Timing matters: a comparative analysis of semi-elective, elective, and emergent laparoscopic paraesophageal hernia repair.

BACKGROUND: Patients with paraesophageal hernias (PEH) who present with obstruction or other acute symptoms are generally treated with one of three approaches: emergent repair, discharge after stabilization with subsequent elective repair, or "semi-elective repair," defined as elective repair performed during the same hospitalization for acute symptoms but at least one day post-admission. Outcomes associated with semi-elective repair are not well established in the literature. To help address this gap, we evaluated 30-day postoperative outcomes following semi-elective laparoscopic PEH repair and compared them with outcomes following elective and emergent PEH repair. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients undergoing elective, semi-elective, and emergent laparoscopic PEH repair from 2011 to 2020. Procedures resulting in conversion to open surgery or those requiring resection were excluded. We evaluated 30-day postoperative outcomes using multivariable linear and logistic regression, as well as propensity score matched analyses. RESULTS: A total of 34,617 patients underwent elective laparoscopic PEH repair, 2,304 underwent semi-elective PEH repair, and 809 underwent emergent PEH repair. Compared to elective repair, semi-elective PEH repair was independently associated with significantly higher rates of transfusion, deep venous thrombosis/thrombophlebitis, pneumonia/pulmonary embolism, surgical site infection, sepsis/septic shock, readmission, increased length of stay, and increased operative time (all p < 0.001). When compared to emergent repair, semi-elective repair was independently associated with a decreased rate of sepsis/septic shock (p = 0.003). CONCLUSIONS: Semi-elective laparoscopic PEH repair is associated with higher postoperative morbidity compared with elective repair, but improved outcomes compared to emergent repair. While semi-elective repair following inpatient stabilization may still be necessary for some patients with acute PEH symptoms, temporizing measures with a planned staged repair should be considered whenever feasible.