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PARAESOPHAGEAL HERNIA REPAIR IN THE US: TRENDS OF UTILIZATION STRATIFIED BY SURGICAL VOLUME AND CONSEQUENT IMPACT ON PERIOPERATIVE OUTCOMES
Francisco Schlottmann*1, Paula D. Strassle2, Fernando A. M. Herbella3, Marco G. Patti1
1Surgery, University of North Carolina, Chapel Hill, NC; 2Epidemiology, University of North Carolina, Chapel Hill, NC; 3Surgery, Federal University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
Introduction: While centralization has been shown to improve outcomes after esophagectomy, the impact of surgical volume on perioperative results after a paraesophageal hernia (PEH) repair has not yet been analyzed.
Aim: We sought to characterize the trend of utilization of this procedure stratified by surgical volume in the US, and analyze its impact on perioperative outcomes.
Methods: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥ 18 years old) who underwent PEH repair were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges. Surgical volume was categorized as small (<6 operations/year), intermediate (6-20 operations/year), or high (>20 operations/year). Hospital utilization trends, stratified across hospital volume, were calculated using Poisson regression. Linear and logistic regression, adjusted for patient demographics, comorbidities, hospital characteristics and laparoscopic approach, were used to assess the effect of surgical volume on patient outcomes.
Results: A total of 63,812 patients were included. Over time, the rate of procedures across high volume centers significantly increased from 65.8 procedures/100 patients to 94.4 procedures/100 patients. The use of the laparoscopic approach was significantly different among the groups (small volume:38.4%; intermediate volume:41.8%; high volume:67.4%). Patients receiving care at a low volume hospital, compared to high volume were more likely to have postoperative bleeding (OR 1.24 95% CI 1.07-1.45), cardiac failure (OR 1.38 95% CI 1.16-1.64) and respiratory failure (OR 1.49 95% CI 1.25-1.77). Patients at intermediate volume hospitals, compared to high volume presented a higher incidence of postoperative bleeding (OR 1.25 95% CI 1.13-1.38), renal failure (OR 1.18 95% CI 1.01-1.36), respiratory failure (OR 1.37 95% CI 1.22-1.53) and shock (OR 1.82 95% CI 1.16-2.86). On average, patients at low volume hospitals stayed 0.9 days longer (95% CI 0.66-1.18) and patients at intermediate volume hospitals stayed 0.7 days longer (95% CI 0.55-0.87) (Table 1).
Conclusions: A spontaneous centralization towards high volume centers for PEH repair has occurred in the last decade. This trend is beneficial for patients as it is associated with higher rates of laparoscopic operations, decreased surgical morbidity, and a shorter length of hospital stay.
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