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01-02-2019

Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair

Authors: Guillaume S. Chevrollier, Andrew M. Brown, Scott W. Keith, Joanne Szewczyk, Michael J. Pucci, Karen A. Chojnacki, Ernest L. Rosato, Francesco Palazzo

Published in: Surgical Endoscopy | Issue 2/2019

Abstract

Background

The increased incidence of anemia in patients with hiatal hernias (HH) and resolution of anemia after HH repair (HHR) have been clearly demonstrated. However, the implications of preoperative anemia on postoperative outcomes have not been well described. In this study, we aimed to identify the incidence of preoperative anemia in patients undergoing primary HHR at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes.

Methods

Using our IRB-approved institutional HH database, we retrospectively identified patients undergoing primary HHR between January 2011 and April 2017 at our institution. We identified patients with anemia, defined as serum hemoglobin levels less than 13 mg/dL in men and 12 mg/dL in women, measured within two weeks prior to surgery, and compared this group to a cohort of patients with normal preoperative hemoglobin. Perioperative outcomes analyzed included estimated blood loss (EBL), operative time, perioperative blood transfusions, failed postoperative extubation, intensive care unit (ICU) admission, postoperative complications, length of stay (LOS), and 30-day readmission. Outcomes were compared by univariable and multivariable analyses, with significance set at p < 0.05.

Results

We identified 263 patients undergoing HHR. The median age was 66 years and most patients were female (78%, n = 206). Seventy patients (27%) were anemic. In unadjusted analyses, anemia was significantly associated with failed postoperative extubation (7 vs. 2%, p = 0.03), ICU admission (13 vs. 5%, p = 0.03), postoperative blood transfusions (9 vs. 0%, p < 0.01), and postoperative complications (41 vs. 18%, p < 0.01). On adjusted multivariable analysis, anemia was associated with 2.6-fold greater odds of postoperative complications (OR 2.57; 95% CI 1.36–4.86; p < 0.01).

Conclusions

In this study, anemia had a prevalence of 27% in patients undergoing primary HHR. Anemic patients had 2.6-fold greater odds of developing postoperative complications. Anemia is common in patients undergoing primary HHR and warrants consideration for treatment prior to elective repair.

Johnson DA, Ruffin WK (1996) Hiatal hernia. Gastrointest Endosc Clin N Am 6:641–666CrossRefPubMed

Lebenthal A, Waterford SD, Fisichella PM (2015) Treatment and controversies in paraesophageal hernia repair. Front Surg 2:13. https://doi.org/10.3389/fsurg.2015.00013 CrossRefPubMedPubMedCentral

Haurani C, Carlin AM, Hammoud ZT, Velanovich V (2012) Prevalence and resolution of anemia with paraesophageal hernia repair. J Gastrointest Surg 16:1817–1820. https://doi.org/10.1007/s11605-012-1967-6 CrossRefPubMed

Hocking BV, Alp MH, Grant AK (1976) Gastric ulceration within hiatus hernia. Med J Aust 2:207–208PubMed

Gupta P, Suryadevara M, Das A, Falterman J (2015) Cameron ulcer causing severe anemia in a patient with diaphragmatic hernia. Am J Case Rep 16:733–736. https://doi.org/10.12659/AJCR.894145 CrossRefPubMedPubMedCentral

Bock AV, Dulin JW, Brooke PA (1933) Diaphragmatic hernia and secondary anemia; ten cases. N Engl J Med 209:615–625. https://doi.org/10.1056/NEJM193309282091301 CrossRef

Holt JM, Mayet FG, Warner GT, Callender ST, Gunning AJ (1968) Iron absorption and blood loss in patients with hiatus hernia. Br Med J 3:22–25CrossRefPubMedPubMedCentral

Cameron AJ, Higgins JA (1986) Linear gastric erosion: a lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 91:338–342CrossRefPubMed

Trastek VF, Allen MS, Deschamps C, Pairolero PC, Thompson A (1996) Diaphragmatic hernia and associated anemia: response to surgical treatment. J Thorac Cardiovasc Surg 112:1340–1344. https://doi.org/10.1016/S0022-5223(96)70149-6 (discussion 1344)CrossRefPubMed

10.

Carrott PW, Markar SR, Hong J, Kuppusamy MK, Koehler RP, Low DE (2013) Iron-deficiency anemia is a common presenting issue with giant paraesophageal hernia and resolves following repair. J Gastrointest Surg 17:858–862. https://doi.org/10.1007/s11605-013-2184-7 CrossRefPubMed

11.

Skipworth RJE, Staerkle RF, Leibman S, Smith GS (2014) Transfusion-dependent anaemia: an overlooked complication of paraoesophageal hernias. Int Sch Res Notices 2014:479240. https://doi.org/10.1155/2014/479240 CrossRefPubMedPubMedCentral

12.

Windsor CW, Collis JL (1967) Anaemia and hiatus hernia: experience in 450 patients. Thorax 22:73–78CrossRefPubMedPubMedCentral

13.

Cameron AJ (1976) Incidence of iron deficiency anemia in patients with large diaphragmatic hernia: a controlled study. Mayo Clin Proc 51:767–769PubMed

14.

Carrott PW, Hong J, Kuppusamy M, Koehler RP, Low DE (2012) Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair. Ann Thorac Surg 94:421–426. https://doi.org/10.1016/j.athoracsur.2012.04.058 (discussion 426)CrossRefPubMed

15.

Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383. https://doi.org/10.1016/0021-9681(87)90171-8 CrossRefPubMed

16.

Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251. https://doi.org/10.1016/0895-4356(94)90129-5 CrossRefPubMed

17.

World Health Organization (2011) Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity: VMNIS

18.

Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedPubMedCentral

19.

Sihvo EI, Salo JA, Räsänen JV, Rantanen TK (2009) Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg 137:419–424. https://doi.org/10.1016/j.jtcvs.2008.05.042 CrossRefPubMed

20.

Segal HL (1931) Secondary anemia associated with diaphragmatic hernia. NY State J Med 31:692

21.

Weston AP (1996) Hiatal hernia with cameron ulcers and erosions. Gastrointest Endosc Clin N Am 6:671–679CrossRefPubMed

22.

Gray DM, Kushnir V, Kalra G, Rosenstock A, Alsakka MA, Patel A, Sayuk G, Gyawali CP (2015) Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome. Dis Esophagus 28:448–452. https://doi.org/10.1111/dote.12223 CrossRefPubMed

23.

Moskovitz M, Fadden R, Min T, Jansma D, Gavaler J (1992) Large hiatal hernias, anemia, and linear gastric erosion: studies of etiology and medical therapy. Am J Gastroenterol 87:622–626PubMed

24.

Panzuto F, Di Giulio E, Capurso G, Baccini F, D’Ambra G, Delle Fave G, Annibale B (2004) Large hiatal hernia in patients with iron deficiency anaemia: a prospective study on prevalence and treatment. Aliment Pharmacol Ther 19:663–670. https://doi.org/10.1111/j.1365-2036.2004.01894.x CrossRefPubMed

25.

Nguyen N, Tam W, Kimber R, Roberts-Thomson IC (2002) Gastrointestinal: Cameron’s erosions. J Gastroenterol Hepatol 17:343CrossRefPubMed

26.

Maganty K, Smith RL (2008) Cameron lesions: unusual cause of gastrointestinal bleeding and anemia. Digestion 77:214–217. https://doi.org/10.1159/000144281 CrossRefPubMed

27.

Chun CL, Conti CA, Triadafilopoulos G (2011) Cameron ulcers: you will find only what you seek. Dig Dis Sci 56:3450–3452. https://doi.org/10.1007/s10620-011-1803-y CrossRefPubMed

28.

Polomsky M, Hu R, Sepesi B, O’Connor M, Qui X, Raymond DP, Litle VR, Jones CE, Watson TJ, Peters JH (2010) A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach. Surg Endosc 24:1250–1255. https://doi.org/10.1007/s00464-009-0755-1 CrossRefPubMed

29.

Stylopoulos N, Gazelle GS, Rattner DW (2002) Paraesophageal hernias: operation or observation? Ann Surg 236:492–500. https://doi.org/10.1097/01.SLA.0000029000.06861.17 (discussion 500)CrossRefPubMedPubMedCentral

30.

Ballian N, Luketich JD, Levy RM, Awais O, Winger D, Weksler B, Landreneau RJ, Nason KS (2013) A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 145:721–729. https://doi.org/10.1016/j.jtcvs.2012.12.026 CrossRefPubMedPubMedCentral

31.

Wu W-C, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, Sharma SC, Vezeridis M, Khuri SF, Friedmann PD (2007) Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 297:2481–2488. https://doi.org/10.1001/jama.297.22.2481 CrossRefPubMed

32.

Gupta PK, Sundaram A, Mactaggart JN, Johanning JM, Gupta H, Fang X, Forse RA, Balters M, Longo GM, Sugimoto JT, Lynch TG, Pipinos II (2013) Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg 258:1096–1102. https://doi.org/10.1097/SLA.0b013e318288e957 CrossRefPubMed

33.

Muñoz M, Gómez-Ramírez S, Campos A, Ruiz J, Liumbruno GM (2015) Pre-operative anaemia: prevalence, consequences and approaches to management. Blood Transfus 13:370–379. https://doi.org/10.2450/2015.0014-15 CrossRefPubMedPubMedCentral

34.

Partridge J, Harari D, Gossage J, Dhesi J (2013) Anaemia in the older surgical patient: a review of prevalence, causes, implications and management. J R Soc Med 106:269–277. https://doi.org/10.1177/0141076813479580 CrossRefPubMedPubMedCentral

35.

Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, Khreiss M, Dahdaleh FS, Khavandi K, Sfeir PM, Soweid A, Hoballah JJ, Taher AT, Jamali FR (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 378:1396–1407. https://doi.org/10.1016/S0140-6736(11)61381-0 CrossRefPubMed

36.

Bodewes TCF, Pothof AB, Darling JD, Deery SE, Jones DW, Soden PA, Moll FL, Schermerhorn ML (2017) Preoperative anemia associated with adverse outcomes after infrainguinal bypass surgery in patients with chronic limb-threatening ischemia. J Vasc Surg 66:1775–1785.e2. https://doi.org/10.1016/j.jvs.2017.05.103 CrossRefPubMedPubMedCentral

37.

Beutler E, Waalen J (2006) The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood 107:1747–1750. https://doi.org/10.1182/blood-2005-07-3046 CrossRefPubMedPubMedCentral

38.

Patel KV (2008) Epidemiology of anemia in older adults. Semin Hematol 45:210–217. https://doi.org/10.1053/j.seminhematol.2008.06.006 CrossRefPubMedPubMedCentral

39.

Centers for Disease Control and Prevention (CDC) (2002) Iron deficiency–United States, 1999–2000. MMWR Morb Mortal Wkly Rep 51:897–899

Title: Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair
Authors: Guillaume S. Chevrollier
Andrew M. Brown
Scott W. Keith
Joanne Szewczyk
Michael J. Pucci
Karen A. Chojnacki
Ernest L. Rosato
Francesco Palazzo
Publication date: 01-02-2019
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 2/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-018-6328-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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