Commentary on “Day-Case Laparoscopic Nissen Fundoplication: A Default Pathway or Is Selection the Key?”

It is truly remarkable to reflect on the advances in surgery over the past two decades that have resulted from the minimally invasive or laparoscopic surgical revolution. In this issue, Kelly et al. ¹ report their experience performing day-case laparoscopic Nissen fundoplication (LNF) and were able to discharge 80% of their patients on the same day of surgery. They had a low rate of complications and counted their most common complication as the need for unplanned admission in the 20% of the patients who failed the day-case LNF. Compare these results with that achieved in the famous study by Spechler ² of Veterans Administration patients reported in 1992. This report involved 247 patients undergoing open Nissen fundoplication. Although there were no operative deaths, 10 patients (15%) had one or more serious operative complications, including splenic injury requiring splenectomy, blood transfusions, esophageal perforation, gastric perforations, inadvertent vagotomy, and liver injuries. Twelve patients (18%) had postoperative complications, including wound infection, wound dehiscence, pulmonary embolism, pleural effusion, postoperative ileus lasting more than 5 days, bleeding requiring transfusion, mediastinal abscess, and intraperitoneal abscess. It is truly remarkable then to look at these results and recognize the dramatic improvements in surgical care that these authors and others have been able to achieve.

Indeed, I am convinced that LNF is feasible as an outpatient same-day surgical case and that it is safe in select patient populations. Women and patients with a higher DeMeester score have a significantly increased risk of requiring hospitalization. In fact, Kelly et al. ¹ suggest that being female increases the risk of being admitted about two times over that of the male population. I must admit that I am perplexed as to why being female increases your risk of postoperative admission, but then so are the authors. The authors note that a body mass index above 30 kg/m² effectively doubles the risk of postoperative admission and that the risk of admission after day-case surgery also increased by 0.855 for every 15 point rise in the DeMeester score of esophageal acid exposure. This may make sense from the standpoint of more difficult and extensive disease process as well as co-morbidities such as obstructive sleep apnea and diabetes, which might complicate the postoperative recovery.

It is surprising that age had no effect on the unplanned admissions after LNF. It could be that since their oldest patient was only 63 years old that the patients whose age would influence postoperative recovery were not studied in this article. The authors create a Tallaght LNF Score to predict the probability of admission after day-case LNF, which I find to be interesting but not terribly useful. Surgical skill, anesthesia adjuncts, and provision for medications to preempt nausea and control pain postoperatively can all be successfully implemented to provide for safe same-day surgical procedures. Optimizations of all these facets of treatment as these authors detail are surely going to improve our care of these patients.