Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol

Nutrition education: Optimising preparation and recovery for benign oesophageal surgery

BACKGROUND

Patients requiring upper gastrointestinal surgery for benign oesophageal conditions are at nutrition risk before and after surgery. There is a dearth of published evidence guiding clinicians on effective collaboration with patients to mitigate perioperative nutritional challenges. We conducted a qualitative study aiming to explore patients' perioperative food, nutrition, and educational experiences to guide future care.

METHODS

Adult patients who had undergone elective, benign oesophageal surgery were invited to participate in semi-structured interviews within 3 weeks of hospital discharge. Interviews were transcribed and analysed with a reflexive form of inductive thematic analysis in addition to synthesised member checking.

RESULTS

Interviews with 12 patients identified three major themes. First, nutrition education fosters a better surgical recovery experience: patients expressed a desire to be prepared for their upcoming surgery and engage in the recovery process with informed food choices. Most patients preferred preoperative education given limited capacity for learning during hospital admission. Second, patients have priorities for nutrition information: patients expressed that educational material should be printed, comprehensive, practical, include familiar foods and focus on managing postoperative physical symptoms. Third, food impacts social and emotional experiences of surgery: resumption of a normal diet was a sign of recovery that enabled social reintegration. Identified themes resonated with Knowles' six-core principles of andragogy.

CONCLUSIONS

Patients with benign oesophageal conditions perceived nutrition education to be a vital aspect of surgical preparation and recovery. Re-designing perioperative education with patient input has the potential to improve outcomes and experiences.

A fast tract to foregut surgery: Pandemic-driven protocol development

BACKGROUND

COVID-19 has overwhelmed many health care systems which has affected the landscape of elective surgery. A pandemic driven protocol was developed to perform foregut surgeries as a Same Day Surgery (SDS) discharge for all comers to reduce resource utilization.

METHODS

Retrospective review of all patients who underwent elective laparoscopic foregut surgery (hiatal hernia, paraesophageal hernia, heller myotomy, and fundoplication) from 8/1/2020-1/31/2022 by a single surgeon after the implementation of a SDS protocol. Patients were compared to a pre-pandemic cohort, from 8/1/2019-4/30/2020, when overnight admission was standard practice.

RESULTS

There were 36 pre-pandemic patients, and 41 pandemic patients successfully discharged the same day of surgery. We failed to detect a statistically significant difference between the two groups regarding 30-day ED visit rate (p-value of 0.4557) and 30-day readmission rate (p-value of 0.6790).

CONCLUSION

The creation of a SDS protocol for foregut surgery is a safe way to deliver much needed care to the community while decreasing resource utilization.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery

BACKGROUND

Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia.

METHODS

A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions.

RESULTS

There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription.

CONCLUSIONS

The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge.

LEVELS OF EVIDENCE

Level III.

Same day discharge does not lead to worse outcomes in patients undergoing uncomplicated laparoscopic foregut surgery

INTRODUCTION

With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery.

METHODS

The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien-Dindo Classification, readmission, and return to the operating room.

RESULTS

6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (p = 0.264), readmission (OR 0.849, 95% CI 0.522-1.419), or return to the operating room (OR 1.15, 95% CI 0.531-2.761) between the two groups.

CONCLUSION

Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.

Transient delayed gastric emptying following laparoscopic Nissen fundoplication for gastroesophageal reflux disease

PURPOSE

Although laparoscopic Nissen fundoplication (LNF) is a kind of minimally invasive surgery, some transition time may still be required to allow the fundoplicated stomach to adapt to the new anatomical position. We observed transient delayed gastric emptying (DGE) post-LNF in our preliminary study. This study aimed to investigate the occurrence rate and development of transient DGE post-LNF.

METHODS

Patients who underwent LNF for gastroesophageal reflux disease (GERD) at our institution were recruited consecutively. They were treated with standardized LNF and prospectively followed up for 2 months. Proper diet guidance and/or pharmacologic therapy were given during these 2 months. GERD Health-Related Quality of Life (GERD-HRQL), DGE symptoms, and DGE status were evaluated preoperatively and postoperatively.

RESULTS

Fifty-one patients underwent LNF and completed a 2-month follow-up. LNF succeeded in all patients. Prior to LNF, no DGE was identified. At the 1-month follow-up, LNF led to a significant reduction in the GERD-HRQL total score but a significantly increased DGE score. Endoscopically, DGE was identified in forty-seven (n = 47, 92.2%) patients. At the 2-month follow-up, the GERD-HRQL scores continued to show decreases compared to the 1 month. The DGE score returned to the baseline value. Endoscopically, no DGE was identified in any patients (n = 0, 0.0%).

CONCLUSIONS

Transient DGE is a very common one-month post-LNF but can recover quickly in the second month following LNF.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs

INTRODUCTION

Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS).

METHODS

Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions.

RESULTS

There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions.

CONCLUSION

Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.