Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease

Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care

OBJECTIVE

We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings.

METHODS

Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated.

RESULTS

After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01).

CONCLUSION

SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Outcomes of same-day discharge sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis

Length of stay after bariatric surgery has progressively shortened. Same-day discharge (SDD) has been reported for the 2 most common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to evaluate the safety and success of SDD following SG and RYGB. Systematic literature search on SDD after bariatric surgery was conducted in Medline, Cochrane library, Google Scholar, and Embase. SDD was defined as discharging the patient during the day of the bariatric operation, without an overnight stay. The primary outcomes of interest were successful SDD, readmission, and morbidity rates. The secondary endpoints included reoperation and mortality rates. A proportion meta-analysis was performed to assess the outcomes of interest. A total of 14 studies with 33,403 patients who underwent SDD SG (32,165) or RYGB (1238) were included in the qualitative synthesis. Seven studies with 5000 patients who underwent SDD SG were included in the quantitative analysis, and pooled proportions (PPs) were calculated for the outcomes of interest. The SDD success rate was 63%-100% (PP: 99%) after SG and 88%-98.1% after RYGB. The readmission rate ranged from .6% to 20.8% (PP: 4%) after SDD SG and 2.4%-4% after SDD RYGB. Overall morbidity, reoperation, and mortality were 1.1%-10% (PP:4%), .3%-2.1% (PP: 1%), and 0%-.1% (PP: 0%), respectively, for SDD SG, and 2.5%-4%,1.9%-2.5%, and 0%-.9%, respectively, for SDD RYGB. SDD after SG seems feasible and safe. The outcomes of SDDRYGB seem promising, but the evidenceis stilllimitedto draw definitive conclusions. Selection criteria and perioperative protocolsmust be standardized to adequately introduce this practice.

Same-Day Home Recovery for Benign Foregut Surgery

Importance

Same-day home recovery (SHR) is now the standard of care for many major surgical procedures and has the potential to become standard practice for benign foregut procedures (eg, hiatal hernia repair, fundoplication, and Heller myotomy).

Objective

To determine whether SHR for patients undergoing benign foregut surgery is feasible, safe, and effective.

Design, Setting, and Participants

This prospective cohort study took place across 19 medical centers within an integrated health care system in northern California from January 2019 through September 2021. Participants included consecutive patients undergoing elective benign foregut surgery.

Exposures

Standardized SHR program.

Main Outcomes and Measures

The primary end point was the rate of SHR. The secondary end points were 7-day and 30-day rates of postoperative emergency department visits, hospital readmissions, and reoperations.

Results

Of 1248 patients who underwent benign foregut surgery from January 2017 through September 2021, 558 were patients before implementation of the SHR program and 690 were patients postimplementation. The mean age of patients was 60 years, and 759 (59%) were female. The preimplementation SHR rate was 64 of 558 patients (11.5%) in 2018 and increased to 82 of 113 patients (72.6%) by 2021 (94/350 [26.9%] in 2019 and 112/227 [49.3%] in 2020; P < .001). There were no statistical differences in the 7-day and 30-day rates of postoperative emergency visits, hospital readmissions, and reoperations or 30-day mortality in the SHR vs non-SHR groups in the postimplementation era.

Conclusions and Relevance

In this study, implementation of a regional SHR program among patients undergoing elective benign foregut surgery was feasible, safe, and effective. The changes in perioperative care require comprehensive patient education and full multidisciplinary support. An SHR program for benign foregut procedures has the potential to improve patient care and cost-effectiveness in care delivery.

Same day discharge does not lead to worse outcomes in patients undergoing uncomplicated laparoscopic foregut surgery

INTRODUCTION

With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery.

METHODS

The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien-Dindo Classification, readmission, and return to the operating room.

RESULTS

6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (p = 0.264), readmission (OR 0.849, 95% CI 0.522-1.419), or return to the operating room (OR 1.15, 95% CI 0.531-2.761) between the two groups.

CONCLUSION

Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.

Risk Factors for Readmission After Same-Day Discharge Sleeve Gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Background

Same-day discharge after sleeve gastrectomy (SG) is gaining popularity. We aimed to determine risk factors associated with readmission in patients who underwent same-day discharge SG.

Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the period 2015–2018. Patients who underwent SG and were discharged the same day of the operation were included in the analysis. Multivariable logistic regression analysis was performed to determine risk factors for readmission.

Results

A total of 466,270 SG were performed during the study period; 14,624 (3.1%) patients were discharged the same day and were included in the analysis. Mean age was 43.4 (14.7–80) years and 11,718 (80.1%) were female. Mean preoperative BMI was 43.7 ± 7.4 kg/m². Mean operative time was 58.3 ± 32.4 min. Thirty-day reoperation, reintervention, and mortality rates were 0.7%, 0.7%, and 0.1%, respectively. Readmission rates were similar in same-day discharge and inpatient SG (2.9% vs. 3%, p = 0.5). Female sex (OR 1.52, 95% CI 1.15–2.00), preoperative gastroesophageal reflux disease (OR 1.33, 95% CI 1.08–1.64), renal insufficiency (OR 3.06, 95% CI 1.01–9.32), and intraoperative drain placement (OR 1.78, 95% CI 1.37–2.31) were independent risk factors for readmission following same-day discharge SG.

Conclusions

Same-day discharge SG appears to be safe and is associated with low readmission rates. However, the identification of preoperative and intraoperative variables associated with higher risk of readmission might help defining safer and more effective same-day discharge protocols.

Graphical abstract

Same-day discharge for laparoscopic Heller myotomy

BACKGROUND

Laparoscopic Heller myotomy is an effective treatment for achalasia. There are little data on the safety and feasibility of same-day discharge after laparoscopic Heller myotomy.

OBJECTIVE

This study aimed to describe the experience with same-day discharge after laparoscopic Heller myotomy at one hospital.

METHODS

A retrospective cohort study including all patients who underwent laparoscopic Heller myotomy between 2007 and 2016 at University Health Network (UHN), Toronto, Canada. There was no consent required as the study was retrospective study. This study was approved by the UHN IRB. Planned same-day discharge patients were compared to planned inpatient with respect to post-op complications, length of stay, and number of emergency visits.

RESULTS

A total of 209 patients were identified. Same-day discharge was planned in 67 (33.5%) cases compared to 133 (66.5%) cases that were planned for inpatient. The study population was 49% male. On average, inpatients had 2.3 pre-operative comorbidities and same-day discharge patients had 1.6 pre-operative comorbidities. The average length of stay for the inpatient group was 3.5 days. Among the same-day surgery group, 15 had an unplanned admission following surgery (22%). Of those who were admitted, the average length of stay was 1.27 days. Only 1 same-day discharge was readmitted after hospital discharge, while 4 in inpatient group were readmitted. The post-operative complication rate was (15%) 20 of inpatient compared to four (6.0%) of same-day discharge. Number of emergency visits for inpatient group were 7 (5.3%) compared to 3 (4.5%) for same-day discharge group. There was one mortality case in inpatient group due to post-op complication.

CONCLUSION

Same-day surgery is feasible for laparoscopic Heller myotomy, with a similar complication and readmission rate as inpatient surgery.

Short-term Outcomes of Day-Case Stoma Closure: A Prospective, Observational Study

BACKGROUND

Elective stoma closure is a common, standardized procedure in digestive surgery.

OBJECTIVE

This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure.

DESIGN

This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure.

SETTING

This study was performed at a French tertiary hospital between January 2016 and June 2018.

PATIENTS

Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III.

OUTCOME MEASURES

The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation).

RESULTS

Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations.

LIMITATIONS

This was a single-center study.

CONCLUSION

In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583.

