title: Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?
abstract: Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement.
  
  
  
  Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05).
  
  
  
  Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement.
  
  
  
  We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Klinginsmith
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Jolley
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lomelin
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
authors.forename: Crystal
authors.initials: C
authors.lastname: Krause
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
authors.forename: Jace
authors.initials: J
authors.lastname: Heiden
authors.affiliation: The Center for Advanced Surgical Technology, Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA. doleynik@unmc.edu.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Oleynikov
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data; D004630:Emergencies; D005260:Female; D018662:Fundoplication / Q000379:methods / Q000706:statistics & numerical data*; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000379:methods / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States
keywords: Anti-reflux procedure; Elective surgery; Emergent surgery; Gastrostomy tube; Laparoscopic surgery; Open surgery; Paraesophageal hernia