Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions

Abstract

Background: The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year old Markov analysis. Recently we have shown that elective laparoscopic PEH repair (ELHR) provides an increase in life-years compared to watchful waiting (WW) in most healthy patients aged 40-90. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. Study Design: A Markov model with updated variables was used to compare life-years (LYs) gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions and / or comorbid conditions. Results: In men and women aged 40-90 years-old with PEH-related symptoms and /or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90 year-olds with symptoms but no Cameron lesions. Conclusions: Using a Markov model with updated values for key variables associated with management options for patients with a PEH we showed that life expectancy was improved with ELHR in most men and women aged 40-90, particularly in the presence of symptoms and / or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.