Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair

Abstract

Background and Objectives: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients. Methods: A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups. Results: Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence. Conclusion: Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Impact of surgical repair on type IV paraesophageal hernias (PEHs)

“…Although comparable results between semi-elective and elective repair [16] [5] were reported, the best timing between EGD decompression and surgery has not been established yet. Conversely, only few authors have reported comparable results between emergent and elective repair, which is similar to our results, suggesting that emergency surgery in large hernias should be performed by experienced hands [17].…”

Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients

“…19,23 Most reports on patients hospitalized with acute PEH complications mix semielective repairs with truly emergent surgery, leading to mortality rates ranging from 3.2% to 27.5%, with a mean of 10%. 1,10,15,22,[24][25][26][27][28][29] Age impacts emergent surgical mortality as it does for ELHR, and we stratified mortality by age groups. Major complications were considered to occur in 22% of patients with a 6% reoperation rate.…”

“…Unlike sliding hiatal hernias, a PEH has the potential for life-threatening complications such as obstruction, gastric ischemia, or perforation. 1 Before 2002, patients with a PEH were advised to undergo surgical repair. 2,3 In 2002, the paradigm changed with the publication of a Markov analysis of hypothetical patients with a PEH.…”

A Massive Para-Esophageal Hernia: An Unusual Cause of Tension Physiology Leading to Cardiac Arrest

“…If the PEH is detected early, elective surgical repair is recommended as emergent intervention is associated with acute organ failure and a reported mortality rate of 50-56%. 3 Conservative management in milder cases consists of bowel rest, total parenteral nutrition, and proton pump inhibitors 4 and can be a bridge to elective intervention. In patients presenting with obstructive symptoms, volvulus and signs of tissue ischemia, immediate surgical intervention is essential.…”