RESULTADOS A CORTO PLAZO DEL CIERRE DE ESTOMA AMBULATORIO UN ESTUDIO OBSERVACIONAL Y PROSPECTIVO

ANTECEDENTES:El cierre electivo de un estoma es un procedimiento común y estandarizado en cirugía digestiva.OBJETIVO:Evaluar la viabilidad de la cirugía ambulatoria para el cierre electivo de estomas.DISEÑO:Un estudio prospectivo, unicéntrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario francés entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incisión local con una puntuación de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de éxito de la cirugía ambulatoria en la población general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la población por protocolo (pacientes que no cumplían con ninguno de los criterios de exclusión preoperatorios o perioperatorios). Los resultados secundarios (en la población por protocolo) fueron la tasa de morbilidad general (según la clasificación de Clavien-Dindo), la tasa de morbilidad mayor (puntuación de Clavien ≥ 3) y los criterios de calidad de la cirugía ambulatoria (consulta no planificada, hospitalización no planificada y reoperación no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la población general; edad media ± desviación estándar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusión y constituyeron la población por protocolo. La tasa de éxito de la cirugía ambulatoria fue del 17% (40 de 236 pacientes) en la población general y del 80% (40 de 50 pacientes) en la población por protocolo. En la población por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugía ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalización no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSIÓN:En pacientes seleccionados, la cirugía ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legítimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

Post-operative complications and readmissions following outpatient elective Nissen fundoplication

INTRODUCTION

Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

RESULTS

Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

CONCLUSIONS

Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.

Laparoscopic sleeve gastrectomy as day-case surgery: a review of the literature

Day-case surgery (DCS) in digestive surgery is a hot topic, and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recently published series of LSG as DCS have demonstrated its feasibility. In this review on LSG performed as DCS, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase databases. Six studies were selected, comprising a total of 6227 patients. Most published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary sleeve gastrectomy for most series, patients with a body mass index ≥40 kg/m² or a body mass index ≥35 kg/m² in the presence of co-morbidities), while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after Roux-en-Y gastric bypass) and personal experience for other series. The mortality rate of LSG as DCS ranges 0%-.08%, while the overall complication rate ranges 0%-10%. The unplanned overnight admission rate after LSG ranges .8%-8%. The unscheduled hospitalization rates range 2.1%-8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. Good selection is necessary in others to avoid increased risk of morbidity and mortality.

Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study

BACKGROUND

Day-case surgery (DCS) has become increasingly popular over recent years, as has laparoscopic liver resection (LLR) for the treatment of benign or malignant liver tumours. The purpose of this prospective study was to demonstrate the feasibility of minor LLR as DCS.

METHODS

Prospective, intention-to-treat, non-randomised study of patients undergoing minor LLR between July 2015 and December 2017. Exclusion criteria were resection by laparotomy, major LLR, difficult locations for minor LLR, history of major abdominal surgery, hepatobiliary procedures without liver parenchyma resection, cirrhosis with Child > A and/or portal hypertension, significant medical history and exclusion criteria for DCS. The primary endpoint was the unplanned overnight admission rate. Secondary endpoints were the reason for exclusion, complication data, criteria for DCS evaluation, satisfaction and compliance with the protocol.

RESULTS

One hundred sixty-seven patients underwent liver resection during the study period. LLR was performed in 92 patients (55%), as DCS in 23 patients (25%). Reasons for minor LLR were liver metastasis (n = 9), hepatic adenoma (n = 5), hepatocellular carcinoma (n = 4), ciliated hepatic foregut cyst (n = 2) and other benign tumours (n = 3). All day-case minor LLR, except two patients, consisted of single wedge resection, while one patient underwent left lateral sectionectomy. There were four unplanned overnight admissions (17.4%), one unscheduled consultation (4.3%), two hospital readmissions (8.6%) and no major complications/mortality. Compliance with the protocol was 69.5%. Satisfaction rate was 91%.

CONCLUSION

In selected patients, day-case minor LLR is feasible with acceptable complication and readmission rates. Day-case minor LLR can therefore be legitimately proposed in selected patients.

Same day discharge for benign laparoscopic hiatal surgery: a feasibility analysis

BACKGROUND

Advances in minimally invasive surgery and the development of enhanced recovery pathways have favored the spread of day-surgery programs. Despite laparoscopic approaches being accepted as the standard of care for benign hiatal diseases, safety and feasibility of same day discharges for laparoscopic hiatal surgeries other than fundoplication has yet to be established.

OBJECTIVE

This study aimed to assess the feasibility of same day discharge for primary and revisional laparoscopic hiatal surgeries including paraesophageal hernia repairs (PEHR), fundoplication for reflux, and Heller myotomy (±diverticulectomy).

