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1000 HIATAL HERNIA REPAIRS, BEYOND A DECADE PATH OF A SINGLE SURGICAL TEAM TO IMPROVE OUTCOMES
Date
May 18, 2024
Objective: To assess improvement in outcomes of hiatal hernia repair at a single center with a single surgical team.
Methods: Same-day surgery (SDS) was planned by implementing an ERAS protocol in elective laparoscopic repairs with ASA II-III on 04/13/2017. The study was divided before and after 04/13/2017 into Previous (PP)/ Contemporary Period (CP). Opioid-free anesthesia (OFA) was implemented on 12/02/2019. CP was subdivided before and after 12/02/2019 into CP-I/CP-II. Fundoplication was replaced with fundopexy on 08/18/2020 for type III-IV primary and all reoperative repairs. Values are reported as median (IQR)
Results: From 11/24/2009 to 10/05/2023, 1000 repairs were performed in 920 patients, 803/1000 (80.3%) primary, 197/1000 (19.7%) reoperative, and 972/1000 (97.2%) laparoscopic. There were 356/1000 (35.6%) PP and 644/1000 (64.4%) CP, 235/644 (36.5%) CP-I and 409/644 (63.5%) CP-II.
PP vs. CP primary repairs: 281/803 (35.0%) vs. 522/803 (65.0%): ASA III: 150/281 (53.4%) vs. 327/522 (62.6%), p=0.013, type III-IV: 162/281 (57.7%) vs. 354/522 (67.8%), p=0.005, operative time: 128.0 min (107.0-155.2) vs. 105.0 (89.8-127.0), p<0.001, OFA: 0/281 (0.0%) vs. 319/522 (61.1%), p<0.001, LOS: 2 days (1-3) vs. 0 (0-1), p<0.001. Reoperative repairs: 75/197 (38.1%) vs. 122/197 (61.9%). Age: 55 (48-66) vs. 64 (53-71), p=0.008, type III-IV: 20/75 (26.7%) vs. 74/122 (60.7%), p<0.001, operative time: 185.0 (155.2-256.5) vs. 152.0 (128.0-200.0), p=0.001, OFA: 0/75 (0.0%) vs. 80/122 (65.6%), p<0.001, LOS: 3 (2-5) vs. 1 (0-2), p<0.001.
CP-I vs. CP-II primary repairs: 194/522 (37.2%) vs. 328/522 (62.8%). Toupet: 152/194 (78.4%) vs. 51/328 (15.5%), p<0.001, fundopexy: 0/194 (0.0%) vs. 249/328 (75.9%), p<0.001, operative time: 108.0 (94.0-127.0) vs. 104.0 (86.0-129.8), p=0.104, OFA: 0/194 (0.0%) vs. 319/328 (97.3%), p<0.001, SDS: 73/194 (37.6%) vs. 246/328 (75.0%), p<0.001. Reoperative repairs: 41/122 (33.6%) vs. 81/122 (66.4%). Toupet: 26/41 (63.4%) vs. 6/81 (7.4%), p<0.001, fundopexy: 0/41 (0.0%) vs. 68/81 (84.0%), p<0.001, operative time: 171.0 (137.2-255.8) vs. 145.0 (126.0-179.8), p=0.007, OFA: 2/41 (4.9%) vs. 78/81 (96.3%), p<0.001, SDS: 0/41 (0.0%) vs. 40/81 (49.4%), p<0.001.
Symptomatic recurrence requiring reoperation occurred in 62/798 (7.8%) primary laparoscopic repairs: 34/276 (12.3%) PP vs. 28/522 (5.4%) CP, p<0.001, 23/194 (11.9%) CP-I vs. 5/328 (1.5%) CP-II, p<0.001, 22/203 (10.8%) Toupet vs. 1/249 (0.4%) fundopexy, p<0.001.
Conclusion: Hiatal hernia repair can be performed as SDS in elective primary and reoperative repairs. ERAS protocols and assembling a single and consistent surgical team are prerequisites to improved outcomes with decreased operative time, increased same-day surgeries, and lower symptomatic recurrence requiring reoperation. Improved outcomes can be achieved in patients with higher ASA and more complex hernias.
