M. Y. Chen1, A. Lee3, M. Muthusamy2,4, G. Sugiyama3, P. J. Chung1,2 1State University of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA 3Zucker School of Medicine at Hofstra Northwell,Department Of Surgery,Hempstead, NY, USA 4Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA
Introduction:
Diaphragmatic hernias are responsible for 1 in every 2000 hospital admissions and studies have shown that the laparoscopic abdominal approach confers decreased morbidity and length of stay (LOS). With the rate of morbid obesity in the US rising, we sought to determine whether morbid obesity was associated with worse outcomes in patients that underwent abdominal laparoscopic diaphragmatic hernia repair (DHR).
Methods:
Using the Nationwide Inpatient Sample (2008-2012) we identified adult (≥18 years) patients that underwent laparoscopic abdominal DHR for diaphragmatic hernias. We excluded cases associated with congenital hernias, obstruction, gangrene, non-elective admissions, cases performed during bariatric procedures, and those missing data. Outcomes of interest included LOS, postoperative complications (mechanical, respiratory, digestive tract, cardiovascular, intraoperative), postoperative infections, and death. Risk variables included age, sex, race, comorbidity status (using the validated van Walraven score), morbid obesity, conversion to open procedure, insurance status, income status, hospital region, hospital type, and hospital bed size. We performed univariate analysis comparing morbidly obese patients to control. We performed multivariable analysis, adjusting for all risk factors, using negative binomial regression for LOS and logistic regression for all other outcomes.
Results:
5,964 patients met criteria and 242 (4.06%) were morbidly obese and 19 (0.32%) died. On univariate analysis, there was significant difference in all risk variables except for income status (p=0.1819), hospital type (p=0.3776), hospital region (p=0.05615). On logistic regression, morbid obesity was only independently associated with increased risk of mechanical complications (OR 4.89, p=0.0039). Negative binomial regression showed that morbid obesity was associated with longer LOS (IRR 1.33, p<0.0001). Other variables independently associated with increased LOS included comorbidity status (IRR 13.2, p<0.0001), conversion to open procedure (IRR 2.73, p<0.0001), Asian/Pacific Islander vs White race (IRR 2.04, p<0.0001), self-pay vs Medicare (IRR 1.30, p<0.0001), Medicaid vs Medicare (IRR 1.19, p<0.0001), receiving care at an urban teaching vs rural hospital (IRR 1.17, p<0.0001), and female vs male sex (IRR 1.07, p=0.0052). Receiving treatment in the west vs northeast region was independently associated with decreased LOS (IRR 0.88, p<0.0001).
Conclusion:
In this large observational study, we found that elective DHR via the laparoscopic abdominal approach is safe in patients that are morbidly obese. However, race, insurance status, and hospital region were found to be significantly associated with LOS, and may account for disparities in care. Further prospective studies are warranted to identify ways to mitigate these factors.