Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.