Methods: Same-day surgery (SDS) was planned by implementing an ERAS protocol in elective laparoscopic repairs with ASA II-III on 04/13/2017. The study was divided before and after 04/13/2017 into Previous (PP)/ Contemporary Period (CP). Opioid-free anesthesia (OFA) was implemented on 12/02/2019. CP was subdivided before and after 12/02/2019 into CP-I/CP-II. Fundoplication was replaced with fundopexy on 08/18/2020 for type III-IV primary and all reoperative repairs. Values are reported as median (IQR)
Results: From 11/24/2009 to 10/05/2023, 1000 repairs were performed in 920 patients, 803/1000 (80.3%) primary, 197/1000 (19.7%) reoperative, and 972/1000 (97.2%) laparoscopic. There were 356/1000 (35.6%) PP and 644/1000 (64.4%) CP, 235/644 (36.5%) CP-I and 409/644 (63.5%) CP-II.
PP vs. CP primary repairs: 281/803 (35.0%) vs. 522/803 (65.0%): ASA III: 150/281 (53.4%) vs. 327/522 (62.6%), p=0.013, type III-IV: 162/281 (57.7%) vs. 354/522 (67.8%), p=0.005, operative time: 128.0 min (107.0-155.2) vs. 105.0 (89.8-127.0), p<0.001, OFA: 0/281 (0.0%) vs. 319/522 (61.1%), p<0.001, LOS: 2 days (1-3) vs. 0 (0-1), p<0.001. Reoperative repairs: 75/197 (38.1%) vs. 122/197 (61.9%). Age: 55 (48-66) vs. 64 (53-71), p=0.008, type III-IV: 20/75 (26.7%) vs. 74/122 (60.7%), p<0.001, operative time: 185.0 (155.2-256.5) vs. 152.0 (128.0-200.0), p=0.001, OFA: 0/75 (0.0%) vs. 80/122 (65.6%), p<0.001, LOS: 3 (2-5) vs. 1 (0-2), p<0.001.
CP-I vs. CP-II primary repairs: 194/522 (37.2%) vs. 328/522 (62.8%). Toupet: 152/194 (78.4%) vs. 51/328 (15.5%), p<0.001, fundopexy: 0/194 (0.0%) vs. 249/328 (75.9%), p<0.001, operative time: 108.0 (94.0-127.0) vs. 104.0 (86.0-129.8), p=0.104, OFA: 0/194 (0.0%) vs. 319/328 (97.3%), p<0.001, SDS: 73/194 (37.6%) vs. 246/328 (75.0%), p<0.001. Reoperative repairs: 41/122 (33.6%) vs. 81/122 (66.4%). Toupet: 26/41 (63.4%) vs. 6/81 (7.4%), p<0.001, fundopexy: 0/41 (0.0%) vs. 68/81 (84.0%), p<0.001, operative time: 171.0 (137.2-255.8) vs. 145.0 (126.0-179.8), p=0.007, OFA: 2/41 (4.9%) vs. 78/81 (96.3%), p<0.001, SDS: 0/41 (0.0%) vs. 40/81 (49.4%), p<0.001.
Symptomatic recurrence requiring reoperation occurred in 62/798 (7.8%) primary laparoscopic repairs: 34/276 (12.3%) PP vs. 28/522 (5.4%) CP, p<0.001, 23/194 (11.9%) CP-I vs. 5/328 (1.5%) CP-II, p<0.001, 22/203 (10.8%) Toupet vs. 1/249 (0.4%) fundopexy, p<0.001.
Conclusion: Hiatal hernia repair can be performed as SDS in elective primary and reoperative repairs. ERAS protocols and assembling a single and consistent surgical team are prerequisites to improved outcomes with decreased operative time, increased same-day surgeries, and lower symptomatic recurrence requiring reoperation. Improved outcomes can be achieved in patients with higher ASA and more complex hernias.
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