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![Page 1: Day-case Laparoscopic Nissen Fundoplication The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford Mr Yuen Soon Locum Consultant.](https://reader035.fdocuments.in/reader035/viewer/2022062318/551b2fba550346cf5a8b6038/html5/thumbnails/1.jpg)
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
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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 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)
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•Ng et al. ANZ J Surg 2005;75:160-164
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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 2005;75:160-164 (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 hourlyMetoclopramide 10mgTramadol 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) *p=0.045
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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
Lap Nissens 2003-2006
0
5
10
15
20
25
30
35
2004 2005 2006
Series1
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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
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
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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
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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
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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 (p=0.25 Anova)
• Not date Dependent (p=0.46 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 UnitThe Royal Surrey County Hospital, Guildford
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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
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Operative Technique
• The Wrap
2cm Long54F 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 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.
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MethodClinical Outcomes:
Symptom 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 Outcomes:Symptom 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 Barrett’s, 1 stricture)
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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)
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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%
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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
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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