Achieving Day-Case Laparoscopic Nissen Fundoplication: An Analysis of Patient and Operative Factors

Abstract

Introduction:

Day-case laparoscopic Nissen fundoplication has been described; however, its achievability and limitations in the setting of a busy Foundation Trust hospital are unclear.

Subjects and Methods:

A retrospective cohort study of all cases undergoing laparoscopic Nissen fundoplication between January 1, 2009 and December 31, 2010 at three hospitals in the largest and the least densely populated Trust in the United Kingdom was undertaken. Primary end points of planned and achieved day-case surgery were compared with logistic regression analysis. Secondary end points were unplanned re-admission and complications.

Results:

During the study period 126 consecutive patients underwent laparoscopic Nissen fundoplication. There were 64 female patients and 62 male patients. Primary surgery was undertaken in 115 patients and revisional surgery in 11. The age range was 21–73 years. Patients had traveled up to 52.3 miles or 80.2 minutes for their surgery. The median length of stay was 0 days in the planned day-case cohort and 1 day in the inpatient cohort. Day-case surgery was planned in 85 (68.55%). Successful day-case discharge was achieved in 71 cases (83.5%). There was no difference in age, geographical remoteness, surgeon volume, or length of surgery between planned and achieved day-case surgery. Patients were more likely to need unplanned admission if their American Society of Anesthesiologists grade was 2, when undergoing revisional surgery, and if the operation was completed after 1300 hours (1 p.m.). After multivariate regression analysis only operation completion time remained significant (P≤.05). The rate of unplanned re-admission related to surgery was 3/126 (2.38%).

Conclusions:

Day-case laparoscopic Nissen fundoplication can be achieved in the majority of patients. Unplanned admission is to be expected in approximately 15% of planned cases and cannot be predicted.

Introduction

Gastroesophageal reflux disease represents a major burden of disease in the western world.¹ The role of antireflux surgery in the management of gastroesophageal reflux disease is well described.² Open and laparoscopic approaches have similar efficacy; however, laparoscopic fundoplication (LF) is associated with less morbidity and shorter inpatient stays.^3,4

Although day-case LF has been described, its achievability and limitations in the setting of a busy Foundation Trust hospital are unclear.^5–10 Day-case surgery has potential advantages in reduced rates of hospital-acquired infection, reduced costs, and increased patient satisfaction. Recent changes in tariff structures will penalize re-admission in the U.K. healthcare system. Consequently appropriate case selection is of prime importance.

Potential barriers to day-case surgery are thought to include geographical remoteness, with several studies restricting day-case patient selection by geography.^8,10 The Northumbria Healthcare Trust is the geographically largest Trust, covering an area from Newcastle in the south and east to Cumbria in the west and the Scottish boarders in the north. The Trust has three hub sites and employs six specialist upper gastrointestinal surgeons, known collectively as Northumbria Upper Gastro-Intestinal Team of Surgeons (NUGITS). The purpose of this study was to evaluate patient and surgical factors that indicate appropriateness for day laparoscopic antireflux surgery and identify factors that predict unplanned admission or re-admission.

Subjects and Methods

A retrospective analysis of all cases undergoing LF by the NUGITS group between January 1, 2009 and December 31, 2010 was undertaken. Cases were identified from the Surgical Interrogation and Retrieval Information System database. Cases of massive paraesophageal hernia were excluded.

Our operative strategy for fundoplication has previously been reported.⁶ Patients were stratified by preoperative intention-to-treat as day case or inpatient. Day-case surgery was defined as discharge on the day of surgery. All day cases were admitted to a dedicated day-case unit. Suitability for day-case discharge was judged by the day-case unit nursing staff. At discharge the contact details of the local upper gastrointestinal nurse specialist were provided to all patients. All patients were discharged into the care of an identified adult. Routine follow-up was planned at 6 weeks after surgery; no additional contact was planned between surgeon and patient.

