Feasibility of 23-hour hospitalization after laparoscopic fundoplication

Same-Day Home Recovery for Benign Foregut Surgery

Importance

Same-day home recovery (SHR) is now the standard of care for many major surgical procedures and has the potential to become standard practice for benign foregut procedures (eg, hiatal hernia repair, fundoplication, and Heller myotomy).

Objective

To determine whether SHR for patients undergoing benign foregut surgery is feasible, safe, and effective.

Design, Setting, and Participants

This prospective cohort study took place across 19 medical centers within an integrated health care system in northern California from January 2019 through September 2021. Participants included consecutive patients undergoing elective benign foregut surgery.

Exposures

Standardized SHR program.

Main Outcomes and Measures

The primary end point was the rate of SHR. The secondary end points were 7-day and 30-day rates of postoperative emergency department visits, hospital readmissions, and reoperations.

Results

Of 1248 patients who underwent benign foregut surgery from January 2017 through September 2021, 558 were patients before implementation of the SHR program and 690 were patients postimplementation. The mean age of patients was 60 years, and 759 (59%) were female. The preimplementation SHR rate was 64 of 558 patients (11.5%) in 2018 and increased to 82 of 113 patients (72.6%) by 2021 (94/350 [26.9%] in 2019 and 112/227 [49.3%] in 2020; P < .001). There were no statistical differences in the 7-day and 30-day rates of postoperative emergency visits, hospital readmissions, and reoperations or 30-day mortality in the SHR vs non-SHR groups in the postimplementation era.

Conclusions and Relevance

In this study, implementation of a regional SHR program among patients undergoing elective benign foregut surgery was feasible, safe, and effective. The changes in perioperative care require comprehensive patient education and full multidisciplinary support. An SHR program for benign foregut procedures has the potential to improve patient care and cost-effectiveness in care delivery.

Post-operative complications and readmissions following outpatient elective Nissen fundoplication

INTRODUCTION

Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

RESULTS

Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

CONCLUSIONS

Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.

Laparoscopic Nissen Rossetti fundoplication: Possibility towards day care anti-reflux surgeries

INTRODUCTION

As we proceed towards more and more day care surgeries we always need to choose patients and procedures within a great deal of safety margin. Anti reflux surgeries are gaining more popularity and awareness and Laparoscopic Nissen Rosetti fundoplication is a safe and effective method of performing them.

METHODS AND OBSERVATIONS

Our case series of 25 patients who underwent day care Laparoscopic Nissen Rossetti fundoplication done over a period of 3 years suggests the feasibility and safety of performing day care anti reflux surgeries with no complications.

DISCUSSION

Surgical outcomes of procedure are unaffected and the main challenge faced remains pain relief and which can be effectively tackled by local blocks or plain NSAIDs.

RESULTS

Laparoscopic Nissen Rossetti fundoplication is a safe procedure to be offered as day care anti-reflux surgery. We encourage more studies in this regards with appropriate blinding to enforce its possibility as day care surgery and help patients with early recovery and decreasing cost of surgeries.

Systematic review of day-case laparoscopic fundoplication

BACKGROUND

The aim of the current study is to review published literature on day-case laparoscopic fundoplication in adults.

DATA SOURCES

Medline, Embase, and Cochrane library was searched by using the medical subjects headings "ambulatory surgical procedures" and "fundoplication" with further free text search and cross references. All articles on planned day-case laparoscopic fundoplication that described patient selection criteria, same-day discharge, complications, and readmissions were reviewed.

CONCLUSIONS

Thirteen cohort studies were included in this review. Ten were on planned same-day discharge with a 93% (739 out of 792) success, 4% (34) complication, and 5% (39) readmission rate. Three studies were on planned 23 hour discharge with a 98% (571 out of 583) success, 4% (25) complications, and 1% (5) re-admission rate. Nausea, pain, fatigue, and pneumothorax were the commonest causes for overnight admission. Dysphagia and pain were the main reasons for readmission. Most patients were satisfied with day-case laparoscopic fundoplication.

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease: a systematic review

BACKGROUND

Ambulatory laparoscopic fundoplication for gastroesophageal reflux disease (GERD) has been developed in order to increase patients' satisfaction and to save bed costs. The aim of this systematic review was to assess the advantages and disadvantages of ambulatory surgery in patients undergoing elective fundoplication for GERD.

METHODS

Two reviewers independently searched and identified 15 prospective or retrospective nonrandomized studies dealing with ambulatory laparoscopic fundoplication for GERD in the Medline, Cancerlit, and Embase databases between January 1990 and July 2010. Outcomes were postoperative mortality, morbidity, conversion and reoperation rates, mean operative time, hospital admission or readmission, unexpected consultation, and patient satisfaction. Because only one comparative study was identified, data compilation and relative risk evaluation through meta-analysis were not possible.

