1
|
DeMeester SR, Bernard L, Schoppmann SF, McKay SC, Roth JS. Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions. J Am Coll Surg 2024; 238:1069-1082. [PMID: 38359322 DOI: 10.1097/xcs.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. STUDY DESIGN A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions. RESULTS In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions. CONCLUSIONS Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.
Collapse
Affiliation(s)
- Steven R DeMeester
- From the Center for Advanced Surgery, The Oregon Clinic, Portland, OR (DeMeester)
| | - Lisa Bernard
- Bernard Consulting, Selkirk, Ontario, Canada (Bernard)
| | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY (Roth)
| |
Collapse
|
2
|
DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
Collapse
Affiliation(s)
| | | | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY
| |
Collapse
|
3
|
Abstract
Background Laparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates. Results We have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes. Conclusions First, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.
Collapse
|
4
|
Braghetto I, Molina JC, Korn O, Lanzarini E, Musleh M, Figueroa M, Rojas J. Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients. Dis Esophagus 2022; 35:6604852. [PMID: 35687053 DOI: 10.1093/dote/doac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/30/2022] [Indexed: 12/11/2022]
Abstract
Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.
Collapse
Affiliation(s)
- Italo Braghetto
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Juan Carlos Molina
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Owen Korn
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Enrique Lanzarini
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Maher Musleh
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Manuel Figueroa
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Jorge Rojas
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| |
Collapse
|
5
|
Adhikari S, Raja S. Commentary: A century of giant paraesophageal hernia (GPEH) repair: A century of controversy! JTCVS Tech 2020; 3:373-374. [PMID: 34317935 PMCID: PMC8305720 DOI: 10.1016/j.xjtc.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Saurav Adhikari
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
6
|
Oude Nijhuis RAB, Hoek MVD, Schuitenmaker JM, Schijven MP, Draaisma WA, Smout AJPM, Bredenoord AJ. The natural course of giant paraesophageal hernia and long-term outcomes following conservative management. United European Gastroenterol J 2020; 8:1163-1173. [PMID: 32829676 PMCID: PMC7724529 DOI: 10.1177/2050640620953754] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Accurate information on the natural course of giant paraesophageal hernia is
scarce, challenging therapeutic decisions whether or not to operate. Objective We aimed to investigate the long-term outcomes, including hernia-related
deaths and complications (e.g. volvulus, gastrointestinal bleeding,
strangulation) of patients with giant paraesophageal hernia that were
conservatively managed, and to determine factors associated with clinical
outcome. Methods We retrospectively analysed charts of patients diagnosed with giant
paraesophageal hernia between January 1990 and August 2019, collected from a
university hospital in The Netherlands. Included patients were subdivided
into three groups based on primary therapeutic decision at diagnosis.
Radiological, clinical and surgical characteristics, along with long-term
outcomes at most recent follow-up, were collected. Results We included 293 patients (91 men, mean age 70.3 ± 12.4 years) with a mean
duration of follow-up of 64.0 ± 58.8 months. Of the 186 patients that were
conservatively treated, a total hernia-related mortality of 1.6% was
observed. Hernia-related complications, varying from uncomplicated volvulus
to strangulation, occurred in 8.1% of patients. Only 1.1% of patients
included in this study required emergency surgery. Logistic regression
analysis revealed the presence of symptoms (odds ratio (OR) 4.4, 95%
confidence interval (CI) 1.8–20.6), in particular obstructive symptoms
(vomiting, OR 15.7, 95% CI 4.6–53.6; epigastric pain, OR 4.4, 95% CI
1.2–15.8 and chest pain, OR 6.1, 95% CI 1.8–20.6) to be associated with the
occurrence of hernia-related complications. Conclusions Hernia-related death and morbidity is low in conservatively managed patients.
The presence of obstructive symptoms was found to be associated with the
occurrence of complications during follow-up. Conservative therapy is an
appropriate therapeutic strategy for asymptomatic patients.
Collapse
Affiliation(s)
- Renske A B Oude Nijhuis
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Margot van der Hoek
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen M Schuitenmaker
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marlies P Schijven
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands
| | - Werner A Draaisma
- Jeroen Bosch Hospital, Department of Surgery, den Bosch, The Netherlands
| | - Andreas J P M Smout
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| |
Collapse
|
7
|
Choi S, Tang A, Murthy S, Raja S. Preoperative Evaluation and Clinical Decision Making for Giant Paraesophageal Hernias: Who Gets an Operation? Thorac Surg Clin 2019; 29:415-419. [PMID: 31564398 DOI: 10.1016/j.thorsurg.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the acute setting, the preoperative evaluation aims to determine the extent of complications from gastric volvulus. In the elective setting, preoperative testing defines the gastroesophageal anatomy and function to select the optimal operation. Through thoughtful preoperative evaluation, the best operative approach can be tailored to each patient.
Collapse
Affiliation(s)
- Sarah Choi
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Andrew Tang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
8
|
Straatman J, Groen LCB, van der Wielen N, Jansma EP, Daams F, Cuesta MA, van der Peet DL. Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study. Dis Esophagus 2018. [PMID: 29538745 DOI: 10.1093/dote/doy010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.
Collapse
Affiliation(s)
| | | | | | - E P Jansma
- Medical library, VU University Medical Center, Amsterdam, The Netherlands
| | - F Daams
- Department of Gastrointestinal Surgery
| | | | | |
Collapse
|
9
|
Benjamin G, Ashfaq A, Chang YH, Harold K, Jaroszewski D. Diaphragmatic hernia post-minimally invasive esophagectomy: a discussion and review of literature. Hernia 2015; 19:635-43. [DOI: 10.1007/s10029-015-1363-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 02/20/2015] [Indexed: 01/25/2023]
|
10
|
Paul S, Andrews W, Nasar A, Port JL, Lee PC, Stiles BM, Sedrakyan A, Altorki NK. Prevalence and Outcomes of Anatomic Lung Resection for Hemoptysis: An Analysis of the Nationwide Inpatient Sample Database. Ann Thorac Surg 2013; 96:391-8. [DOI: 10.1016/j.athoracsur.2013.03.097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/12/2013] [Accepted: 03/18/2013] [Indexed: 11/27/2022]
|