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Laparoscopic Treatment of Paraesophageal Hernia Complicated with Gastric Volvulus

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Paraesophageal hernias are rare, accounting only for about 5% of all hiatal hernias but can sometimes lead to life-threatening complications such as bleeding, obstruction, incarceration, and strangulation. Accordingly, the surgical repair of paraesophageal hernia must be performed irrespectively of symptoms. Laparoscopic techniques of paraesophageal hernia offer several advantages compared with open techniques, including smaller incision, less traumatic handling of tissues, less postoperative pain. In this report, we describe a case of paraesophageal hernia complicated with gastric volvulus, which has been successfully repaired by the laparoscopic approach. A 79-year-old female was suffering from dysphagia, abdominal pain and intermittent vomiting for several months, and a paraesophageal hernia with partial gastric outlet obstruction due to gastric volvulus was diagnosed. The patient underwent the reduction of the hernia, dissection of the sac, crural repair and fundoplication via a laparoscopic approach. She recovered early and has been doing well on follow up with no recurrence.
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J Korean Surg Soc 2009;77:S5-8
증례
DOI: 10
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4174/jkss
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2009
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77
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Suppl
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책임저자: 송교영, 서울시 서초구 반포동 505
󰂕
137-701, 가톨릭대학교 서울성모병원 외과
Tel: 02-2258-2873, Fax: 02-595-2822
E-mail: skygs@catholic.ac.kr
접수일
200965, 게재승인일
2009714
위염전을 동반한 식도곁탈장의 복강경적 치료
가톨릭대학교 의과대학 서울성모병원 위장관외과학교실
이한홍송교영전해명박조현
Laparoscopic Treatment of Paraesophageal Hernia Complicated with Gastric Volvulus
Han Hong Lee, M.D., Kyo Young Song, M.D., Hae Myung Jeon, M.D., Cho Hyun Park, M.D.
Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
Paraesophageal hernias are rare, accounting only for about 5% of all hiatal hernias but can sometimes lead to
life-threatening complications such as bleeding, obstruction, incarceration, and strangulation. Accordingly, the
surgical repair of paraesophageal hernia must be performed irrespectively of symptoms. Laparoscopic techniques
of paraesophageal hernia offer several advantages compared with open techniques, including smaller incision, less
traumatic handling of tissues, less postoperative pain. In this report, we describe a case of paraesophageal hernia
complicated with gastric volvulus, which has been successfully repaired by the laparoscopic approach. A 79-year-old
female was suffering from dysphagia, abdominal pain and intermittent vomiting for several months, and a
paraesophageal hernia with partial gastric outlet obstruction due to gastric volvulus was diagnosed. The patient
underwent the reduction of the hernia, dissection of the sac, crural repair and fundoplication via a laparoscopic
approach. She recovered early and has been doing well on follow up with no recurrence. (J Korean Surg Soc
2009;77:S5-8)
Key Words : Paraesophageal hernia, Gastric volvulus, Laparoscopy
중심 단어
:
식도곁탈장
,
위염전
,
복강경
서론
식도곁탈장은 드문 질환으로 모든 틈새탈장(hiatal hernia)
5% 내외로 발생하는 것으로 알려져 있다.(1) 식도곁탈장
대부분 노령 인구에서 진단되며 이들 환자들은 연령으
로 인해 발생되는 심각한 질환을 자주 동반한다. 식도곁탈
장은 위점막 대량 출혈, 위천공, 교액, 위염전과 같은 합병
증을 일으킬 수 있기 때문에 증상과 관계없이 수술적 치료
요하는 것으로 알려져 있다.(2) 개복 혹은 개흉 수술은
과도한 조직의 조작으로 인한 조직 손상과 큰 절개 흉터를
남기며 특히 고령 환자에서는 높은 이환율과 사망률을
이는 반면, 복강경 수술은 작은 절개와 비교적 낮은 조직
손상, 좋은 시야 확보 등의 이점을 가지며 술 후 통증과 회
복에도 나은 결과를 보이는 것으로 알려져 있다.(3) 최근 저
자들은 위염전이 동반된 식도곁장 환자에서 복강경 식도
곁탈장 교정술 1예를 경험하였기에 문헌 고찰과 함께 보고
하는 바이다.
