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Day-case Laparoscopic Nissen Fundoplication

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. Evidence Our Results Past Present

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Day-case Laparoscopic Nissen Fundoplication

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

  3. 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) Previous reports

  4. Ng et al. ANZ J Surg 2005;75:160-164

  5. “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)

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

  7. 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 Patients

  8. 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 Anaesthetic technique

  9. 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 Analgesia

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

  11. Surgeon telephone number District nurse visit Visual analogue scores pain and nausea Analgesia requirement and patient satisfaction at 2 week follow-up Post-operative care and assessment

  12. 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 Results

  13. 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 Pain and nausea scores

  14. 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 Analgesia and anti-emetics

  15. 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 Follow up

  16. 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 Patient satisfaction

  17. Laparoscopic fundoplication can be successfully undertaken as a day case Patients find it acceptable It appears to be safe Adequate home support is necessary Conclusions

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

  19. Numbers

  20. Defined as True Day Case Discharged in Morning Pre-ward round Discharged in Morning Post Ward Round Admitted to Main Hospital Inpatient Procedure Day Case

  21. Day Case

  22. Age?

  23. Date

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

  25. 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) Conclusion

  26. Patient Surgical Nursing Keys to successful day case

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

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

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

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

  31. 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 Aims

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

  33. 150 consecutive patients Single surgeon March 1994- January 2000 Telephone Interview Clinical Outcomes Chi-squared test for statistics Method

  34. 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. MethodClinical Outcomes:Dysphagia

  35. 0 None. 1 Minimal. Still much improved on pre-operative state 2 Yes. Back to pre-operative state MethodClinical Outcomes:Symptom Recurrence

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

  37. 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) MethodsPatient Information

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

  39. Results: Symptom Recurrence

  40. Results: Symptom Recurrence

  41. 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 Conclusions

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