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Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality

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Abstract

Background

Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patients ≥ 65 years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reach ≤ 0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians.

Methods

We identified 12,422 patients from the 2015–2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with age ≥ 65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR.

Results

Patients age ≥ 65 had a higher 30-day mortality (0.5% vs 0.2%; p < 0.001). Subset analysis of patients age 65–80 and > 80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (p < 0.001). Independent predictors of mortality in patients ≥ 65 years were age > 80 (OR 5.23, p < 0.001) and COPD (OR 2.59, p = 0.04). Patients ≥ 65 had a slightly higher incidence of pneumonia (2% vs 1.2%; p < 0.001), unplanned intubation (0.8% vs 0.5%; p < 0.05), pulmonary embolism (0.7% vs 0.3%; p = 0.001), bleeding requiring transfusion (1% vs 0.5%; p < 0.05), and LOS (2.38 vs 1.86 days, p < 0.001) with no difference in sepsis, return to OR or readmission.

Conclusion

This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patients < 80 years toward elective repair of PEH.

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Authors and Affiliations

  1. Department of Surgery, NYU Grossman School of Medicine, 530 First Avenue, HCC, 6th Floor, Suite 6 C, New York, NY, 10016, USA

    Tanuja Damani, Juliet J. Ray, Mahmoud Farag & Paresh C. Shah

Authors
  1. Tanuja Damani
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  2. Juliet J. Ray
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  3. Mahmoud Farag
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  4. Paresh C. Shah
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Correspondence to Tanuja Damani.

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Disclosures

Dr. Tanuja Damani is a speaker, proctor, and consultant for Intuitive Surgical. Dr. Paresh Shah is a speaker for Intuitive Surgical, consultant for Stryker, and co-founder of Care Centra. Drs. Juliet Ray and Mahmoud Farag have no conflicts of interest or financial ties to disclose.

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Accepted for Oral Presentation, Scientific Forum at Clinical Congress, American College of Surgeons, October 2020, Chicago IL

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Damani, T., Ray, J.J., Farag, M. et al. Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality. Surg Endosc 36, 1407–1413 (2022). https://doi.org/10.1007/s00464-021-08425-x

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  • DOI: https://doi.org/10.1007/s00464-021-08425-x

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