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Day-case Laparoscopic Nissen Fundoplication

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Presentation on theme: "Day-case Laparoscopic Nissen Fundoplication"— Presentation transcript:

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

2 Day Case Lap Nissens Evidence Our Results Past Present Our tricks

3 Previous reports Cohn et al. Todays Surg. Nurse 1997;19:27-30 (n=4)
Milford and Paluch Surg Endosc 1997;11: (61) Trondsen et al. BJS 2000;87: (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: (n=557) Bailey et al. BJS 2003; 90: (n=20) Ray Surg Endosc.2003;17: (n=310) Victorzon et al. Scand J Surg 2006;95(3):162-5 (n=28)

4 Ng et al. ANZ J Surg 2005;75:

5 Ng et al. ANZ J Surg 2005;75:160-164 (Review)
“on the data considered the complication rates and readmission rates are comparable to inpatient procedures” Ng et al. ANZ J Surg 2005;75: (Review)

6 Aim To assess the feasibility, the acceptability and the safety of
Day-case laparoscopic Nissen fundoplication

7 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

8 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

9 Analgesia Diclofenac 100mg pr on induction
20ml 0.5% bupivicaine infiltrated Cyclizine, Co-proxamol, morphine, tramadol prn Co-Codamol 2 tablets, 4 hourly Diclofenac 100mg, 8 hourly Metoclopramide 10mg Tramadol 100mg

10 Operative technique Standard 5 port approach
360o Nissen fundoplication over 54FR bougie “optional” Selective division of short gastric arteries Posterior crural repair

11 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

12 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

13 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

14 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

15 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

16 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

17 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

18 What Next? Retrospective Study of Lap Nissen 2004-2006
Numbers of Day cases performed Return Rates

19 Numbers

20 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

21 Day Case

22 Age?

23 Date

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

25 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)

26 Keys to successful day case
Patient Surgical Nursing

27 Patient Factors Patient selection Education/Counselling Expectation
Patient support At home At hospital

28 Surgical Factors Appropriate operation Good Anaesthetist
PONV Analgesia Training the “team”

29 Nursing Factors Dedicated ward Well defined pathway Enthusiastic team
Discharge criteria Dietetic follow-up Information sheets Enthusiastic team


31 Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications
The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford

32 Aims To assess The long term clinical outcome of 360o laparoscopic Nissen Fundoplication The clinical outcome of a selective approach to division of the short gastric arteries

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

34 Method 150 consecutive patients Single surgeon
March January 2000 Telephone Interview Clinical Outcomes Chi-squared test for statistics

35 Method Clinical Outcomes:Dysphagia
Ongoing dysphagia at follow up De Meester grade of dysphagia 0 None. 1 Occasional transient sensation of food sticking. 2 Episodes of bolus obstruction requiring liquids to clear 3 Progressive dysphagia for solids requiring medical attention or admission.

36 Method Clinical Outcomes: Symptom Recurrence
0 None. 1 Minimal. Still much improved on pre-operative state 2 Yes. Back to pre-operative state

37 Method Clinical Outcomes: Symptom Recurrence
Gas Bloat Bowel Function Patient Satisfaction

38 Methods Patient 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)

39 Methods Follow up Follow up rate 93% (140 of 150 patients)
Short gastric Time to Follow up arteries divided Mean Range Yes 30 pt 33 months 7-60m No 110 pt 30 months 8-76m Total 140 pt 31 months 8-76m

40 Results: Symptom Recurrence

41 Results: Symptom Recurrence

42 Conclusions 360o laparoscopic Nissen fundoplication Long term outcome
Low dysphagia rates Low symptom recurrence rates High Patient Satisfaction A selective approach to division of the short gastric arteries does not affect clinical outcome

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