RESULTS

A total of 1459 adult patients underwent an ambulatory laparoscopic fundoplication for GERD, 876 in a day-case setting and 583 in an outpatient setting. The procedure appears feasible for selected patients and expert surgeons, and it has a very low mortality rate and conversion, reoperation, and overall morbidity rates of 3.6, 0.6, and 11.1%, respectively. Hospital admission, nonprogrammed consultation, and hospital readmission rates were as high as 20, 11, and 12%, respectively. No study looked at comparative long-term functional results between ambulatory and inpatient procedures. Patient satisfaction rates based on self-evaluation were high.

CONCLUSION

The data available to date in the literature, mostly of level 4 evidence, suggest that laparoscopic fundoplication for GERD appears to be safe and feasible in a day-surgery setting, subject to careful patient selection and surgeon expertise. Randomized control trials are urgently needed to better evaluate this promising care management.

Prospective study of routine day-case laparoscopic modified Lind partial fundoplication

BACKGROUND

The aim of the present study was to prospectively assess the feasibility, safety, and acceptability of performing day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease on a routine basis and to determine possible implications for health care costs to the hospital.

METHODS

All patients undergoing laparoscopic fundoplication between November 2005 and November 2007 under the care of one surgeon were included in the study. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I and II with adequate home support. The surgical procedure was laparoscopic modified Lind fundoplication in all the cases. Patients were reviewed in the clinic at 6 weeks and were subsequently assessed through a structured postal questionnaire at a median of 1 year.

RESULTS

Over the 25-month period, a total of 130 laparoscopic modified Lind fundoplications were performed, of which 103 (79.2%) met the inclusion criteria for day-case surgery. The patients were 16 to 75 years of age. Ninety (87.4%) were discharged on the same day as planned, and 11 patients were admitted overnight because of nausea. At clinic follow-up at a median of 6 weeks all patients expressed satisfaction and were reflux free. There was a significant reduction of mean modified Visick score and visual analog scale for reflux at a median of 1 year after surgery.

CONCLUSIONS

Routine day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease is safe and well tolerated, with high levels of patient satisfaction and reduced costs to the hospital. Patients with ASA grade >2 and redo antireflux surgery should not be considered for day-case surgery. Hospital readmission was required in less than 3% of patients after discharge home, but those readmissions were not related to early discharge on the same day of surgery.

Feasibility of laparoscopic Nissen fundoplication as a day-case procedure

BACKGROUND

The aim of this prospective double-cohort pilot study is to evaluate the feasibility and desirability of laparoscopic Nissen fundoplication (LNF) performed in day-care when compared with laparoscopic cholecystectomy (LC) in day-care.

METHODS

Patients who underwent a LNF in day-care were prospectively evaluated. LNF patients were treated according to LC in day-care protocol. Outcome parameters were EQ-5D, visual analogue scale (VAS), and patient satisfaction.

RESULTS

From October 2005 to March 2008, 22 patients underwent LNF and 48 patients LC in day-care. After LNF, 21 out of 22 (95%) patients were discharged the same day. Seven (32%) patients were seen postoperatively in the Emergency Department with dysphagia or pain and two (9%) patients were readmitted. After LC, 45 out of 48 (94%) patients were discharged the same day. Six (12.5%) patients were seen postoperatively in the Emergency Department because of wound infection or pain and three (6%) were readmitted. EQ-5D and VAS scores were significantly worse after LNF in day-care (repeated measurements, p < 0.0001 and p < 0.0001). In a telephone survey 66.7% preferred a short hospital stay over day-care surgery after LNF compared with 30.9% after LC (p = 0.011).

CONCLUSIONS

LNF in day-care is feasible and safe, but postoperative pain scores are high and most prefer short hospital stay.

Current indications for laparoscopy in day-case surgery

Day-surgery setting allows to combine patients' satisfaction to cost-saving policies that seems to be more and more important for a modern hospital management. Minimally invasive surgery seems to be the ideal surgical approach for day-case procedures since, reducing trauma to a minimal level, allows patients to return quick to a normal life with minimal nursing assistance. Extensive review of the most recent article has been performed in this article in order to define the current evidences that support the use of laparoscopic surgery in a day-case setting. Laparoscopic cholecystectomy, anti-reflux procedure and hernia repair seems to be justified according to the results of the published data. Patients' selection and hospital organization seem to be mandatory in order to obtain successful results.

Day-case laparoscopic Nissen fundoplication in children

BACKGROUND

The aim of this study was to assess the acceptability and safety of day-case laparoscopic Nissen fundoplication for gastroesophageal reflux disease in children.

METHODS

All children who underwent a laparoscopic Nissen fundoplication procedure were analyzed retrospectively, and the cases who had day surgery were selected over a 2-year period (May 2003-August 2005). All patients had proven symptomatic reflux disease. Inclusion criteria were that children were over 6 months of age and had a American Society of Anesthesiologists grade I or II with acceptable home support. A standard anesthetic, analgesic protocol was used. Caregivers were contacted by telephone on the night of discharge and on the following morning; all patients were seen at 1 week and 6 months postoperatively.

