Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications.

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Day-case Laparoscopic Nissen Fundoplication
Mr Yuen Soon Locum Consultant Surgeon Oesophagogas
tric and Laparoscopic Surgery Dr Antony
Bateman SHO Surgery
The Minimal Access Therapy Training Unit The
Royal Surrey County Hospital, Guildford
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Day Case Lap Nissens

• Evidence
• Our Results
• Past
• Present
• Our tricks

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Previous reports

• Cohn et al. Todays Surg. Nurse 19971927-30
  (n4)
• Milford and Paluch Surg Endosc 1997111550-52
  (61)
• Trondsen et al. BJS 2000871708-11 (n45)
• Narain PK et al. J Laparoendosc Adv Surg Tech A
  2000105-11 (n22)
• Finley and McKernan Surg Endosc. 200115823-826
  (n557)
• Bailey et al. BJS 2003 90560-562 (n20)
• Ray Surg Endosc.200317378-80 (n310)
• Victorzon et al. Scand J Surg 200695(3)162-5
  (n28)

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• Ng et al. ANZ J Surg 200575160-164

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on the data considered the complication rates
and readmission rates are comparable to inpatient
procedures

• Ng et al. ANZ J Surg 200575160-164 (Review)

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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

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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

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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
• 5 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

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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

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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

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What Next?

• Retrospective Study of Lap Nissen 2004-2006
• Numbers of Day cases performed
• Return Rates

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Numbers
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Day Case

• Defined as True Day Case
• Discharged in Morning Pre-ward round
• Discharged in Morning Post Ward Round
• Admitted to Main Hospital
• Inpatient Procedure

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Day Case
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Age?
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Date
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Readmission

• 2 patients
• One at day 6 to A/E with Chest Infection
• One at day 8 with abdominal pain and vomiting

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Conclusion

• 93 of Lap Nissens completed as day case/ short
  stay patient
• Not age dependent (p0.25 Anova)
• Not date Dependent (p0.46 Anova)

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Keys to successful day case

• Patient
• Surgical
• Nursing

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Patient Factors

• Patient selection
• Education/Counselling
• Expectation
• Patient support
• At home
• At hospital

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Surgical Factors

• Appropriate operation
• Good Anaesthetist
• PONV
• Analgesia
• Training the team

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Nursing Factors

• Dedicated ward
• Well defined pathway
• Discharge criteria
• Dietetic follow-up
• Information sheets
• Enthusiastic team

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Long Term Clinical Outcome of 150 Consecutive
Laparoscopic Nissen Fundoplications

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

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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

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Operative Technique

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

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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

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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
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Results Symptom Recurrence
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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