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Even in Comparable Patients, Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes: A Propensity-Adjusted Analysis
Vernissia Tam*1, James D. Luketich1, Daniel G. Winger2, Inderpal S. Sarkaria1, Ryan M. Levy1, Neil A. Christie1, Omar Awais1, Manisha Shende1, Katie S. Nason1
1University of Pittsburgh Medical Center, Pittsburgh, PA; 2Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA

Non-elective paraesophageal hernia (PEH) repair is associated with greater morbidity and mortality compared to elective repair. Often, however, patients undergoing non-elective repair are older, with more comorbidities, factors also associated with worse outcomes. Propensity-adjusted analysis balances these characteristics between two treatment groups, enabling a more precise analysis of outcomes after non-elective repair. We sought to determine whether postoperative morbidity and mortality differed between non-elective and elective paraesophageal hernia repair, after accounting for differences in pretreatment characteristics which impact the propensity for non-elective surgery.
Data were abstracted for 924 patients who underwent PEH repair (1/1997-8/2010). Boosted regression modeling, to account for interactions between variables, was used to generate propensity scores (exposure defined as non-elective versus elective repair). After adjusting for propensity for non-elective repair using inverse probability of treatment weighting, odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined.
Non-elective PEH repair was performed in 171 patients (19%; 171/924). Propensity score weighting generated standardized differences of less than 20% across all covariates. (Figure) Mortality was 2.3% (n=21) with major complications in 22% (n=201). Prior to propensity adjustment, odds of mortality (OR 7.6; 95% CI 3.12-18.8) and major morbidity (OR 2.78; 95% CI 1.94-3.99) were significantly higher for non-elective compared to elective repair. After accounting for propensity for non-elective surgery and adjusting for age greater than 80 and age-adjusted Charlson Comorbidity Index (CCI) score of 6 or greater, odds of mortality with non-elective repair was nearly 3 times greater (OR 2.74, CI 0.93-8.1), and odds of major morbidity nearly 2 times greater (OR 1.67, CI 1.07-2.61) than for elective repair. (Table) CCI score of 6 or greater was found to have good specificity (88%) and sensitivity (76%) for predicting mortality regardless of elective or emergent repair.
Non-elective repair of large paraesophageal hernias is associated with worse outcomes than elective repairs, even after using propensity for non-elective repair to account for significant differences in baseline characteristics that are associated with both an increased likelihood of non-elective surgery and worse outcomes. This analysis provides further support for elective repair of symptomatic large paraesophageal hernia by surgeons with extensive expertise in advanced foregut surgery, even in elderly patients or those with significant comorbid diseases. Caution may be warranted in patients with very high age-adjusted Charlson comorbidity scores (6 or greater), but this requires further study.

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