Hosein Salim, Carlson Tyson, Flores Laura, Armijo Priscila Rodrigues, Oleynikov Dmitry
Center for Advanced Surgical Technology, University of Nebraska Medical Center, Omaha, NE, USA.
Department of Surgery, General Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
Surg Endosc. 2021 Jan;35(1):423-428. doi: 10.1007/s00464-020-07404-y. Epub 2020 Feb 10.
We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings.
Vizient 2015-2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0.
9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR.
Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.
我们旨在研究在择期和急诊/紧急情况下不同食管裂孔疝修补术（HHR）方法的疗效和应用情况。
查询Vizient 2015 - 2017数据库中接受HHR的成年患者。患者分为开放手术组（OHHR）、腹腔镜手术组（LHHR）或机器人辅助手术组（RHHR），并根据择期或紧急状态以及入院时疾病严重程度进一步分层。比较所有组的手术结局和费用。使用SPSS v.25.0进行统计分析。
共纳入9171名成年人（OHHR组n = 1534；LHHR组n = 6796；RHHR组n = 841）。LHHR是最常用的方法（74.1%），其次是OHHR（16.7%）和RHHR（9.2%）。与择期手术相比，OHHR在紧急情况下的使用频率是其三倍。总体而言，与LHHR和RHHR相比，OHHR的平均住院时间更长（9.41天对<4天），术后并发症发生率更高（8.8%对<3.8%）、死亡率更高（2.7%对<0.5%）且平均直接费用更高（27,842美元对<10,407美元），所有p<0.05。对轻度至重度病情的择期病例分析表明，在并发症（p<0.05）、费用（p<0.001）和住院时间（p<0.013）方面，LHHR和RHHR优于OHHR；病情极重的择期患者数量不足，无法进行有意义的分析。在紧急情况下，微创方法占主导地位，只有病情极重的患者采用OHHR。尽管是紧急情况，但对于轻至中度病情的患者，OHHR在住院时间（p = 0.002，p<0.0001）和费用（p = 0.0133，p<0.001）方面在统计学上低于LHHR和RHHR。在重度至极重度病情的患者中，尽管OHHR使用更多，但并不优于LHHR；事实上，并发症、费用和死亡率趋势（所有p>0.05）有利于LHHR。
我们的分析表明，目前LHHR是总体上最常用的方法。除病情最严重的患者外，与OHHR相比，LHHR和RHHR与更低的费用、更短的住院时间、更少的并发症和更低的死亡率相关。如果技术可行，即使在紧急/急诊情况下，也应为患者提供微创HHR。
