Acute Vs. Elective Paraesophageal Hernia Repair: Endoscopic Gastric Decompression Allows Semi-Elective Surgery in a Majority of Acute Patients

Historically, patients presenting acutely with paraesophageal hernia and requiring urgent operation demonstrated inferior outcomes compared to patients undergoing elective repair. A prospective IRB-approved database was used to retrospectively review 570 consecutive patients undergoing paraesophageal hernia repair between 2000 and 2016. Thirty-eight patients presented acutely (6.7%) and 532 electively. Acute presentation was associated with increased age (74 vs. 69 years) but similar age-adjusted Charlson comorbidity scores. A history of chest pain, intrathoracic stomach ≥75%, and mesoaxial rotation were more common in acute presentations. Emergency surgery was required in three patients (8%), and 35 patients were managed in a staged approach with guided decompression prior to semi-elective surgery. Acute presentation was associated with an increased hospital stay (5 (2–13) days vs. 4 (1–27) days, p = 0.001). There was no difference in postoperative Clavien-Dindo severity scores. One patient in the elective group died, and the overall mortality was 0.2%. Our findings suggest that a majority of patients presenting with acute paraesophageal hernia can undergo a staged approach instead of urgent surgery with comparable outcomes to elective operations in high-volume centers. We suggest elective repair for patients presenting with a history of chest pain, intrathoracic stomach ≥75%, and a mesoaxial rotation.