Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia

BackgroundAcute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24 h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH.MethodsA retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24 h were excluded.ResultsA total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25 days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission.ConclusionA trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.