Tailored staged approach for acute paraesophageal hernia: safe and effective in high-risk patients

The management of patients with acute paraesophageal hernia (APEH) remains to be standardized. This study evaluates the safety and outcomes of a novel staged approach for patients with APEH, which is based on gastric decompression followed by non-operative management and either emergency or semi-elective surgical treatment when deemed necessary.

Observational study of a consecutive case series of APEH patients admitted to the hospital between 2007 and 2024, with a minimum follow-up of 3 months. All patients were managed according to the staged approach. Clinical outcomes including postoperative complications, recurrence, and readmission rates were assessed.

Fifty-eight patients (70.7% women) with a mean age of 81 ± 9.2 years (20.7% of patients aged over 90 years) and significant comorbidities were included. Early decompression via nasogastric tube and/or esophagogastroduodenoscopy relieved symptoms in 81% of cases, avoiding emergency surgery. Surgery was deemed unsuitable for 15 patients of whom 4 died due to acute complications, while 11 were successfully managed non-operatively. Surgical intervention was performed in 43 patients (74.1%) primarily through laparoscopic fundoplication, 10 of whom required urgent procedures. Compared to semi-elective repair, urgent surgery was associated with a higher rate of major postoperative complications (40% vs. 21.2%). Over a median follow-up of 27 months, 5 patients (11.6%) required readmission within a 90-day period and 3 (7%) experienced hernia recurrence. None of the patients died.

A staged approach for the management of APEH was feasible, with definitive repair achieved in 93% of surgical patients, via laparoscopy in 72% of cases, and without perioperative mortality.