The Choice of Primary Repair or Mesh Repair for Paraesophageal Hernia

A Decision Analysis Based on Utility Scores

Nadia M. Obeid, MD; Vic Velanovich, MD

Disclosures

Annals of Surgery. 2013;257(4):655-664. 

In This Article

Results

Using the baseline frequencies presented in Figures 1 and 2, the utility score for primary repair is 99.12, and for mesh repair, it is 99.59. Therefore, mesh repair would appear to be slightly better.

Figure 3 shows the sensitivity analysis by varying the recurrence rate while all other aspects of the decision analysis are unchanged. This shows that if neither primary repair nor mesh repair had a recurrence, then both repairs would be equivalent, as expected because neither would have the adverse outcomes associated with a recurrence. However, if the repairs had similar recurrence rates, then primary repair would be favored. Another way to interpret this graft is to determine a "threshold." For example, if one believes that the recurrence rate for primary repair is 50%, then mesh repair has to be less than 44% to be superior, with all other aspects being unchanged.

Figure 3.

Sensitivity analysis for primary repair and mesh repair showing change in utility score outcome as it varies by frequency of the occurrence of PEH recurrence.

Figure 4 shows the effect of the reoperation rate while all other aspects of the decision analysis are at the baseline. This shows that if the reoperation rates were similar, then mesh repair would be superior. The threshold for primary repair to be superior is that if primary repair had no recurrences, then it would be superior only if the reoperation rate for mesh repair was greater than 44%.

Figure 4.

Sensitivity analysis for primary repair and mesh repair showing change in utility score outcome as it varies by frequency of the occurrence of the need for reoperation for recurrent PEH.

What these sensitivity analyses show is the importance of both the recurrence rate and reoperation rate. Table 4 and Table 5 show the effects of varying this combination. The reader can then decide what he or she actually believes is the correct recurrence rate and reoperation rate for each type of repair and find the corresponding utility score in the tables. For example, if one believes that mesh repair has a 10% recurrence rate and a 30% reoperation rate, then primary repair would be superior at the threshold of a 20% recurrence rate and a 5% reoperation rate.

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