title: Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis.
abstract: Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting.
  
  
  
  We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined.
  
  
  
  Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair.
  
  
  
  Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.
authors: Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
authors: Vernissia
authors: V
authors: Tam
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: James D
authors: JD
authors: Luketich
authors: University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, PA, USA.
authors: Daniel G
authors: DG
authors: Winger
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: Inderpal S
authors: IS
authors: Sarkaria
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: Ryan M
authors: RM
authors: Levy
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: Neil A
authors: NA
authors: Christie
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: Omar
authors: O
authors: Awais
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA.
authors: Manisha R
authors: MR
authors: Shende
authors: Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Center Ave, Shadyside Medical Building, Suite 715, Pittsburgh, PA, 15232, USA. nasonks@upmc.edu.
authors: Katie S
authors: KS
authors: Nason
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D057216:Propensity Score; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Elective surgical procedures; Emergency surgery; Hiatal hernia; Outcome assessment; Propensity score