증례
79여자가 6개월간 지속된 소화불량과 3개월 전부터
시작된 좌상복부 통증과 간헐인 구토와 토혈을 주소로
외래 방문하여 시행한 내시경 소견 위날문막힘
(gastric outlet obstruction) 발견되어 외과로 의뢰되었다.
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Fig. 1. A chest X-ray shows the presence of a gastric air bubble
in the chest.
Fig. 2. An upper GI series shows a contrast stasis in fundus by
gastric outlet obstruction due to gastric volvulus.
Fig. 3. A contrast enhanced CT scan shows a wide defect of the
esophageal hiatus combined with herniation of the stomach
and omental fat.
Fig. 4. Trocar placement.
과거력 상 우측 서혜부 탈장과 자궁 탈출로 수술받은 경력
있었고 최근 3년간 8 kg 정도의 체중 감소를 보이고 있었
. 방문 시 활력 징후는 혈압 100/50 mmHg, 맥박수는 110
/, 호흡수 20/, 체온 37.3
o
C였으며 이학적 검사상 좌
상복부와 명치 부위의 통증 및 압통이 존재하였다. 모든
사실 소견은 정상 범위였고 흉부 방사선 검사에서 흉강 내
에 위의 공기 음영으로 의심되는 소견이 보였다(Fig. 1).
컴퓨터 단층 촬영술과 상부위장관 조영술 소견상 기관
(organoaxial) 위염전으로 인해 부분적인 위날문막힘을 보
이는 식도곁탈장이 관찰되었다(Fig. 2, 3).
수술은 전신 마취 하에 앙와위를 취하였으며 10 mm
카메라 투관침을 삽입한 후 명치 부위에 12 mm 투관침을
삽입하였다. 좌상복부와 우상복부 늑골하연 2
3 cm 하방
에 각각 11 mm5 mm 투관침을 삽입하고 좌측 옆구리에
5 mm 투관침을 삽입하였고 복강내압은 12 mmHg로 유지하
였다(Fig. 4). 횡격막 우각 결손을 통해 위바닥이 탈출되어
있었으며 그물막과 가로창자의 일부 또한 탈출되어 있는
것을 관찰할 수 있었다. 그물막의 염증으로 탈장 주머니와
유착이 심하여 탈출된 장기 정복이 매우 어려웠다. 장기를
정복하니 큰 틈새 결손을 확인할 수 있었으며(Fig. 5), 유착
Han Hong Lee, et al
Laparoscopic Treatment of Paraesophageal Hernia Complicated with Gastric Volvulus
S7
Fig. 6. A postoperative upper GI series shows a favorable contrast
passage in the stomach. A chest X-ray shows the presence
of a gastric air bubble in the chest.
Fig. 5. A large hiatal defect in the thoracic cavity after reducing
contents.
