|
|
Back to 2017 Program and Abstracts
OUTCOMES FOLLOWING ACUTE VS. ELECTIVE PARAESOPHAGEAL HERNIA REPAIR:EMERGENCY SURGERY IS ONLY SELECTIVELY REQUIRED IN PATIENTS WITH ACUTE PRESENTATION
Andrea Wirsching*1, Mustapha El Lakis2, Kamran Mohiuddin1, Michal Hubka1, Donald Low1
1General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA; 2Endocrine Oncology Branch, National Cancer Institute, Center for Cancer Research, Bethesda, MD
Background: Although rare in the general population, Type III and IV paraesophageal hernias (PEH) are increasingly seen in older patients and certain patients will present acutely with incarceration or obstruction. Historically, outcomes of acute presentations have been inferior to elective repairs.
Methods: A prospective IRB approved database was used to retrospectively review all patients undergoing PEH repair between 2000-2016. Demographics, presenting symptoms and outcomes were compared between patients undergoing acute repair (AR) and elective repair (ER).
Results: 565 underwent surgical repair during this study period, 39 acute (6.9%) and 527 elective. In patients presenting acutely, 4 (10%) required immediate surgery (2 perforations, 2 vascular compromise), 35 presented with acute incarceration and were treated with endoscopic or radiographic guided decompression prior to surgery. Patients presenting acutely were older (73±15y vs. 69±11y, p=0.048) and had a decreased BMI (25±11kg/m2 vs. 29±7kg/m2, p=0.001). Heartburn, Regurgitation, early satiety and dysphagia were more common in ER (p≤0.005 each). Chest pain was more frequent with AR (69% vs. 44%, p=0.004). There was no difference in preoperative Charlson Comobidity Index (CCI), age adjusted CCI, and ASA Score. PEH type III and type IV were distributed similarily between groups (type III: 77% vs. 81%, p=0.726; type IV: 23% vs. 13%, p=0.140, for AR and ER, respectively). Intrathoracic stomach >75% and mesoaxial rotation were more common in AR (69% vs. 48%, p=0.02; 13% vs. 3%, p=0.003). Operative time was increased with similar blood loss (173±72min vs. 152±39min, p=0.002). Hill repair and Gastrostomy were performed more often in AR (p=0.015 and p=0.001). There was no difference in postoperative complications, Clavien-Dindo Severity Scores, or 30day-readmission rate. AR was associated with an increased length of hospital stay (6±3d vs. 4±2d, p<0.001). One patient in the ER group died, overall mortality 0.2%. Postoperative regurgitation and heartburn were less common after AR vs. ER (0% vs. 11% and 3% vs. 16%, p=0.04 each), while chest pain and dysphagia were similar (13% vs. 10% and 9% vs. 17%, p>0.3 each). Barium swallow studies were available 5-7 months after surgery in a majority of patients. Reflux and recurrent hernia were similar for AR and ER (12% vs. 22% and 16% vs. 15%, p>0.05 each).
Conclusion: Acute presentations 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 and subsequently undergo semielective repair. Patients with large PEH, recurrent chest pain, and especially those with mesoaxial rotation should routinely be considered for elective repair.
Back to 2017 Program and Abstracts
|
