|
Back to 2015 Annual Meeting Program
Outcome Comparison of Elective vs. Acute Presentation of Giant Type III and IV Paraesophageal Hernia in a High Volume Center
Kamran Mohiuddin*1, Michal Hubka2, Donald Low1
1Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA; 2Virginia Mason Medical Center, Seattle, WA
Introduction: Although rare in the general population, Type III and IV paraesophageal hernias (PEH) are increasingly seen in older patients, especially women. These hernias produce a wide variety of symptoms but a component will present acutely with incarceration or obstruction. Outcomes of treatment of acute presentations have historically been inferior to elective repair.
Methods: A prospective IRB approved database was used to retrospectively review all patients undergoing PEH repair between 2000-2014. Demographic, presenting factors and outcomes were compared between patient presenting for acute repair (AR) and those undergoing elective repair (ER).
Results: 469 consecutive patients underwent surgical repair during this study period, 39 acute (8.3%), 430 elective. In patients presenting acutely, 4 (10%) required immediate surgery (2 perforations, 2 localized vascular compromise), 35 presented with acute incarceration and were treated with endoscopic or radiographic guided decompression prior to surgery. Patients presenting acutely were older (71.5 vs. 67.8), decreased BMI (28.3 vs. 30.2), had less preoperative heartburn (p=.01), regurgitation (p=.01) and dysphagia but a higher incidence of intermittent chest pain (p=.02). Mean Charlson comorbidity score, incidence of Type IV hernias (28% vs. 14%) and presentation of intrathoracic stomach >75% (60% vs. 43%) were all more common in the acute group. Operations were longer (174 vs. 154 min.) but blood loss was similar. In AR, mean length of hospital stay was higher (5.72 vs. 4.4 days), median (4 vs 4). There was no difference in perioperative complications on incidence of readmissions. One patient in the ER group died, overall mortality 0.2%.
Conclusions: Acute presentation associated with PEH can be managed successfully with comparable outcomes to elective operations in high volume centers. Many patients can and should be treated with guided decompression for acute incarceration and obstruction. Patients with large PEH and recurrent chest pain should routinely be considered for elective repair.
Back to 2015 Annual Meeting Program
|