METHODS

A retrospective cohort study including all patients undergoing elective laparoscopic hiatal procedures in the division of Thoracic surgery between 2011 and 2016 at McGill University Health Centre was performed. Planned day-surgery (DAYCASE) was compared to planned inpatient (INPATIENT) cohorts with respect to operative and postoperative outcomes, length of stay, readmission, and emergency room visits.

RESULTS

A total of 261 patients were identified, 161 female (62%); median age 62 (20). The case distribution was: PEHR (123; 47.1%), Heller myotomy (94;36%, 7 diverticulectomy), and fundoplication (44; 16.9%). Twenty patients had revisional procedures (7.7%). Same day discharge was planned in 98 cases (38%) and was successful in 80 (81.6%). Proportion of DAYCASE increased form 12% prior to 2013 to 67% in 2016. INPATIENTs were older (median 66 vs. 60 years), and had a higher proportion of PEHR (55 vs. 34%), p < 0.05. Both cohorts were comparable in gender proportion, ASA classification, and length of surgery. Complications, readmission, and emergency visits did not differ between the two cohorts. On multivariate analysis, female gender (OR 37, 95% CI 1.46-936, p = 0.028), surgery beginning after noon (OR 5.4, 95% CI 1.1-26.9, p = 0.038), intraoperative complications (OR 20.4 95% CI 1.5-286, p = 0.025), and postoperative complications (OR 52.1, 95% CI 4.5-602, p = 0.002) were independently associated with unplanned admission.

CONCLUSIONS

Day-case surgery for complex laparoscopic hiatal procedures is feasible and can be achieved in a significant number of patients without compromising safety.

Advanced Laparoscopic Surgery in a Free-Standing Ambulatory Setting

To decrease the impact and cost of surgery, there is a trend toward developing treatment models for complex conditions on a fully outpatient basis. This is a retrospective study of the initial experience of advanced laparoscopic procedures performed on a same-day outpatient basis in the ambulatory campus of a university hospital. Over 3 years, 55 patients underwent 50 Nissen fundoplications and 5 adrenalectomies. There were 2 intraoperative complications, with no mortality and no conversion. The median postoperative stay was 4.5 hours. Readmission at 1 month was 11%. Data on the nursing postoperative telephone follow-up were available for 50 patients; 34 (62%) were successfully contacted.Twenty four (70%) had no complaint. Preliminary high-level cost data indicate a cost advantage. Advanced laparoscopic procedures can be done safely in a pure ambulatory setting; the current readmission rate can be reduced with improved pain management and better telephone follow-up strategies. Cost savings are likely.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10% to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as 'Fast Track (FT) surgery', or 'Enhanced Recovery Programmes' to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to assess fully the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH METHODS

We searched the following databases, The Cochrane Gynaecological Cancer Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials. This search was updated and re-run in May 2012 and November 2014.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were identified that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high-quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed. This review has been updated in 2012 and 2014. The results of the original review published in 2010 remain unchanged.

Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)

BACKGROUND

Day-case surgery (DCS) has boomed over recent years, as has laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity. The objective of this study was to evaluate the safety and feasibility of day-case SG.

METHODS

This was a prospective, nonrandomized study of 100 patients undergoing day-case SG from May 2011 to July 2013. All patients met the criteria for DCS and for the treatment of morbid obesity. Standard surgical, anesthetic, and analgesic protocols were used. The primary study endpoint was the unplanned overnight admission rate. Secondary endpoints were standard DCS criteria, frequency and type of complications, and satisfaction rate of performing day-case SG. The short-term postoperative course of patients undergoing day-case and conventional SG also were compared.

RESULTS

A total of 416 patients were screened and 100 (24%) were included. There were 8 unplanned overnight admissions. Seven unexpected consultations, 7 hospital readmissions, and 5 major complications were recorded, including 3 cases of unexpected surgery for gastric leak. At follow-up, 96% of the patients were satisfied with day-case SG. The short-term postoperative course was similar among patients undergoing DCS and conventional management.

CONCLUSION

In selected patients, day-case SG is feasible with acceptable complication and readmission rates. The postoperative course was similar to that observed for standard SG.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10% to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as 'Fast Track (FT) surgery', or 'Enhanced Recovery Programmes' to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to assess fully the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH METHODS

We searched the following databases, The Cochrane Gynaecological Cancer Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials. This search was updated and re-run to 1 May 2012, for this update.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were identified that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high-quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed. This review has been updated in 2012. The results of the original review published in 2010 remain unchanged.

