Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications

1
Long Term Clinical Outcome of 150 Consecutive
Laparoscopic Nissen Fundoplications

• The Minimal Access Therapy Training Unit
• The Royal Surrey County Hospital, Guildford

2
Aims

• To assess
• The long term clinical outcome of 360o
  laparoscopic Nissen Fundoplication
• The clinical outcome of a selective approach to
  division of the short gastric arteries

3
Operative Technique

• The Wrap
• 2cm Long 54F boogie
• Fully mobilise the gastric fundus
• Large window
• Mobile wrap

4
Method

• 150 consecutive patients
• Single surgeon
• March 1994- January 2000
• Telephone Interview
• Clinical Outcomes
• Chi-squared test for statistics

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MethodClinical OutcomesDysphagia

• Ongoing dysphagia at follow up
• De Meester grade of dysphagia
• 0 None.
• 1 Occasional transient sensation of food
  sticking.
• 2 Episodes of bolus obstruction requiring
  liquids to clear
• 3 Progressive dysphagia for solids requiring
  medical
• attention or admission.

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MethodClinical OutcomesSymptom Recurrence

• 0 None.
• 1 Minimal.
• Still much improved
• on pre-operative state
• 2 Yes. Back to pre-operative state

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Method Clinical OutcomesSymptom Recurrence

• Gas Bloat
• Bowel Function
• Patient Satisfaction

8
MethodsPatient Information

• Proven GORD (pH studies upper GI Endoscopy )
• Indication for Surgery
• 93 Failed Medical Therapy
• 40 Patient preference
• 7 complications of GORD
• (6 Barretts, 1 stricture)

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MethodsFollow up
Follow up rate 93 (140 of 150 patients)
Short gastric Time to Follow up arteries
divided Mean Range

• Yes 30 pt 33 months 7-60m
• No 110 pt 30 months 8-76m
• Total 140 pt 31 months 8-76m

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Results Symptom Recurrence
11
Results Symptom Recurrence
12
Conclusions

• 360o laparoscopic Nissen fundoplication
• Long term outcome
• Low dysphagia rates
• Low symptom recurrence rates
• High Patient Satisfaction
• A selective approach to division of the short
  gastric arteries does not affect clinical outcome

13
Day-case Laparoscopic Nissen Fundoplication
The Minimal Access Therapy Training Unit The
Royal Surrey County Hospital, Guildford
14
Previous reports

• Milford and Paluch Surg Endosc 1997111550-52
• Trondsen et al BJS 2000871708-11

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Aim

• To assess the feasibility, the acceptability and
  the safety of
• Day-case laparoscopic Nissen fundoplication

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Patients

• 20 patients (12 males, 8 females)
• Age Median (Range) 47(25-69)
• ASA I or II
• Adequate home support
• Counselled in out patient clinic
• Written information sheet
• Pre-assessment clinic
• Admitted on day of surgery at 07.30

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Anaesthetic technique

• Standard anaesthetic, analgesia and anti-emetic
  protocol
• Granesetron 1mg iv
• Rocuronium (0.1mg/kg) iv
• Propofol (8-12mg/kg/hour)/fentanyl (to a total of
  30 m?/kg) iv
• Sevoflurane/nitrous oxide and fentanyl iv

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Analgesia

• Diclofenac 100mg pr on induction
• 20ml 0.5 bupivicaine infiltrated
• Cyclizine, Co-proxamol, morphine, tramadol
• prn Co-Codamol 2 tablets, 4 hourly
• Diclofenac 100mg, 8 hourly
• Metoclopramide 10mg
• Tramadol 100mg

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Operative technique

• Standard 5 port approach
• 360o Nissen fundoplication over 54FR
• bougie optional
• Selective division of short gastric arteries
• Posterior crural repair
• Fascial repair

20
Post-operative care and assessment

• Surgeon telephone number
• District nurse visit
• Visual analogue scores pain and nausea
• Analgesia requirement and patient satisfaction at
  2 week follow-up
• Wilcoxon signed rank test

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Results

• Median (range) anaesthetic and operating time 88
  minutes (40-155)
• All patients discharged on the day of surgery,
  6hr 40m (4.5-9hrs)
• None of the patients required readmission
• One patient was assessed in casualty department
  the following morning
• No post-operative complications at 2 weeks

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Pain and nausea scores

• Hours post surgery
• 4 12 24 48
• Pain 2 (0-9) 3 (0-9) 3 (0-8) 2 (0-5)
• Nausea 0 (0-10) 1 (0-9) 1 (0-8) 0 (0-10)
• Median (range) p0.045

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Analgesia and anti-emetics

• 13 patients used single analgesia (Co-dydramol or
  diclofenac) for between 2 and 7 days (median 2
  days)
• 2 patients needed additional opiate analgesia
  (Tramadol) for 2 and 3 days
• 3 patients used no analgesia following discharge
• None of the patients took anti-emetics at home

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Follow up

• All the patients were contacted by the surgeon on
  the night of discharge
• 6 patients were not contacted by a district nurse
  the following day

25
Patient satisfaction

• All the patients were happy with the
  information that had been provided for them
• All said that they would recommend the procedure
  as a daycase to a friend
• 17 patients expressed complete satisfaction and
  would be happy to undergo daycase laparoscopic
  surgery again

26
Conclusions

• Laparoscopic fundoplication can be successfully
  undertaken as a day case
• Patients find it acceptable
• It appears to be safe
• Adequate home support is necessary