title: Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients.
abstract: BACKGROUND
  This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair.
  
  
  METHODS
  Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test.
  
  
  RESULTS
  Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures.
  
  
  CONCLUSIONS
  Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.
authors.affiliation: Department of Surgery and Institute for Minimally Invasive Surgery Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Noopur
authors.initials: N
authors.lastname: Gangopadhyay
authors.forename: Juan M
authors.initials: JM
authors.lastname: Perrone
authors.forename: Nathaniel J
authors.initials: NJ
authors.lastname: Soper
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
authors.forename: J Christopher
authors.initials: JC
authors.lastname: Eagon
authors.forename: Mary E
authors.initials: ME
authors.lastname: Klingensmith
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Frisella
authors.forename: L Michael
authors.initials: LM
authors.lastname: Brunt
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006551:Hernia, Hiatal / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology; D010535:Laparoscopy; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome