title: Emergent Surgery Does Not Independently Predict 30-Day Mortality After Paraesophageal Hernia Repair: Results from the ACS NSQIP Database.
abstract: OBJECTIVE
  Patients undergoing emergency surgery for paraesophageal hernia (PEH) repair have a higher adjusted mortality risk based on Nationwide Inpatient Sample (NIS). We sought to examine this relationship in the National Surgical Quality Improvement Program (NSQIP), which adjusts for patient-level risk factors, including factors contributing to patient frailty.
  
  
  METHODS
  This is a retrospective analysis of the NSQIP from 2009 through 2011. A modified frailty index was created based on previously validated methodology.
  
  
  RESULTS
  Of 3498 patients with PEH repair, 175 (5 %) underwent emergent surgery. Older age, lower BMI, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), current dialysis, SIRS, and sepsis were significantly more common among emergent patients. These patients also had a poorer functional status, higher American Society of Anesthesiologists (ASA), and higher frailty scores and more likely to undergo open surgery. Postoperative complications were proportionally more common, and LOS was longer (8.5 vs. 3.4 days) among emergent patients (all p < 0.05). In univariate analysis, emergent patients demonstrated ten times greater mortality than the elective surgery group (8 vs. 0.8 %). On adjusted analysis, emergent surgery was no longer independently associated with mortality. Frailty score 2 or above and preoperative sepsis significantly predicted increased mortality while laparoscopic repair and BMI 25-50 and BMI ≥30 (vs. BMI <18.5) were significantly protective in the entire group of patients.
  
  
  CONCLUSIONS
  Increased mortality among patients undergoing emergent PEH repair may be related to severity of disease and other preoperative comorbid illness. Without an emergent indication, some of these patients likely would have been excluded as candidates for elective surgical intervention.
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. taugustin@gmail.com.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. taugustin@gmail.com.
authors.forename: Toms
authors.initials: T
authors.lastname: Augustin
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. eschnei1@jhmi.edu.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. eschnei1@jhmi.edu.
authors.forename: Eric
authors.initials: E
authors.lastname: Schneider
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. alaeded@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. alaeded@ccf.org.
authors.forename: Diya
authors.initials: D
authors.lastname: Alaedeen
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. krohm@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. krohm@ccf.org.
authors.forename: Matthew
authors.initials: M
authors.lastname: Kroh
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. aminiaa@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. aminiaa@ccf.org.
authors.forename: Ali
authors.initials: A
authors.lastname: Aminian
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. reznicd@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. reznicd@ccf.org.
authors.forename: David
authors.initials: D
authors.lastname: Reznick
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. walshm@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. walshm@ccf.org.
authors.forename: Matthew
authors.initials: M
authors.lastname: Walsh
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA. brethas@ccf.org.|The Johns Hopkins School of Medicine, Baltimore, MD, USA. brethas@ccf.org.
authors.forename: Stacy
authors.initials: S
authors.lastname: Brethauer
mesh_terms: D000328:Adult; D000368:Aged; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D004630:Emergencies; D005260:Female; D006551:Hernia, Hiatal / Q000150:complications / Q000401:mortality* / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects* / Q000401:mortality*; D006760:Hospitalization; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States
keywords: Elective surgery; Emergency surgery; Laparoscopy; Mortality; NSQIP; Paraesophageal hernia repair