된 탈장 주머니를 초음파 절삭기구(harmonic scalpel)이용
하여 주위 조직에서 박리한 후 절제하였다. 박리 도중 아래
가로막혈관(inferior phrenic vessel)을 손상시키지 않도록 주
의하였고 특히 횡경막 우각과의 박리 시에 후미주신경
(posterior vagus nerve)확인하고 보존하였다. 큰 틈새
손의 경우, 식도 후면에 봉합을 과도하게 집중시키면 식도
앞쪽으로 휘어지는 현상이 나타나므로 이를 방지하기
위하여 식도 후면과 전면에 1 cm 간격으로 각각 2개의 봉합
을 하여 횡경막 결손을 문합하였다. 틈새 교정의 적절한
기는 횡경막 결손 봉합시 당기고 있던 위를 놓았을 때 식도
가 어떠한 협착이나 느슨함이 없이 틈새 공간을 메우는 것
으로 확인하였다. 위식도 역류를 방지하기 위해 Nissen
바닥주름술(fundoplication)을 시행하였는데 이때 위바닥 포
장부위(fundic wrapping)2
3 cm 가량의 길이를 유지하고
포장부위와 식도 사이에 5 mm 복강경 기구가 드나들
있을 정도의 공간을 주어 술 후 나타날 수 있는 소화 불량
과 공기 팽만을 최소화하도록 하였. 출혈부위가 없는 것
인하고 5 mm 투관침 삽입부를 통해 폐쇄성 흡인 배액
관을 삽입한 후 창상을 봉합하여 수술을 마쳤다. 수술 시간
은 총 212분이 소요되었다. 환자는 술 9병일 째 시행한
상부위장관 조영술에서 조영제의 유출이나 막힘이 없이 통
과가 좋아진 것을 확인할 수 있었으며(Fig. 6), 술 후 1개월
외래에서 시행한 내시경에서 약간의 위팽창 소견이
찰되었으나 막힘 증상은 보이지 않았다.
고찰
틈새탈장은 위와 위식도 접합부, 그리고 틈새 결손의 관
계에 따라 4가지 분류로 나누어 진다. 1형은 미끄럼틈새
탈장(sliding hiatal hernia)으로 위식도 접합부가 흉강 내로
이동하는 것을 말하며 틈새탈장의 대부분을 차지한다.
2형이 식도곁탈장으로 위식도 접합부는 가로막에 정상적
으로 위치하나 위바닥이 틈새 결손의 부위를 통해 흉강으
탈장되는 것을 말하며 틈새탈장의 5%정도에서 발생한
. 3형은 1형과 2형이 혼합된 것이고 제 4형은 위가 완
전히 흉강 내로 이동한 것으로 대장이나 비장 같은 다른
내장 기관의 탈장을 동반하여 일명 거꾸로 (upside-
down stomach)”상태를 보이게 된다.(4)
증상은 모호하고 탈장의 크기에 따라 매우 다양하게
타나며 탈장의 크기가 증가할 때까지 오랜 기간 동안 나타
나지 않는 경우도 종종 있다.(5) 전형적인 증상으로는 소화
불량, 구역, 구토, 식후통증, 상복부 불쾌감, 위식도 역류와
같은 상부위장관 폐쇄와 관련된 증상들이 포함되며 흉통,
체중감소, 점막 출혈로 인한 만성 빈혈 등이 나타날 수
. 고령의 환자의 경우에는 급작스럽고 중한 심와부 동통
과 구토증상이 가장 흔하게 나타난다. 흉통 및 심와부 동통
은 심근 경색이나 대동맥 박리, 폐색전과 같은 심각한 심폐
질환과 감별을 요한다.(6)
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식도곁탈장의 진단은 방사선학적 소견으로 확진된다.
방사선 검사 소견에서 관찰되는 흉강 공기 액체층
(air-fluid level)진단에 도움이 되며 바륨 조영술을 시행하
흉강 내 위치하는 위에서 조영제가 차오르는 모습으로
확진할 있다. 컴퓨터 단층 촬영술 또한 진을 위한 진단
적 도구로 사용되며 탈장의 크기, 방위(orientation), 탈장주
머니 내부의 내용물 등의 확인이 가능하다.(7) 내시경으로
위식도 접합부의 위치와 식도염의 존재 유무의 확인에
도움이 된다.(6)
식도곁탈장 환자들은 치명적인 합병증이 발생할 가능성
을 내재하고 있다. 흔한 합병증으로는 위장관 폐쇄와 동반
흉강 위의 감돈 교액, 위궤양과 그로 인한 출혈
등이 있으며 드물게 궤양이 천공되어 농흉이나 긴장성
흉을 만들기도 한다. 용적 저하와 흉강 내 동맥 압박으로
심대상부전(cardiac decompensation) 또한 나타날
.(7) 위벽이 염전으로 인해 과도하게 팽창되고 울혈된 경
혈관 확장으로 인한 심각한 출혈을 야기할 수도 있다.
