Wait only to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes

Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes.

From the 2005-2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities.

Of 224 patients, 149 (67%) were early and 75 (33%) were interval, with mean 3.6 days. Repairs were 89% transabdominal, 9% included fundoplication, and 18% gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31% (p = 0.2) and mortality 5.4 versus 4% (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13%, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80% reduction in sepsis (95% confidence interval (CI), 0.05-0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups.

Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.