Day-case Laparoscopic Nissen Fundoplication

The Minimal Access Therapy Training UnitThe Royal Surrey County Hospital, Guildford

Mr Yuen SoonLocum Consultant Surgeon

Oesophagogastric and Laparoscopic Surgery

Dr Antony BatemanSHO Surgery

Day Case Lap Nissens

• Evidence

• Our Results– Past – Present

• Our tricks

Previous reports

• Cohn et al. Todays Surg. Nurse 1997;19:27-30 (n=4)

• Milford and Paluch Surg Endosc 1997;11:1550-52 (61)

• Trondsen et al. BJS 2000;87:1708-11 (n=45)

• Narain PK et al. J Laparoendosc Adv Surg Tech A 2000;10:5-11 (n=22)

• Finley and McKernan Surg Endosc. 2001;15:823-826 (n=557)

• Bailey et al. BJS 2003; 90:560-562 (n=20)

• Ray Surg Endosc.2003;17:378-80 (n=310)

• Victorzon et al. Scand J Surg 2006;95(3):162-5 (n=28)

•Ng et al. ANZ J Surg 2005;75:160-164

“on the data considered the complication rates and readmission rates are

comparable to inpatient procedures”

Ng et al. ANZ J Surg 2005;75:160-164 (Review)

Aim

To assess the feasibility, the acceptability and the safety of

Day-case laparoscopic Nissen fundoplication

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

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

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 hourlyMetoclopramide 10mgTramadol 100mg

Operative technique

• Standard 5 port approach

•360o Nissen fundoplication over 54FR bougie “optional”

•Selective division of short gastric arteries

•Posterior crural repair

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

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

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) *p=0.045

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

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

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

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

What Next?

• Retrospective Study of Lap Nissen 2004-2006

• Numbers of Day cases performed

• Return Rates

Numbers

Lap Nissens 2003-2006

0

5

10

15

20

25

30

35

2004 2005 2006

Series1

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

Day Case

Length of Stay

0

5

10

15

20

25

30

35

True Day Case PreWr( 23.59 hour stay) PostWR(24 hour stay) Admitted In patient Intent

Series1

Age?

20-2930-39

40-4950-59

60-69>70

True Day Case

PreWr( 23.59 hour stay)

PostWR(24 hour stay)

Admitted

In patient Intent

0%6%

0%

8%8%

0%0%

6%

0%0%

23%

20%

60%

33%

56%

67%

31%

20%20%

39%

22%

17%

38% 40%

20%

17%

22%

8%

0%

20%

0%

10%

20%

30%

40%

50%

60%

70%

True Day Case

PreWr( 23.59 hour stay)

PostWR(24 hour stay)

Admitted

In patient Intent

Date

True Day CasePreWr( 23.59

hour stay) PostWR(24hour stay) Admitted

In patientIntent

2004

2005

2006

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2004

2005

2006

Readmission

• 2 patients– One at day 6 to A/E with Chest Infection

– One at day 8 with abdominal pain and vomiting

Conclusion

• 93% of Lap Nissens completed as day case/ short stay patient

• Not age dependent (p=0.25 Anova)

• Not date Dependent (p=0.46 Anova)

Keys to successful day case

Patient

Surgical

Nursing

Patient Factors

• Patient selection

• Education/Counselling

• Expectation

• Patient support– At home– At hospital

Surgical Factors

• Appropriate operation

• Good Anaesthetist– PONV– Analgesia

• Training the “team”

Nursing Factors

• Dedicated ward

• Well defined pathway– Discharge criteria– Dietetic follow-up– Information sheets

• Enthusiastic team

Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen

Fundoplications

The Minimal Access Therapy Training UnitThe Royal Surrey County Hospital, Guildford

Aims

To assess

1 The long term clinical outcome of 360o laparoscopic Nissen Fundoplication

2 The clinical outcome of a selective approach to division of the short gastric arteries

Operative Technique

• The Wrap

2cm Long54F boogie

• Fully mobilise the gastric fundus

• Large window

• Mobile wrap

Method

• 150 consecutive patients

• Single surgeon

• March 1994- January 2000

• Telephone Interview

• Clinical Outcomes

• Chi-squared test for statistics

MethodClinical Outcomes:Dysphagia

• Ongoing dysphagia at follow up

• De Meester grade of dysphagia0 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.

MethodClinical Outcomes:

Symptom Recurrence

0 None.

1 Minimal.

Still much improved

on pre-operative state

2 Yes. Back to pre-operative state

Method Clinical Outcomes:Symptom Recurrence

• Gas Bloat

• Bowel Function

• Patient Satisfaction

MethodsPatient Information

• Proven GORD (pH studies & upper GI Endoscopy )

• Indication for Surgery– 93 Failed Medical Therapy– 40 Patient preference– 7 complications of GORD

• (6 Barrett’s, 1 stricture)

MethodsFollow up

Yes 30 pt 33 months 7-60m

No 110 pt 30 months 8-76m

Total 140 pt 31 months 8-76m

Short gastric Time to Follow uparteries divided Mean Range

Follow up rate 93% (140 of 150 patients)

Results: Symptom Recurrence

Short gastric

arteries divided

Yes No Total P value

No of Patients 30 110 140

None 27 94 121 ns

Minimal 2 13 15 ns

Symptom Recurrence (%)

Yes 1 3 4 ns

Overall effectiveness 97%

Short gastric

arteries divided

Yes No Total P value

No of Patients 30 110 140

Gas Bloat 7 21 28 ns

Flatulence 4 12 16 ns

Patient Satisfaction

28 101 129 ns

Results: Symptom Recurrence

Conclusions

360o laparoscopic Nissen fundoplicationLong 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