Paraesophageal Hernia: Observation Risky for Frail Patients

Veronica Hackethal, MD

August 31, 2015

Frail patients with paraesophageal hernia (PEH) may have more complications if they follow the watchful waiting approach than if they undergo elective repair, according to a study published online August 26 in JAMA Surgery.

"In a large-scale national registry, emergency PEH repair was uncommon (3.6% of cases) but was associated with an unadjusted 9-fold increased odds of mortality and a 5-fold increased odds of serious morbidity. After adjustment for patient factors and operative technique, however, emergency PEH repair predicted serious morbidity but not mortality," write Jennifer Kaplan, MD, and colleagues from the Department of Surgery, University of California, San Francisco. "These results reinforce the idea that the primary driver of surgical outcome was patient frailty, and, as such, frailty should be assessed whenever recommendations for PEH are being made."

PEH carries a high risk for acute gastric volvulus, strangulation, bleeding, and obstruction. Emergency repair of PEH has a high mortality rate. Perhaps for these reasons, the standard of care for PEH for decades was surgery, regardless of symptoms. All this changed in 2002, with the publication of a study that found that watchful waiting may be better than elective repair in patients with minimal symptoms and age 65 years and older. Since then, many patients have chosen watchful waiting. The number of patients needing emergency PEH repair, however, has climbed, sometimes with devastating results, the authors explain.

In the study, researchers compared outcomes of emergency PEH repair with those of elective repair. They reviewed data about all PEH repairs in adults reported to the American College of Surgeons National Surgical Quality Improvement Program between 2005 and 2012. They defined serious morbidity as a return to the operating room, cardiac complication, sepsis, shock, ventilation for 48 hours, unplanned reintubation, or cerebrovascular accident or stroke.

The analysis included 10,656 patients, of whom 383 (3.6%) had emergency PEH repair and 10,273 (96.4%) had elective repair.

Twenty-one percent of patients who had emergency PEH repair experienced serious morbidity compared with 5.2% of those who had elective repairs (P < .001).

Unadjusted analyses linked emergency PEH repair with increased odds of 30-day mortality and 30-day serious morbidity (odds ratio [OR], 8.8 [95% confidence interval (CI), 5.4 - 14.6; P < .001], and OR, 4.9 [95% CI, 3.8 - 6.4; P < .001], respectively).

On multivariate analysis, emergency repair no longer predicted mortality (OR, 1.2; 95% CI, 0.6 - 2.6; P = .60) but still increased the odds of serious morbidity (OR, 1.8; 95% CI, 1.3 - 2.5; P < .001).

Multivariate analysis also linked age older than 65 years, low serum albumin, dependent functional status, and open surgery to increased morbidity (OR, 1.5 [95% CI, 1.2 - 1.8; P < .001]; OR, 1.5 [95% CI, 1.2 - 2.0; P = .001]; OR, 2.9 [95% CI, 2.2 - 4.0; P < .001]; and OR, 1.8 [95% CI, 1.5 - 2.3; P < .001], respectively).

Those who received emergency PEH repair spent 5 more days in the hospital than those who had elective repairs (mean, 8 days vs 3 days, respectively; P < .001).

The mortality rate was lowest with laparoscopic elective repair (0.46%).

The authors point out that elective laparoscopic PEH repair has become safer since 2002 and has morbidity and mortality rates similar to those of laparoscopic cholecystectomy.

"With such excellent short-term outcomes, elective laparoscopic repair should be weighed into treatment recommendations for patients with a PEH, particularly younger patients," they conclude.

The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online August 26, 2015. Extract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.