Paraesophageal Hernia Repair Outcomes in Elective, Urgent, and Emergent Patient Populations

BACKGROUND: Paraesophageal hernias are often managed expectantly until symptoms necessitate surgical intervention. The potential progression of paraesophageal hernia to obstruction or ischemic complications spawns debate regarding the elective repair of minimally symptomatic disease. This study evaluates outcomes of elective and nonelective paraesophageal hernia repairs to inform outcomes based on presentation. STUDY DESIGN: A review of all hiatal hernia repairs between 2017 and 2023 was performed at a single institution. Hernia characteristics, patient comorbidities, operative variables, and patient outcomes were assessed in a comparison of elective (El), urgent (Ur), and emergent (Em) repairs of paraesophageal hernias (types II to IV). Patient outcomes were measured by assessing textbook outcomes (TO), defined as the absence of any postoperative complications, reoperation, discharge to a location other than home, or death. RESULTS: After exclusion of type I repairs, 645 type II to IV paraesophageal hernia repairs were identified. Elective repairs more frequently used the laparoscopic or robotic approach (96.3% El, 88.1% Ur, 40% Em; p < 0.001), included fundoplication (96.6% El, 71.6% Ur, 13.3% Em; p < 0.001), and less frequent gastrostomy tube placement. TO were more frequent in elective repair (88.1% El, 58.2% Ur, 46.7% Em; p < 0.001). Predictors of non-TO include heart disease, diabetes, type IV hernia, emergent repair, and laparotomy. Increased reoperations, pneumonia, and kidney injury were seen more frequently with urgent and emergent repairs. Emergent repair patients experienced increased length of stay (interquartile range 3 to 13 days), death (6.7%), and discharge to skilled care facilities (33.3%). CONCLUSIONS: Paraesophageal hernia repair outcomes are better when performed electively; understanding the implications of nonelective repair may inform decisions regarding elective repair vs watchful waiting.