Systematic review of day-case laparoscopic fundoplication

BACKGROUND

The aim of the current study is to review published literature on day-case laparoscopic fundoplication in adults.

DATA SOURCES

Medline, Embase, and Cochrane library was searched by using the medical subjects headings "ambulatory surgical procedures" and "fundoplication" with further free text search and cross references. All articles on planned day-case laparoscopic fundoplication that described patient selection criteria, same-day discharge, complications, and readmissions were reviewed.

CONCLUSIONS

Thirteen cohort studies were included in this review. Ten were on planned same-day discharge with a 93% (739 out of 792) success, 4% (34) complication, and 5% (39) readmission rate. Three studies were on planned 23 hour discharge with a 98% (571 out of 583) success, 4% (25) complications, and 1% (5) re-admission rate. Nausea, pain, fatigue, and pneumothorax were the commonest causes for overnight admission. Dysphagia and pain were the main reasons for readmission. Most patients were satisfied with day-case laparoscopic fundoplication.

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease: a systematic review

BACKGROUND

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease (GERD) has been developed in order to increase patients' satisfaction and to save bed costs. The aim of this systematic review was to assess the advantages and disadvantages of ambulatory surgery in patients undergoing elective fundoplication for GERD.

METHODS

Two reviewers independently searched and identified 15 prospective or retrospective nonrandomized studies dealing with ambulatory laparoscopic fundoplication for GERD in the Medline, Cancerlit, and Embase databases between January 1990 and July 2010. Outcomes were postoperative mortality, morbidity, conversion and reoperation rates, mean operative time, hospital admission or readmission, unexpected consultation, and patient satisfaction. Because only one comparative study was identified, data compilation and relative risk evaluation through meta-analysis were not possible.

RESULTS

A total of 1459 adult patients underwent an ambulatory laparoscopic fundoplication for GERD, 876 in a day-case setting and 583 in an outpatient setting. The procedure appears feasible for selected patients and expert surgeons, and it has a very low mortality rate and conversion, reoperation, and overall morbidity rates of 3.6, 0.6, and 11.1%, respectively. Hospital admission, nonprogrammed consultation, and hospital readmission rates were as high as 20, 11, and 12%, respectively. No study looked at comparative long-term functional results between ambulatory and inpatient procedures. Patient satisfaction rates based on self-evaluation were high.

CONCLUSION

The data available to date in the literature, mostly of level 4 evidence, suggest that laparoscopic fundoplication for GERD appears to be safe and feasible in a day-surgery setting, subject to careful patient selection and surgeon expertise. Randomized control trials are urgently needed to better evaluate this promising care management.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10 to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as "Fast Track (FT) surgery", or "Enhanced Recovery Programmes" to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to fully assess the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH STRATEGY

We searched the following databases, The Cochrane Gynaecological Cancer Collaborative Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were found that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed.

Prospective study of routine day-case laparoscopic modified Lind partial fundoplication

BACKGROUND

The aim of the present study was to prospectively assess the feasibility, safety, and acceptability of performing day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease on a routine basis and to determine possible implications for health care costs to the hospital.

METHODS

All patients undergoing laparoscopic fundoplication between November 2005 and November 2007 under the care of one surgeon were included in the study. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I and II with adequate home support. The surgical procedure was laparoscopic modified Lind fundoplication in all the cases. Patients were reviewed in the clinic at 6 weeks and were subsequently assessed through a structured postal questionnaire at a median of 1 year.

RESULTS

Over the 25-month period, a total of 130 laparoscopic modified Lind fundoplications were performed, of which 103 (79.2%) met the inclusion criteria for day-case surgery. The patients were 16 to 75 years of age. Ninety (87.4%) were discharged on the same day as planned, and 11 patients were admitted overnight because of nausea. At clinic follow-up at a median of 6 weeks all patients expressed satisfaction and were reflux free. There was a significant reduction of mean modified Visick score and visual analog scale for reflux at a median of 1 year after surgery.

