatively (Hb≥12.0 in females, ≥14.0 in males) in 55 (71%) patients. This resolution was observed more commonly in women (40/50, 80%) than men (15/27, 56%, P < 0.05). Also younger patients (<70 years) were more likely to resolve their anemia (29/33 vs. 26/44; P < 0.05) and have a greater post-operative Hb (14.0 vs. 13.0 g/dL; P < 0.05) than older patients. 40 patients required preoperative iron supplementation, 29 (73%) were able to discontinue iron following surgery. There was no significant difference in the resolution of anemia in patients with or without Cameron erosions (19/25 vs. 36/52, p=0.54).

This single institution study shows a high incidence of iron-deficiency anemia (45.6%) in patients with giant PEH. Elective repair results in resolution of the anemia and discontinuation of iron supplementation therapy, in more than 70% of patients. This improvement in Hb is independent of the presence of pre-operative Cameron erosions. This study demonstrates the clinical and potential economic benefits of elective PEH repair of patients with Giant PEH and iron-deficiency anemia.

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