CONTEMPORAY 30-DAY AND 90-DAY COMPLICATIONS OF ANTIREFLUX AND HIATAL HERNIA SURGERY
Megan L. Ivy*, Alexander S. Farivar, George N. Baison, Cassandra Griffin, Adam J. Bograd, Peter T. White, Brian E. Louie
Swedish Medical Center, Seattle, WA
Purpose
The morbidity and mortality rates of anti-reflux and hiatal hernia surgery are reported as 3%-21% and 0.2%-0.5%. These data come from large national/population level studies, focusing on broad 30-day outcomes and lack granular data on complications and their severity. Institutional studies tend to focus on long-term and quality of life outcomes. Given the range of morbidity, there is a need to not only understand 30, but 90-day morbidity, along with the severity and composition of these complications. We aim to evaluate the incidence of 30 and 90-day morbidity and mortality in a large, single institution dataset.
Methods
We retrospectively reviewed 2343 cases of anti-reflux and hiatal hernia surgery from 2003-20 for intra-operative complications causing post-operative sequelae, as well as morbidity and mortality within 90 days. All complications were graded using the Clavien-Dindo (CD) Grading System, and the highest-grade of complication was used per patient during 30-day and 31–90-day intervals.
Results
Out of 2343 patients, 64.5% (1511) were female, and the median age was 60 (IQR:50-69). The average BMI was 29.0 (SD 5.255), and the median Charlson Comorbidity Index was 2 (IQR:1-3).
Primary surgery accounted for 87.1% (2041) of cases, while 12.9% of cases were revisions. The surgical approach was primarily minimally invasive, with 96.2% (2556) being laparoscopic and 1.9% (45) being robotic. There was a 0.4% (8) conversion of laparoscopic to open surgery. An additional 0.8% (18) were open. A transthoracic approach accounted for 0.7% (16) of cases. The median length of stay (LOS) was 1 day (IQR:1-3). Re-admission rate within 90 days was 4.2% (98/2343), with 54.1% (53/98) patients being re-admitted due to poor oral intake/failure to thrive.
The complication rate was 20% (470/2343) within 30 days, with 10.5% (247) CD grade 1, 4.3% (100) CD Grade 2, 2.4% (55) CD Grade 3a, 1.4% (33) CD Grade 3b, 1.0% (24) CD Grade 4a, 0.3% (8) CD Grade 4b, and 0.1% (3) CD grade 5. The rate of additional complications in the 31–90-day period dropped to 2.3% (55/2343), with 0.9% (22) CD grade 1, 0.2% (7) CD grade 2, 0.8% (18) CD grade 3a, 0.1% (3) CD grade 3b, 0.1% (2) CD grade 4a, 0.04% (1) CD grade 4b, and 0.1% (2) CD grade 5. Table 1 shows examples of complications in each CD grade.
Conclusion
Antireflux and hiatal hernia surgery are safe operations with rare mortality and modest rates of morbidity. However, the majority of the complications patients experience are minor (CD < 3a) and are easily managed. A minority of patients will experience major complications (CD> 3a) that require additional procedures and management to secure a safe outcome. These data are helpful to inform patients of the risks of surgery.
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