Systematic review of day-case laparoscopic Nissen fundoplication

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.

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.

Laparoscopic Nissen Rossetti fundoplication: Possibility towards day care anti-reflux surgeries

INTRODUCTION

As we proceed towards more and more day care surgeries we always need to choose patients and procedures within a great deal of safety margin. Anti reflux surgeries are gaining more popularity and awareness and Laparoscopic Nissen Rosetti fundoplication is a safe and effective method of performing them.

METHODS AND OBSERVATIONS

Our case series of 25 patients who underwent day care Laparoscopic Nissen Rossetti fundoplication done over a period of 3 years suggests the feasibility and safety of performing day care anti reflux surgeries with no complications.

DISCUSSION

Surgical outcomes of procedure are unaffected and the main challenge faced remains pain relief and which can be effectively tackled by local blocks or plain NSAIDs.

RESULTS

Laparoscopic Nissen Rossetti fundoplication is a safe procedure to be offered as day care anti-reflux surgery. We encourage more studies in this regards with appropriate blinding to enforce its possibility as day care surgery and help patients with early recovery and decreasing cost of surgeries.

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.

A comparison of pre-operative comorbidities and post-operative outcomes among patients undergoing laparoscopic nissen fundoplication at high- and low-volume centers

INTRODUCTION

Commonly cited data promoting laparoscopic Nissen fundoplication (LNF) as safe and efficacious are typically published by single centers, affiliated with teaching institutions with a high volume of cases, but LNF is not universally performed at these hospitals. The purpose of this study is to assess where these procedures are being done and to compare pre-operative comorbidities and post-operative outcomes between high-and low-volume centers using a state-wide inpatient database.

METHODS

This is a retrospective study using data from the North Carolina Hospital Association Patient Data System. Selected patients include adults (>17 years old) that have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease as an inpatient from 2005 to 2008. Patients that underwent operative management for emergent purposes or had associated diagnoses of esophageal cancer or achalasia were excluded from the study. High-volume centers were defined as institutions that performed ten or more LNFs per year averaged over a period of 4 years. Comparative statistics were performed on comorbidities and complications between high- and low-volume centers.

RESULTS

A total of 1,019 patients underwent LNF for GERD in North Carolina between 2005 and 2008 in the inpatient setting. High-volume centers performed 530 LNFs (52%) while low-volume centers performed 489 LNFs (48%). Patients at high-volume centers were older (median 52.5 years old vs. 49.0 years old, p = 0.019), had a higher incidence of diabetes (13.4% vs. 8.8%, p = 0.026), chronic obstructive pulmonary disease (5.1% vs. 2.0 %, p = 0.015), hyperlipidemia (9.6% vs. 4.7%, p = 0.004), and cystic fibrosis (2.8% vs. 0.8%, p = 0.03). Patients with a history of transplantation were also more likely to undergo LNF at a high-volume center (15.8% vs. 1.6%, p < 0.0001). There were no deaths among the two groups and also no difference between median length of stay (2.7 days for high-volume center vs. 2.6 days for low-volume center). Low-volume centers had a higher incidence of intraoperative accidental puncture or laceration (3.3% vs. 0.9%, p = 0.017) while high-volume centers had a higher incidence of atelectasis (5.3% vs. 2.5%, p = 0.031).

CONCLUSION

A significant proportion of the LNFs in North Carolina are performed at low-volume centers. High-volume centers perform LNF on older patients with more comorbidities. Low-volume centers have three times more accidental perforations, yet there is no detectable difference in mortality or median length of stay. It is impossible to tell if these perforations are managed at these low-volume centers or transferred to facilities with a higher level of care. These findings argue for regionalization of LNF and for a reevaluation of the global safety of this operation.

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.

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.

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.

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.

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.