이러한 합병증들은 보존적 치료만을 받은 환자들의 30
45%에서 발생하는 것으로 알려져 있으며 발생시 50% 이상
사망률을 보인다고 보고되고 있어 수술적 치료는 증상
유무에 관계없이 진단 모든 환자들에게서 추천된
.(8)
식도곁탈장의 복강경 수술 과정은 대개 탈장 주머니
내용물의 정복, 식도 틈새의 봉합, 위바닥주름술과
은 항역류 술기 순으로 이어진다. 복강경 수술은 기술적으
로 많은 숙련도를 요하나 개복 수술에 비해 낮은 이환율과
사망률, 후 통증의 경감, 일상 생활의 빠른 복귀, 그리고
증상의 뚜렷한 완화를 보여 현재 개복 수술을 대치할 안전
하고 유용한 술기로 받아들여 지고 있다. 특히 증상이 없는
환자들의 경우 더욱 고려해 볼 만하다. 하지만 식도곁탈장
복강경 수술에 대한 논란의 여지는 아직도 남아있다.
Boushey (3)은 식도곁탈장의 복강경 수술이 8.6%의 낮은
증상 재발을 이고 재수술을 요하는 예는 단지 3%인 효과
적이며 안전한 술기라고 보고하였으나 Hashemi (9)은 복
강경 수술이 개복 수술보다 높은 재발률을 보인다고 기술
하였다. , Stylopoulos (10)은 식도곁탈장을 진단받았으
나 증상이 없거나 미미한 환자들은 주의 깊게 관찰하는 것
만으로도 충분하다고 보고하였다. 수술 술기 측면에서는
항역류 술기의 추가 여부가 논쟁 거리가 되고 있다.(4)
저자들의 증례는 오랜 기간의 소화불량과 소량의 위장관
출혈이 동반된 구토 증세와 같이 전형적이지만 비특이적
증상만이 나타난 경우로 합병증의 발생 전에 복강경 수술
시행하여 고령의 환자를 정상적인 일상으로 복귀시킬
있었다. 고령 인구가 소화관 폐쇄 증상을 때 식도곁
탈장을 감별 진단으로 검토해야 할 것이며 진단 시 복강경
식도곁탈장 교정술을 시행함으로써 합병증 및 사망 발생을
미연에 방지할 수 있다. 복강경 교정술은 식도곁탈장의 치
료에 효과적인 최소 침습 수술 방법으로 사료되어 문헌고
찰과 함께 보고하는 바이다.
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The surgical approach to paraesophageal hernias (PEH) has changed with the advent of laparoscopic techniques. Variation in both perioperative outcomes and hernia recurrence rates are reported in the literature. We sought to evaluate the short- and intermediate-term outcomes with laparoscopic PEH repair. We performed a retrospective review of patients having laparoscopic repair of PEH between June 1998 and September 2002. We included patients with more than 120 days of follow-up. A total of 58 patients with a mean age of 60.4 (standard deviation [SD] 15.0) years had a laparoscopic procedure to repair a primary PEH, as well as adequate follow-up, during the study period. The types of PEH included type II (n = 13), III (n = 44) and IV (n = 1). The most common symptoms were epigastric pain (57%), dysphagia (40%), heartburn (31%) and vomiting (28%). Associated procedures included 56 (96%) Nissen fundoplications and 2 (4%) gastropexies. We closed all crural defects either with or without pledgets, and 2 patients required the use of mesh. There was 1 conversion to open surgery owing to intraoperative bleeding secondary to a consumptive coagulopathy; we observed no other major intraoperative emergencies. Minor or major complications occurred in 15 patients (26%). Late postoperative complications included 1 umbilical hernia. The mean length of stay in hospital was 3.8 (SD 2.5) days. After surgery, 19 patients were completely asymptomatic, and the majority of the remaining patients (83%) described marked symptom improvement. Upper gastrointestinal series performed in symptomatic patients in the postoperative setting identified 5 recurrent paraesophageal hernias (8.6%) and 5 small sliding hernias (9%). Laparoscopic repair of PEH is associated with improved long-term symptom relief, low morbidity and acceptable recurrence rates when performed in an experienced centre.