CONCLUSIONS

Routine day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease is safe and well tolerated, with high levels of patient satisfaction and reduced costs to the hospital. Patients with ASA grade >2 and redo antireflux surgery should not be considered for day-case surgery. Hospital readmission was required in less than 3% of patients after discharge home, but those readmissions were not related to early discharge on the same day of surgery.

The accordion severity grading system of surgical complications

BACKGROUND

A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications.

METHODS

129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications.

RESULTS

T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others.

CONCLUSIONS

Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.

The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study

OBJECTIVES

This study was conducted to evaluate the added value of an enhanced recovery after surgery (ERAS) programme in laparoscopic liver resections for solid tumours.

METHODS

Patients undergoing laparoscopic liver resection between July 2005 and July 2008 were included. Indications for resections included presumed benign and malignant liver lesions. Primary outcome was total length of hospital stay (LOS). Secondary outcomes were functional recovery, complications, conversions, blood loss and duration of operation.

RESULTS

Thirteen patients were treated by laparoscopic liver resections in the ERAS programme in one centre (group 1). Their outcomes were compared with outcomes of 13 laparoscopic procedures performed either before the introduction of the ERAS programme during 2003-2005 in the same centre or during the same period in other centres using traditional care (group 2). Median total LOS was 5.0 days (range 3-10 days) in group 1 and 7.0 days (3-12 days) in group 2. This difference was not statistically significant. Functional recovery occurred 2 days earlier in group 1 (median 3.0 days [range 1-7 days] vs. median 5.0 days [range 2-8 days]; P < 0.044). There were no significant differences in complications, conversions or duration of operation. Blood loss was significantly less in the ERAS group (median 50 ml [range 50-200 ml] vs. median 250 ml [range 50-800 ml]; P < 0.002).

CONCLUSIONS

This exploratory, multicentre, fast-track laparoscopic liver resection study is the first such study conducted. Although small, the study suggests that a multimodal enhanced recovery programme in laparoscopic liver surgery is feasible, safe and may lead to accelerated functional recovery and reductions in LOS.

Feasibility of laparoscopic Nissen fundoplication as a day-case procedure

BACKGROUND

The aim of this prospective double-cohort pilot study is to evaluate the feasibility and desirability of laparoscopic Nissen fundoplication (LNF) performed in day-care when compared with laparoscopic cholecystectomy (LC) in day-care.

METHODS

Patients who underwent a LNF in day-care were prospectively evaluated. LNF patients were treated according to LC in day-care protocol. Outcome parameters were EQ-5D, visual analogue scale (VAS), and patient satisfaction.

RESULTS

From October 2005 to March 2008, 22 patients underwent LNF and 48 patients LC in day-care. After LNF, 21 out of 22 (95%) patients were discharged the same day. Seven (32%) patients were seen postoperatively in the Emergency Department with dysphagia or pain and two (9%) patients were readmitted. After LC, 45 out of 48 (94%) patients were discharged the same day. Six (12.5%) patients were seen postoperatively in the Emergency Department because of wound infection or pain and three (6%) were readmitted. EQ-5D and VAS scores were significantly worse after LNF in day-care (repeated measurements, p < 0.0001 and p < 0.0001). In a telephone survey 66.7% preferred a short hospital stay over day-care surgery after LNF compared with 30.9% after LC (p = 0.011).

CONCLUSIONS

LNF in day-care is feasible and safe, but postoperative pain scores are high and most prefer short hospital stay.

Current indications for laparoscopy in day-case surgery

Day-surgery setting allows to combine patients' satisfaction to cost-saving policies that seems to be more and more important for a modern hospital management. Minimally invasive surgery seems to be the ideal surgical approach for day-case procedures since, reducing trauma to a minimal level, allows patients to return quick to a normal life with minimal nursing assistance. Extensive review of the most recent article has been performed in this article in order to define the current evidences that support the use of laparoscopic surgery in a day-case setting. Laparoscopic cholecystectomy, anti-reflux procedure and hernia repair seems to be justified according to the results of the published data. Patients' selection and hospital organization seem to be mandatory in order to obtain successful results.

The safety of the same-day discharge for selected patients after laparoscopic fundoplication: a prospective cohort study

BACKGROUND

We conducted a prospective cohort study to assess the acceptability, feasibility and safety of day-case laparoscopic fundoplication for gastroesophageal reflux disease in an university-based tertiary care center.

