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THE IMPACT OF BMI ON 30-DAY AND 90-DAY MORBIDITY AND MORTALITY OF HIATAL HERNIA REPAIR
Chloe E. Hanson
*, Megan Ivy, Alexander S. Farivar, Peter T. White, Adam J. Bograd, Emily M. Mackay, Brian E. Louie
Thoracic Surgery, Swedish Medical Center, Seattle, WA
Introduction: The safety of hiatal hernia (HH) repair has been shown with modest morbidity and rare mortality with rare serious complications. Known risk factors for morbidity include increasing age, hernia size and ASA score along with revision operations, and open approach. Obesity is not consistently identified as a risk factor, however studies have suggested that complications may be influenced by weight but with inconsistent body mass index (BMI) categories and lack of a standardized complication grading scheme. Our objective is to describe and evaluate the impact of BMI on 30 and 90-day morbidity and mortality using Clavien-Dindo (CD).
Methods: We retrospectively reviewed primary elective HH repairs from 2003-2023 for intraoperative complications causing postoperative sequalae, and morbidity and mortality at 30 and 90 days. Complications were graded using the CD Grading System. The highest grade of complication was used per patient. BMI was grouped as BMI<18.5, BMI 18.5-34.9, BMI 35-39.9, and BMI>40 to stratify.
Results: We analyzed 2558 patients with an average BMI of 29.3 ranging from <18.8 to >40 with most having a BMI<30 (59%, 1503/2558), and 12% with a BMI>35 (325/2558)(Table 1). Most patients were healthy non-smokers with a type I or III hernia. Age, sex, CCI, and hernia size were all significantly associated with BMI, with higher BMI patients being younger, predominantly female, having a lower CCI, with a larger hernia.
The overall 30-day complication rate was 19.1% (488/2558), the majority of which were CD<3a (75%, 370/488) (Table 2). Higher BMI patients were not at an elevated risk of complications (Table 2). Underweight patients were at higher risk of CD 2 complications compared to heavier patients (p=0.04). There was no difference between the BMI groups for CD?3a complications (p>0.35).
The overall 90-day complication rate was 3.6% (91/2558), with the majority being CD<3a (68%, 62/91). Higher BMI patients were not at increased risk for 90-day complications and there was no difference between the BMI groups for each CD grade (p=0.85).
Length of stay (1 day, IQR 1-2), ICU admission (1.5%, 38/2558), intraoperative events (3.7%, 94/2558), and transfusions (0.1%, 3/2558) did not increase with increasing BMI.
The 30-day mortality rate was 0.1% (3/2558) with an overall 90-day mortality rate of 0.2% (4/2558). Mortality was not different among the BMI groups (p=0.2).
Conclusion: Across a range of BMIs, hiatal hernia repair appears safe with modest morbidity and low mortality. Higher BMI patients were younger with less comorbidities, as we were more selective. Underweight patients may be at higher risk for low grade complications. At high volume centers, increasing weight should not necessarily exclude patients from anti reflux surgery from a safety standpoint. Underweight patients may benefit from preoperative risk stratification and optimization.
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