Prognostic factors of sepsis following laparoscopic hiatal hernia repair

Abstract

BACKGROUND

Laparoscopic hiatal hernia repair (LHHR) is the surgical intervention of choice for symptomatic hiatal hernias; however, a major complication such as postoperative sepsis presents a serious challenge, particularly in elderly and comorbid patients. Acute kidney injury (AKI) occurring in patients with sepsis is termed sepsis-associated AKI. This complication has been reported to affect 40%–50% of intensive care unit patients with sepsis and is an independent risk factor for increased mortality and prolonged hospital stay. A large proportion of patients who develop sepsis after LHHR may subsequently develop AKI, but the incidence, predictors, and prognosis of AKI remain mostly unknown in this setting despite the clinical importance of this complication. The objective of this study was to identify independent prognostic factors and examine the AKI-mortality association in a surgical cohort.

AIM

To evaluate the prognostic factors associated with postoperative sepsis following LHHR, with particular emphasis on the incidence, risk factors, and clinical impact of AKI in this patient population. The primary objectives were to determine perioperative predictors of sepsis severity, assess AKI as an independent prognostic determinant, and establish evidence-based recommendations for postoperative monitoring and management strategies.

METHODS

We conducted a retrospective analysis of 214 patients who underwent LHHR at the Department of Gastrointestinal Surgery between January 2019 and December 2024. Patients who developed sepsis within 30 days of surgery were identified and compared with non-sepsis controls. Sepsis was defined according to the Sepsis-3 consensus criteria. AKI was diagnosed and staged using the Kidney Disease: Improving Global Outcomes criteria. Logistic regression analysis identified independent predictors of sepsis, AKI, and in-hospital mortality. Receiver operating characteristic curve analysis evaluated the discriminative capacity of identified predictors, and Kaplan–Meier curves compared survival outcomes between the AKI and non-AKI subgroups among patients with sepsis.

RESULTS

Of 214 patients, 42 (19.6%) developed postoperative sepsis. Among patients with sepsis, 18 (42.9%) were diagnosed with AKI: 7 (38.9%) with Kidney Disease: Improving Global Outcomes stage 1, 6 (33.3%) with stage 2, and 5 (27.8%) with stage 3. The overall in-hospital mortality rate among patients with sepsis was 16.7% (7/42); mortality was significantly higher in the AKI subgroup (38.9%, 7/18) than in the non-AKI subgroup (0.0%, P < 0.001). Independent predictors of sepsis included American Society of Anesthesiologists class ≥ III [odds ratio (OR) 3.42, 95% confidence interval (CI): 1.68–6.97, P = 0.001], operative time > 180 minutes (OR 2.85, 95%CI: 1.41–5.77, P = 0.003), and preoperative hypoalbuminemia (OR 2.61, 95%CI: 1.27–5.35, P = 0.009). Independent predictors of AKI among patients with sepsis included Sequential Organ Failure Assessment score ≥ 8 at sepsis onset (OR 4.73, 95%CI: 1.52–14.72, P = 0.007), vasopressor requirement (OR 3.86, 95%CI: 1.24–12.04, P = 0.020), and preoperative creatinine elevation (OR 3.14, 95%CI: 1.03–9.61, P = 0.044). AKI-stage progression was associated with incremental mortality (stage 1: 14.3%; stage 2: 33.3%; stage 3: 80.0%, P < 0.001).

CONCLUSION

Postoperative sepsis following LHHR carries significant morbidity, with AKI representing a critical determinant of prognosis. AKI stage correlates strongly with in-hospital mortality, and its early identification should guide intensified organ support and renal-protective strategies. Preoperative optimization of nutritional status and renal function, combined with vigilant postoperative sepsis monitoring, may mitigate these risks. Prospective multicenter studies are required to validate predictive scoring systems and evaluate targeted interventions for this high-risk cohort.

Keywords: Laparoscopic hiatal hernia repair; Postoperative sepsis; Acute kidney injury; Prognosis; Perioperative outcome; Organ dysfunction; Kidney Disease: Improving Global Outcomes criteria

Core Tip: Postoperative sepsis occurs in 19.6% of patients undergoing laparoscopic hiatal hernia repair, with acute kidney injury (AKI) complicating 42.9% of septic cases. All in-hospital deaths occurred in the AKI subgroup, with stage 3 AKI carrying 80.0% mortality. American Society of Anesthesiologists class ≥ III, operative time > 180 minutes, and preoperative hypoalbuminemia independently predict sepsis. Combined Sequential Organ Failure Assessment and Kidney Disease: Improving Global Outcomes staging achieves superior mortality discrimination (area under the curve 0.924). Early AKI recognition and preoperative nutritional optimization are critical for improving outcomes.