METHODS

The procedure was proposed as routine for patients with proven symptomatic uncomplicated gastroesophageal reflux disease fulfilling predetermined inclusion criteria from September 2003 to December 2005. Standard anesthetic, surgical, analgesic, and antiemetic protocols were used. Acceptability, admission, complication, and reoperation rates and patient satisfaction were evaluated. Postoperative pain and nausea were assessed using an 11-point numeric rating scale (NRS). The Gastrointestinal Quality of Life Index (GIQLI) was administered before and after surgery.

RESULTS

Among 100 patients screened, 40 (40%) were included. Seven patients were admitted because of inadequate pain control (n = 3), nausea or vomiting (n = 3), or anxiety (n = 1); 33 were discharged as planned 6 to 8 hours after operation. Only 1 patient was readmitted and reoperated because of fundoplicature migration following uncontrolled vomiting. At follow-up, 92.5% of patients were satisfied with the day-case treatment. If offered a similar operation in the future, 82.5% of patients would have accepted day-case treatment. The Gastrointestinal Quality of Life Index was 90.7 (+/-21.2) preoperatively compared with 105.8 (+/-21.8) postoperatively (P < .001).

CONCLUSIONS

Day-case laparoscopic fundoplication is feasible in selected patients. However, (1) strict control of postoperative nausea and pain is essential, and (2) preoperative standardized education program for ambulatory surgery might be useful in order to enhance patient acceptability and satisfaction rates.

Laparoscopic floppy Nissen fundoplication for gastro-oesophageal reflux disease is feasible as a day-case procedure

BACKGROUND/AIMS

We launched a prospective study to assess the feasibility of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease in March 2003. The specific aims were to assess safety, acceptability and patient satisfaction.

METHODS

The inclusion criteria were American Society of Anaesthesiologists grade I-II surgical risk, body mass index < 35, and adult company at home (less than 50 km travel) or at patient hotel (more than 50 km travel). Patients were informed about the surgical procedure, the expected postoperative course, and the possible postoperative problems and complications. Surgery was performed under general anaesthesia with proposal-infusion, fentanyl, rocuronium and sevoflurane with air + oxygen. All patients received parenteral propacetamol, NSAID, local anaesthetics and metoclopramide, as pre-emptive analgesia before awakening. A total 360 degree floppy Nissen fundoplication was performed in all patients.

RESULTS

Twenty-eight patients were included. There was one conversion to open surgery. All the other patients were discharged as planned and there were no readmissions. No intra- or postoperative complications occurred. Postoperative pain, nausea, fatigue and dysphagia were moderate. At interview the morning following the operation three patients reported they would rather have stayed over night at the hospital. However, all patients were ready for a similar procedure as day-case surgery again, if offered. At follow-up 26/28 (< 92.9%) patients were satisfied with the day-case treatment, one patient had no preference. All patients would recommend this operation as day-case surgery for a family member or friend.

CONCLUSION

Laparoscopic day-case surgery for gastro-oesophageal reflux disease appears to be safe and well tolerated by the patients.

Systematic review of enhanced recovery programmes in colonic surgery

BACKGROUND

Fast track (FT) programmes optimize perioperative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The aim of this review was to assess FT programmes for elective segmental colonic resections.

METHODS

A systematic review was performed of all randomized controlled trials and controlled clinical trials on FT colonic surgery. The main endpoints were number of applied FT elements, hospital stay, readmission rate, morbidity and mortality. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Six papers were eligible for analysis (three randomized controlled and three controlled clinical trials), including 512 patients. FT programmes contained a mean of nine (range four to 12) of the 17 FT elements as defined in the literature. Primary hospital stay (weighted mean difference - 1.56 days, 95 per cent confidence interval (c.i.) - 2.61 to - 0.50 days) and morbidity (relative risk 0.54, 95 per cent c.i. 0.42 to 0.69) were significantly lower for FT programmes. Readmission rates were not significantly different (relative risk 1.17, 95 per cent c.i. 0.73 to 1.86). No increase in mortality was found.

