Definitive, urgent repair of acutely incarcerated paraesophageal hernias is comparable to an elective repair.

backgroundEmergent repair of paraesophageal hernias (PEHs) is rare. This study aimed to compare outcomes of elective and urgent PEH repairs in patients with type II-IV PEHs.

methodsThis was a single-center retrospective review of type II-IV PEHs from February 2014 to April 2024. The operations were classified as elective or urgent. Indications for urgent repair included acute incarceration and/or gastric outlet obstruction, which required immediate NGT decompression and/or EGD followed by definitive repair during the same hospital admission. Outcomes were 90-day hernia recurrence, mortality, readmission, and reoperation. Significant associations between operative cohort and outcomes were evaluated using univariable logistic regression.

resultsA total of 207 patients were included (female: 82%, median age: 64 years, ASA III: 57%). Type III PEH was most frequent (n = 116, 56%), followed by type IV (n = 64, 31%). There were 21 patients included in the urgent cohort. Of these, gastric decompression was performed via EGD in 16 patients (76%) and only NGT placement in two patients (10%). The median time to definitive repair was 6 [IQR 1.0-13.5] days. Laparoscopic (n = 126, 61%) and robotic (n = 75, 36%) approaches were similar between the elective and urgent cohorts (p = 0.70). Nissen fundoplication (n = 108, 52%) was the most common anti-reflux operation performed. The median length of stay (3 vs 4 days, p = 0.10) and hernia recurrence (n = 3 vs n = 1, p = 0.32) were comparable between the cohorts. There was one mortality in the urgent cohort secondary to a respiratory complication. Reoperations occurred in four patients, all in the elective cohort for gastric perforation, ischemic Roux limb, and early postoperative recurrence (n = 2). Readmissions included 18 (10%) and 3 patients (14%) from the elective and urgent cohorts, respectively (p = 0.55).

conclusionAcutely incarcerated PEHs are infrequent and require immediate gastric decompression. In stable patients, definitive urgent MIS repair can be performed safely during the same admission, with low risk of postoperative complications or recurrence, comparable to elective operations.