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Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications

Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications. The Minimal Access Therapy Training Unit The Royal Surrey County Hospital, Guildford. To assess The long term clinical outcome of 360 o laparoscopic Nissen Fundoplication

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Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications

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

  2. 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

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

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

  5. 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

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

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

  8. 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

  9. 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

  10. Results: Symptom Recurrence

  11. Results: Symptom Recurrence

  12. 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

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

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

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

  16. 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

  17. 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

  18. 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

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

  20. 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 Post-operative care and assessment

  21. 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

  22. 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

  23. 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 Analgesia and anti-emetics

  24. 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

  25. 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

  26. 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

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