CONCLUSIONS

FT appears to be safe and shortens hospital stay after elective colorectal surgery. However, as the evidence is limited, a multicentre randomized trial seems justified.

Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay

BACKGROUND

In western countries, laparoscopic gastric banding is increasingly used in the surgical treatment of morbid obesity. This study aimed to investigate the feasibility, safety, morbidity, and costs of an outpatient procedure (OP) compared with an overnight stay (OS).

METHODS

In a 2-year period, 50 consecutive patients were randomized to an OP group or an OS group.

RESULTS

In the OP group, 76% of the patients were successfully discharged the same day, without readmissions. Four procedures were converted, and one complication occurred. The patients in the OP group seemed to experience more pain (p = 0.009). Satisfaction scores were 8.1 (OP) and 8.8 (OS) (p = 0.06). Half of the OP patients and most of the OS patients preferred a clinical admission. The OP treatment cost 600 euros less than OS.

CONCLUSION

With proper patient selection, laparoscopic gastric banding can be performed safely and at lower cost as an outpatient procedure.

Systematic review of day-case laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication is increasingly being performed on a day-case basis. The aim of the present paper was to systematically review published data on day-case or ambulatory laparoscopic fundoplication and discuss the differing criteria for patient selection, postoperative management and patient outcomes presented in each series.

METHODS

An optimally sensitive search strategy of subject headings and text words were used and the databases used included MEDLINE, PubMed and the Cochrane Library. All databases were searched from 1 January 1994 onwards.

RESULTS

A total of seven papers were included in the present review, of which six were prospective single-cohort studies. Overall, there was large heterogeneity among the studies but with similar complication and readmission rates.

CONCLUSIONS

Short-term outcomes for laparoscopic Nissen fundoplication in terms of complications and readmission rates are comparable to inpatient procedures. However there is a paucity of published data.

Outpatient laparoscopic splenectomy: patient safety and satisfaction

BACKGROUND

We assessed the feasibility of outpatient laparoscopic splenectomy, as performed by an experienced laparoscopic term and combined with optimal anesthesia.

METHODS

Inclusion criteria in the study was limited to patients not hospitalized before the procedure who had hematological or neoplastic indications for splenectomy and were classified as American Society of Anesthesiologists (ASA) I-III. They received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic splenectomy was performed via three trocars. The specimen was removed via an incision in the left iliac fossa.

RESULTS

Ten of the 12 patients were discharged 3-6 h postoperatively; the other two were admitted primarily to hospital. One was readmitted due to a fever, which was finally explained by measles. The median operative times was 58 min (range, 45-135). Patient satisfaction was excellent in nine and intermediate in two cases; it was poor in one case, due to postoperative pain.

CONCLUSION

Laparoscopic splenectomy can be completed in a relatively short time; therefore, it is feasible, safe, and satisfactory for most patients as an outpatient procedure.

Day-case laparoscopic Nissen fundoplication

BACKGROUND

The aim was to assess the acceptability and safety of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease (GORD).

METHODS

This prospective study commenced in December 1999 and lasted for 18 months. All patients had proven symptomatic GORD. Inclusion criteria were American Society of Anesthesiologists grade I or II with adequate home support. A standard anaesthetic, analgesic and antiemetic protocol was used. Patients were contacted by telephone on the night of discharge and arrangements were made for a nurse to visit the following day. Postoperative pain and nausea were assessed using visual analogue scores (scale 0-10) on a self-completion questionnaire.

RESULTS

Twenty patients were included. There were no postoperative complications. All patients were discharged on the day of surgery. Median time to discharge was 6 h 30 min (range 4.5 to 9 h). One patient reattended casualty the following morning but none required readmission. There was no significant difference in median pain or nausea scores the evening after surgery or the next morning. All patients were satisfied with the information given and aftercare provided. All would recommend it to a friend and 19 of 20 would undergo the procedure as a day case again.

CONCLUSION

This study suggests that day-case laparoscopic fundoplication is feasible. Patients find it acceptable and it appears safe.

Multimodal strategies to improve surgical outcome

OBJECTIVE

To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures.

BACKGROUND

New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.

METHODS

We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach.

RESULTS

The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs.

CONCLUSIONS

Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

[Surgical treatment of gastroesophageal reflux disease in adults]

Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.