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Paraesophageal hernias: operation or observation?
Nicholas Stylopoulos1, G Scott Gazelle, David W Rattner
1Massachusetts General Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts 02114, USA.
Annals of Surgery
|October 9, 2002
Summary
Watchful waiting (WW) is a reasonable management strategy for asymptomatic or minimally symptomatic paraesophageal hernias. Elective laparoscopic repair (ELHR) offers benefits to fewer than 20% of patients, with lower emergency surgery risks than previously thought.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Decision Analysis
Background:
- Management of asymptomatic paraesophageal hernias is controversial.
- Surgeons often advocate for elective repair to prevent complications and emergency surgery.
- Previous data may overestimate emergency surgery risks.
Purpose of the Study:
- To evaluate the hypothesis that routine elective laparoscopic repair is optimal for asymptomatic or minimally symptomatic paraesophageal hernias.
- Compare outcomes of elective repair versus watchful waiting.
- Inform clinical decision-making for this patient group.
Main Methods:
- A Markov Monte Carlo decision analytic model was employed.
- Compared elective laparoscopic paraesophageal hernia repair (ELHR) with watchful waiting (WW).
- Input variables derived from pooled studies and national databases (1964-2000).
Main Results:
- Emergency surgery mortality is overestimated (5.4% vs. 17% in prior studies).
- ELHR mortality is 1.4%; WW annual emergency surgery risk is 1.1%.
- Watchful waiting is predicted as optimal for 83% of patients, ELHR for 17%.
Conclusions:
- Routine elective laparoscopic repair is not universally beneficial for asymptomatic or minimally symptomatic paraesophageal hernias.
- Watchful waiting is a viable initial management strategy.
- Emergency surgery risks are less severe than previously assumed.