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

2. 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

3. Operative Technique The Wrap 2cm Long54F boogie Fully mobilise the gastric fundus Large window Mobile wrap

4. Method 150 consecutive patients Single surgeon March 1994- January 2000 Telephone Interview Clinical Outcomes Chi-squared test for statistics

5. 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.

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

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

8. 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)

9. 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)

10. Results: Symptom Recurrence

12. 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

13. Day-case Laparoscopic Nissen Fundoplication The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford

14. Previous reports Milford and Paluch Surg Endosc 1997;11:1550-52 Trondsen et al BJS 2000;87:1708- 11

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

16. 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

17. 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

18. 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

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

20. 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 Wilcoxon signed rank test

21. 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

22. Pain and nausea scores Hours post surgery 4 12 24 48 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

23. 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 3 patients used no analgesia following discharge None of the patients took anti-emetics at home

24. 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

25. 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

26. 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