K. A. Schlosser1, S. R. Maloney1, T. Prasad1, B. T. Heniford1, P. D. Colavita1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA
Introduction:
The successful management of achalasia can be complicated by the presence of paraesophageal hernias, a combination that is felt to be uncommon. This study examines short term outcomes Laparoscopic Heller Myotomy(LHM) with or without concomitant paraesophageal hernia repair (PEHR).
Methods:
The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent LHM with or without PEHR (2010-2016). Concomitant bariatric procedures were excluded. Demographics, operative approach, and outcomes were compared over time and by procedure group. Overall complication rate was defined as Clavien-Dindo ≥1, while major complication was defined as Clavien-Dindo ≥ 3.
Results:
3,579 patients underwent LHM from 2010-2016. 8.0% of procedures included PEHR, and 1.2% included PEHR with mesh placement. LHM with concomitant PEHR accounts for 1.3% of all PEHR in this time period (286 of 20,798 PEHR). Mean age of LHM was 52.6±16.3yr, mean BMI was 27.6±6.5m2/kg, 50.2% were female, 9.9% had diabetes, and 15.8% were active smokers. Most cases were elective (94.5%). When compared to LHM, patients undergoing open LHM with PEHR were older (58.2±16.3 vs 52.1±16.2yr, p<0.0001), more often inpatients (77.0 vs. 88.1%, p<0.0001) and had higher rates of hypertension (31.1% vs. 45.5% p<0.0001) and long-term steroid use (2.4 vs 4.9%, p=0.01). LHM with PEHR patients had higher rates of reoperation, mortality, overall complications, and major complications (1.5 vs. 3.6%, 3.5 vs. 4.7%, 3.8 vs. 9.1%, respectively; p<0.0009 all values). Over time, the frequency of LHM performed with concomitant PEHR increased from 2.3% of all LHM in 2006 to 10.7% in 2016 (p<0.0001).
Multivariate analysis was used to control for multiple potential confounding factors including concomitant PEHR, age, BMI, steroid use, and hypertension. PEHR with LHM was associated with double the rate of reoperation (OR 2.3, CI 1.1-4.7), and double the overall and major complication rate (OR 2.0, CI 1.2-3.1; OR 2.0, CI 1.1-3.6, respectively). Chronic steroid use was associated with increased length of stay (+2.8d, SE 0.4, p<0.0001), with readmission (OR 3.2, CI 1.6-6.7), and with overall complication rate (OR 3.0, CI 1.6-5.8). Hypertension treated by medications was also associated with increased length of stay (+0.4d, SE 0.15, p=0.01), overall complication rate (OR 1.8, CI 1.2-2.7), and major complications (OR 2.1, CI 1.3-3.7).
Discussion:
The performance of LHM with concomitant PEHR has increased in frequency from 2010 to 2016 for unclear reasons. While patients who have LHM with PEHR have higher complication rates, multivariate analysis demonstrates equivalent short-term outcomes when controlling for confounding factors.