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Paraesophageal hernia comprises only 2 approximately 5% of all hiatal hernias but is prone to incarceration and strangulation. For this reason they must be recognized and repaired as expeditiously as possible. The laparoscopic approach has already been successfully applied to the repair of the more common sliding hiatal hernia and it seems reasonable to propose that the paraesophageal hernia, provided it is not complicated, might also be repaired by the laparoscopic technique. We present here a case of paraesophageal hernia which has been successfully repaired by the laparoscopic approach. A 73-year-old female suffering from postprandial fullness in the retrosternal area was diagnosed preoperatively with paraesophageal hiatal hernia with gastroesophageal acid reflux and was submitted for laparoscopic repair. The procedure entailed reduction of the hernia, mobilization of the esophagogastric junction with crural repair and partial fundoplication. At the 9th-month follow-up, the patient had remained asymptomatic and follow-up studies revealed no evidence of hernia or acid reflux. As a result of this favorable experience with minimal morbidity, early hospital discharge, and effective control of symptoms without adverse sequalae, laparoscopic repair can be considered as the curative and minimal invasive method in the management of paraesophageal hernia.
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The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure. An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome. A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected. Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.
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Patients undergoing laparoscopic paraesophageal hernia (PEH) repair risk substantial morbidity. The aim of the present study was to analyze predictive factors for postoperative morbidity and mortality. A total of 354 laparoscopic PEH repairs were analyzed from the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). Age (<70 and > or =70 years) and risk (low: American Society of Anesthesiologists (ASA) scores 1 + 2; high ASA scores 3 + 4) groups were defined and multivariate logistic regression was conducted. In patients > or =70 years of age postoperative morbidity (24.4% versus 10.1%; p = 0.001) and mortality (2.4% versus 0%; p = 0.045) were significantly higher than in patients <70 years of age. In patients with gastropexy, this significant age difference was again present (38.8% versus 10.5%; p = 0.001) whereas in patients with fundoplication no difference between age groups occurred (11.9% versus 10.1%; p = 0.65). Mortality did not differ. High-risk patients had a significantly higher morbidity (26.0% versus 11.2%; p = 0.001) but not mortality (2.1% versus 0.4%; p = 0.18). The multivariate logistic regression identified the following variables as influencing postoperative morbidity: Age > or =70 years (Odds Ratio [OR] 1.99 [95% CI 1.06 to 3.74], p = 0.033); ASA 3 + 4 (OR 2.29 [95% Confidence Interval (CI) 1.22 to 4.3]; p = 0.010); type of operation (gastropexy) (OR 2.36 [95% CI 1.27 to 4.37]; p = 0.006). In patients undergoing laparoscopic paraesophageal hernia repair age, ASA score, and type of operation significantly influence postoperative morbidity and mortality. Morbidity is substantial among elderly patients and those with co-morbidity, questioning the paradigm for surgery in all patients. The indication for surgery must be carefully balanced against the individual patient's co-morbidities, age, and symptoms, and the potentially life threatening complications.
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We describe the case of a 79-year-old woman who presented with resolved episodes of vomiting and was found to have a paraesophageal hernia. Her initial evaluation was unremarkable, and the diagnosis was established only by the use of screening chest radiography. Once the diagnosis was confirmed, the patient required urgent surgical repair. Paraesophageal hernia is a rare clinical entity with the potential for life-threatening complications, making the diagnosis itself an indication for surgery. This case illustrates the fact that significant pathology may be present with few, if any, physical findings in the elderly patient, and thorough evaluations are required for the diagnosis of such occult pathology.
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Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.
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To examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. The management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. A Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted life-years (QALYs). Analysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. If ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.