Abstract
Abstract
Topic
Benign Disease: Esophageal Surgery
Background
With increasing life expectancy, more elderly patients are diagnosed with large paraesophageal hernias (PEHs). However, the optimal management of PEHs in patients aged ≥70 years remains debated because of concerns regarding operative risk, frailty, and postoperative recovery. While elective minimally invasive repair is commonly performed in younger populations, evidence describing perioperative safety, short-term outcomes, and patient-reported satisfaction in older individuals is limited. As this population continues to grow, better characterization of surgical outcomes is essential to guide shared decision-making. We therefore evaluated perioperative and short-term outcomes of PEH repair in patients aged ≥70 years at our institution.
Methods
We conducted an institutional review board–approved, single-center observational study of consecutive patients aged ≥70 years who underwent primary PEH repair by a single surgeon between September 2016 and June 2025. Demographic, clinical, operative, and postoperative data were collected prospectively and analyzed retrospectively. Predefined outcomes included in-hospital postoperative complications (graded by Clavien-Dindo classification), length of stay (LOS), intensive care unit (ICU) admission, 30- and 90-day readmissions, 90-day mortality, quality of life (GERD-HRQL), patient satisfaction, need for endoscopic dilation, and hernia recurrence at last follow-up. Operative variables included surgical approach, fundoplication type, mesh use, adjunct procedures, operative time, and blood loss. Mid-term follow-up data were obtained from clinic visits and standardized surveys. Logistic regression models were used to evaluate associations between clinical variables and outcomes, reporting odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as p<0.05.
Results
A total of 203 patients were included (74.9% female), with a median age of 76 years (maximum 96) and median BMI of 27.5 kg/m2. Non-elective surgery was performed in 16.7%. Most procedures were laparoscopic (87.1%) or robotic (11.9%), with a 1% conversion rate. Median operative time was 90 minutes and median blood loss was 25 mL. Postoperative complications occurred in 16.7% of patients, (5.9% Clavien-Dindo ≥III). Median LOS was 2 days; 5.4% required ICU admission. Thirty- and 90-day readmission rates were 7.4% and 10.9%, respectively. Ninety-day mortality was 0.5%. At a median 12-month follow-up, GERD-HRQL scores was 1, and 90.6% of patients would recommend surgery. Endoscopic dilation was required in 13.8%. Increasing age (OR 1.14, 95%CI 1.04-1.26, p=.008) and non-elective surgery (OR 7, 95%CI 2-24.6, p=.002) predicted ICU admission; non-elective surgery also predicted complications (OR 2.5, 95%CI 1.1-5.9, p=.034) and 30-day readmission (OR 5.2, 95%CI 1.7-15.6, p=.003).
Conclusion
Minimally invasive PEH repair is safe and effective in patients aged ≥70 years, with low mortality, short hospital stay, and high patient satisfaction. Although overall morbidity was acceptable, non-elective surgery was associated with increased ICU utilization, postoperative complications, and readmissions. These findings support consideration of elective repair in appropriately selected elderly patients to reduce adverse outcomes associated with urgent intervention. Further comparative studies incorporating younger cohorts and adjusting for comorbidities and frailty are needed to better define the independent impact of age on surgical risk and to refine patient selection strategies in this growing population.