title: Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care?
abstract: BACKGROUND
  Although surgical repair is universally recognized as the gold standard for treatment of paraesophageal hernia (PEH), the optimal surgical approach is still the subject of debate. To determine which surgical technique is safest, we compared the outcomes of laparoscopic (lap), open transabdominal (TA), and open transthoracic (TT) PEH repair using the NSQIP database.
  
  
  METHODS
  From 2005 to 2011, we identified 8,186 patients who underwent a PEH repair (78.4% lap, 19.2% TA, 2.4% TT). Primary outcome measured was 30-day mortality. Secondary outcomes included hospital length of stay, and NSQIP-measured postoperative complications. Multivariable analyses were performed to compare the odds of each outcome across procedure type (lap, TA, and TT) while adjusting for other factors.
  
  
  RESULTS
  Transabdominal patients had the highest 30-day mortality rate (2.6%), compared with 0.5% in the lap patients (p < 0.001) and 1.5% in TT patients. Mean length of stay was statistically significantly longer for TA and TT patients (7.8 days and 6.5 days, respectively) compared with lap patients (3.3 days). After adjusting for age, American Society of Anesthesiologists score, emergency cases, functional status, and steroid use, TA patients were nearly 3 times as likely as lap patients to experience 30-day mortality (odds ratio [OR], 2.97; 95% CI, 1.69 to 5.20; p < 0.001). Moreover, TA and TT patients had significantly increased odds of overall (OR 2.12; 95% CI 1.79 to 2.51; p < 0.001; OR 2.73; 95% CI 1.88 to 3.96; p < 0.001; respectively) and serious morbidity (OR 1.90; 95% CI 1.53 to 2.37, p < 0.001; OR 2.49; 95% CI 1.54 to 4.00; p < 0.001; respectively).
  
  
  CONCLUSIONS
  In the absence of published data indicating improved long-term outcomes after open TA or TT approach, our findings support the use of laparoscopy, whenever technically feasible, because it yields improved short-term outcomes.
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Benedetto
authors.initials: B
authors.lastname: Mungo
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: dmolena2@jhmi.edu.
authors.forename: Daniela
authors.initials: D
authors.lastname: Molena
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Miloslawa
authors.initials: M
authors.lastname: Stem
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Feinberg
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Anne O
authors.initials: AO
authors.lastname: Lidor
mesh_terms: D000328:Adult; D000368:Aged; D016208:Databases, Factual; D005260:Female; D006551:Hernia, Hiatal / Q000401:mortality / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D010535:Laparoscopy / Q000379:methods* / Q000401:mortality; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D059039:Standard of Care; D016896:Treatment Outcome