RESULTS

In the study period, 68 children underwent a laparoscopic Nissen fundoplication procedure performed by the first author. Twenty-one (21) children were suitable for day-case surgery, and all procedures were performed as the first case on an elective list. Postoperatively, all but 2 patients were discharged on the afternoon of the surgery. Time to discharge was 6 hours 30 minutes (range, 5-8 hours). No patient required a readmission. There was minimal pain, but no nausea, in the evening following the surgery; pain responded effectively to standard oral analgesia. All caregivers were satisfied with the information given and aftercare provided. All caregivers would recommend the procedure to other caregivers and all would allow for their children to undergo the procedure as a day case again. There have been no cases of recurrent symptoms in the 6-month follow-up period.

CONCLUSIONS

This paper is the first report in the pediatric literature to suggest that day-case laparoscopic fundoplication is feasible in children. Patients and caregivers find the procedure acceptable and it appears to be safe.

Laparoscopic floppy Nissen fundoplication for gastro-oesophageal reflux disease is feasible as a day-case procedure

BACKGROUND/AIMS

We launched a prospective study to assess the feasibility of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease in March 2003. The specific aims were to assess safety, acceptability and patient satisfaction.

METHODS

The inclusion criteria were American Society of Anaesthesiologists grade I-II surgical risk, body mass index < 35, and adult company at home (less than 50 km travel) or at patient hotel (more than 50 km travel). Patients were informed about the surgical procedure, the expected postoperative course, and the possible postoperative problems and complications. Surgery was performed under general anaesthesia with proposal-infusion, fentanyl, rocuronium and sevoflurane with air + oxygen. All patients received parenteral propacetamol, NSAID, local anaesthetics and metoclopramide, as pre-emptive analgesia before awakening. A total 360 degree floppy Nissen fundoplication was performed in all patients.

RESULTS

Twenty-eight patients were included. There was one conversion to open surgery. All the other patients were discharged as planned and there were no readmissions. No intra- or postoperative complications occurred. Postoperative pain, nausea, fatigue and dysphagia were moderate. At interview the morning following the operation three patients reported they would rather have stayed over night at the hospital. However, all patients were ready for a similar procedure as day-case surgery again, if offered. At follow-up 26/28 (< 92.9%) patients were satisfied with the day-case treatment, one patient had no preference. All patients would recommend this operation as day-case surgery for a family member or friend.

CONCLUSION

Laparoscopic day-case surgery for gastro-oesophageal reflux disease appears to be safe and well tolerated by the patients.

Systematic review of day-case laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication is increasingly being performed on a day-case basis. The aim of the present paper was to systematically review published data on day-case or ambulatory laparoscopic fundoplication and discuss the differing criteria for patient selection, postoperative management and patient outcomes presented in each series.

METHODS

An optimally sensitive search strategy of subject headings and text words were used and the databases used included MEDLINE, PubMed and the Cochrane Library. All databases were searched from 1 January 1994 onwards.

RESULTS

A total of seven papers were included in the present review, of which six were prospective single-cohort studies. Overall, there was large heterogeneity among the studies but with similar complication and readmission rates.

CONCLUSIONS

Short-term outcomes for laparoscopic Nissen fundoplication in terms of complications and readmission rates are comparable to inpatient procedures. However there is a paucity of published data.

Day-case laparoscopic Nissen fundoplication

BACKGROUND

The aim was to assess the acceptability and safety of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease (GORD).

METHODS

This prospective study commenced in December 1999 and lasted for 18 months. All patients had proven symptomatic GORD. Inclusion criteria were American Society of Anesthesiologists grade I or II with adequate home support. A standard anaesthetic, analgesic and antiemetic protocol was used. Patients were contacted by telephone on the night of discharge and arrangements were made for a nurse to visit the following day. Postoperative pain and nausea were assessed using visual analogue scores (scale 0-10) on a self-completion questionnaire.

RESULTS

Twenty patients were included. There were no postoperative complications. All patients were discharged on the day of surgery. Median time to discharge was 6 h 30 min (range 4.5 to 9 h). One patient reattended casualty the following morning but none required readmission. There was no significant difference in median pain or nausea scores the evening after surgery or the next morning. All patients were satisfied with the information given and aftercare provided. All would recommend it to a friend and 19 of 20 would undergo the procedure as a day case again.

CONCLUSION

This study suggests that day-case laparoscopic fundoplication is feasible. Patients find it acceptable and it appears safe.

Laparoscopic antireflux surgery at an outpatient surgery center

BACKGROUND

Laparoscopic fundoplication (LF) procedures have been shown to be safe and effective for the control of gastroesophageal reflux disease (GERD). Preliminary reports suggest that LF can be performed safely in an ambulatory surgery center. We report on our extensive experience with outpatient LF.

METHODS

Since May 1995, we have performed laparoscopic antireflux procedures in 557 consecutive patients at a freestanding outpatient surgery center. All patients had esophageal manometrics and esophagogastroduodenoscopy (EGD) within 1 year of their surgical procedure. This series included 16 patients with large paraesophageal hernias (mostly type III) and 22 patients with prior antireflux procedures. Most patients (n = 494) underwent Nissen fundoplication.

RESULTS

Patients were typically given clear liquids 6 hs postoperatively and discharged home in