PHILADELPHIA – Current clinical practice is to repair symptomatic diaphragmatic hernias to avoid complications such as obstruction or gangrene. However, practice patterns are based largely on limited data from institutional case series, according to Dr. Subroto Paul and his colleagues at Cornell University in New York.
Mortality was significantly higher in patients with uncomplicated hernia who went on to readmission with obstruction or gangrene, Dr. Paul said at the annual meeting of the American Association for Thoracic Surgery, where he presented an analysis of the National Inpatient Sample (NIS) database.
Over a 10-year-period, 193,554 patient admissions were identified for the primary diagnosis of diaphragmatic hernia of any type. An uncomplicated diaphragmatic hernia was the diagnosis in 161,777 (83.6%) admissions. Of these, 38,764 (24.0%) patients underwent an elective repair of their hernia as the principal procedure for their admission.
A diagnosis of diaphragmatic hernia with obstruction or gangrene was the reason for admission in 31,127 (16.1%) and 651 (0.3%) patients, respectively. Mortality was significantly higher in patients who were admitted with obstruction or gangrene (4.5% vs. 27.5%, respectively), compared with patients who were admitted for an elective hernia repair (1%).
Morbidity from pneumonia and sepsis was also significantly higher in patients who were admitted for obstruction or gangrene. Symptomatic admission was associated with more intensive hospitalization, as evidenced by significantly increasing length of stay – 6 days (uncomplicated) vs. 9 days (obstruction) vs. 17.5 days (gangrene) – and the need for mechanical ventilation (3.6% vs. 9.7 vs. 41.3%, respectively).
Based on their mortality data, the authors also performed a lifetime risk analysis that suggested that elective repair is associated with a favorable risk-benefit profile for patients in their 50s, 60s, and perhaps early 70s.
"In this large national database study, the prevalence of diaphragmatic hernia per hospital admission is 1:2,000. Admissions resulting from gangrene or obstruction are not uncommon and are associated with worse outcomes than [is repair] in uncomplicated hernias.
"This analysis suggests the practice of repair of uncomplicated diaphragmatic hernia may avoid the morbidity and mortality associated with either obstruction or gangrene," he concluded.
Dr. Paul reported that he had no relevant disclosures.