title: Surgical management of emergency and elective giant paraesophageal hiatus hernias.
abstract: BACKGROUND
  Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting.
  
  
  METHODS
  Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed.
  
  
  RESULTS
  Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184).
  
  
  CONCLUSIONS
  This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.
authors.affiliation: Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom. i.shaikh@doctors.org.uk
authors.forename: Irshad
authors.initials: I
authors.lastname: Shaikh
authors.forename: Philip
authors.initials: P
authors.lastname: Macklin
authors.forename: Peter
authors.initials: P
authors.lastname: Driscoll
authors.forename: Andrew
authors.initials: A
authors.lastname: de Beaux
authors.forename: Graeme
authors.initials: G
authors.lastname: Couper
authors.forename: Simon
authors.initials: S
authors.lastname: Paterson-Brown
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017558:Elective Surgical Procedures; D004638:Emergency Treatment; D005260:Female; D006551:Hernia, Hiatal / Q000473:pathology / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged