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Day-case Laparoscopic Nissen Fundoplication The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford Mr Yuen Soon Locum Consultant.

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Presentation on theme: "Day-case Laparoscopic Nissen Fundoplication The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford Mr Yuen Soon Locum Consultant."— Presentation transcript:

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

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 “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 360 o 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 Pain 2 (0-9)3 (0-9)3 (0-8)2 (0-5)* Nausea0 (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 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 –Discharge criteria –Dietetic follow-up –Information sheets Enthusiastic team

30

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 1The long term clinical outcome of 360 o laparoscopic Nissen Fundoplication 2The clinical outcome of a selective approach to division of the short gastric arteries

33 Operative Technique The Wrap 2cm Long54F 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 0None. 1Minimal. Still much improved on pre-operative state 2Yes. 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 Yes30 pt33 months7-60m No110 pt30 months8-76m Total140 pt31 months8-76m Short gastricTime to Follow up arteries dividedMeanRange Follow up rate 93% (140 of 150 patients)

40 Results: Symptom Recurrence

41

42 Conclusions 360 o 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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