Background Emergency surgery for a hiatus hernia is usually a high-risk procedure in acutely unwell patients. Common surgical techniques include reduction of the hernia, cruropexy then either fundoplication or gastropexy with a gastrostomy. This is an observational study in a tertiary referral centre for complicated hiatus hernias to compare recurrence rates between these two techniques. Methods Eighty patients are included in this study, from October 2012 to November 2020. This is a retrospective review and analysis of their management and follow-up. Recurrence of the hiatus hernia that mandates surgical repair was the primary outcome of this study. Secondary outcomes include morbidity and mortality. Results In total, 38% of the patients included in the study had fundoplication procedures, 53% had gastropexy, 6% had complete or partial resection of the stomach, 3% had fundoplication and gastropexy and one patient had neither (n = 30, 42, 5, 2,1, respectively). Eight patients had symptomatic recurrence of the hernia which required surgical repair. Three of these patients had acute recurrence and 5 after discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1) (p value = 0.5). 38% of patient had no complications and 30-day mortality was 7.5% Conclusion To our knowledge, this is the largest single centre review of outcomes following emergency hiatus hernia repairs. Our results show that either fundoplication or gastropexy can be used safely to reduce the risk of recurrence in the emergency setting. Therefore, surgical technique can be tailored based on the patient characteristics and surgeon experience, without compromising the risk of recurrence or post-operative complications. Mortality and morbidity rates were in keeping with previous studies, which is lower than historically documented, with respiratory complications most prevalent. This study shows that emergency repair of hiatus hernias is a safe operation which is often a lifesaving procedure in elderly comorbid patients.
Aims Emergency presentation of giant hiatus and diaphragmatic hernias are associated with significant morbidity and mortality. The preoperative risk prediction tools not only can help clinicians stratify risk, but they can also be valuable tools to outline surgical risks to patients and families. This study aimed to evaluate the suitability of different risk prediction models when predicting morbidity and mortality in emergency giant hiatus and diaphragmatic hernia repairs. Methods This was a retrospective cohort study of all emergency hiatus and diaphragmatic hernia repairs at a tertiary upper gastrointestinal centre from 2010 to 2021. We compared the outcomes to the predicted mortality and morbidity of different risk prediction models. The mortality models SORT, NELA and ACS-NSQIP were compared using the area under the curve (AUC). We evaluated morbidity by calculating the comprehensive complication index (CCI). Using Spearman correlation, CCI was compared to P-POSSUM and ACS-NSQIP predicted morbidity. Results 108 patients were included in the analysis. The 30-day mortality rate was 6.93%. ACS-NSQIP had the highest predictive power for mortality (AUC ¼ 0.845) in comparison to NELA (AUC¼0.809) and SORT (AUC ¼ 0.740). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho ¼ 0.489, p < 0.001 and 0.446, p < 0.001 respectively). Conclusions ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, P-POSSUM and SORT. Multi-centre prospective studies could be used to validate these findings. ACS-NSQIP may have a role in pre-assessment and consenting emergency giant hiatus and diaphragmatic hernia repairs.
Aims Operative management of emergency presentation with a hiatal hernia aims to reduce the herniated stomach, dissect the hernial sac and reapproximate the crura. This will often be followed by fundoplication or gastropexy to minimise the risk of recurrence. This study compares the recurrence rates between patients who underwent fundoplication and gastropexy. Methods From October 2012 to November 2020, 80 patients were admitted to a tertiary oesophagogastric centre requiring emergency surgery to repair a giant hiatal hernia. We conducted a retrospective review and analysis of their admission and follow-up. The primary outcome measure was acute and post-discharge symptomatic recurrence of hiatal hernia. Results Of the 80 patients requiring emergency hiatal hernia surgery, 38% had fundoplication procedures, 53% had gastropexy, and 3% had both (n 30, 42, 2 respectively). One patient had neither, and 6% (n 5) patients had a complete or partial stomach resection due to necrosis. Eight patients (10%) had a symptomatic recurrence of hiatal hernia requiring a repeat operation; three within the index admission, five postdischarge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n 4, 3, 1)(p-value 0.5). 19% (n 15) patients were readmitted. Post-operative mortality was 6% (n 5). Conclusions There is no conclusive evidence in the literature favouring fundoplication versus gastropexy. The surgeon's experience and patient factors influence choice of technique. This review, which includes the largest cohort of patients available in the literature, demonstrates that surgical technique does not influence the symptomatic recurrence rate in our patient group.
Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair reduces the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study looked at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had a symptomatic recurrence of the hiatus hernia that required operative correction during index admission or subsequent admission. The median length of hospital stay was eight days (IQR 5–16). There was a positive correlation between the number of complications and length of stay. Post-operative mortality was 9%. Conclusion Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.
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