Comparison between the day-case and inpatient cohorts and between successful day of surgery discharge and unplanned admission was made for age, sex, American Society of Anesthesiologists (ASA) grade, distance from patient's home to site at which surgery undertaken, primary or revisional surgical procedure, surgeon volume, length of surgery, and timing of operating theater list. Distance was calculated from residential postcode to hospital postcode using the RAC route finder and was recorded as distance in miles and journey time in minutes. Surgical volume was defined as high if the operator had undertaken a minimum of 20 cases in the study period. Cases were defined as being on an AM list if they were completed by 1300 hours (1 p.m.). Age, distance, journey time, and length of surgery were analyzed as continuous and categorical variables. The reason for unplanned admission was assessed on a case-by-case basis.

An unplanned re-admission was defined as any case requiring inpatient stay following planned discharge. Unplanned re-admissions were reviewed on a case-by-case basis.

Statistics

Continuous data were tested for kurtosis to determine normality. Normally distributed data are reported as mean (95% confidence interval [CI]) and are compared using Student's t test. The 2×2 categorical variables were compared by chi-squared test, and the rest were compared by chi-squared test for trend. Stepwise multivariate logistic regression analysis was performed to identify independent associations between variables and primary end points. The likelihood ratio test (LR) measured independent variable significance for improved model fit. All analyses were conducted in STATA version 9.0 software (StataCorp LLC, College Station, TX). A P value of <.05 was considered statistically significant.

Results

Between January 1, 2009 and December 31, 2010, 126 consecutive patients underwent Nissen LF for gastroesophageal reflux disease by six surgeons from the NUGITS group at three hospital sites. There were 64 female patients and 62 male patients. Primary surgery was undertaken in 115 patients and revisional surgery in 11. The age range was 21–73 years; the mean age was 48.7 years (range, 21.6–73.81 years). Patients had traveled up to 52.3 miles (range, 0.29–52.3 miles) or 80.2 minutes (range, 2–80.18 minutes) for their surgery. Operative timings were recorded in 108 patients, the median operative time was 58 minutes (range, 25–135 minutes), with 81 (75%) cases operated on an a.m. list and 27 (25%) on a p.m. list. American Society of Anaesthesia (ASA) grades were recorded in 122 cases, with 50 patients recorded as ASA 1, 62 as ASA 2, and 3 as ASA 3. The median length of stay was 0 days in the day-case cohort and 1 day in the inpatient cohort.

No mesh was used to repair the hiatal defect. All cases were completed laparoscopically. One case had a cholecystectomy performed at the same time.

Day-case surgery was planned in 85 (68.55%) of patients. There were significant differences in gender, age, ASA, type of surgery, surgeon volume, and operating theater list between cases planned as day case and those planned as inpatient (Table 1). No cases were planned as day case over the age of 71 years or with an ASA grade of 3.

Table 1.

Patient and Operative Factors of Patients Undergoing Day-Case or Inpatient Laparoscopic Antireflux Surgery

Factor	Planned day case	Planned inpatient	P value
Gender			.001^a
Male	53	9
Female	32	32
Age (years) [mean (95% CI)]	46.77 (49.1–56.4)	52.78 (43.9–49.7)	.008^b
ASA			.026^c
Grade 1	37	13
Grade 2	41	21
Grade 3	0	3
Distance (miles) from home to hospital in miles [mean (95% CI)]	10.2 (7.5–12.9)	9.0 (2.4–15.6)	.36^b
Travel time (minutes) from home to hospital [mean (95% CI)]	18.0 (14.9–21.2)	15.4 (8.0–22.9)	.25^b
Primary			.008^a
Yes	82	33
Revisional	3	8
High-volume surgeon			.001^a
≥20 cases	76	22
<20 cases	9	19
Length of surgery (minutes)			.063^c
≤45	19	7
46–90	48	18
>90	3	7
Operating theater list			.001^a
Mane	67	14
p.m.	8	19

By chi-squared test.

By Student's t test.

By chi-squared test for trend.

ASA, American Society of Anesthesiologists; CI, confidence interval.

In the univariate analysis patients planned as day case compared with those planned as inpatient were younger (mean age, 46.77 years versus 52.78 years; P<.05), were more likely to be male (85.5% in males versus 50% in females; P≤.05), had lower ASA grades (P≤.05), were more likely to be primary repairs (P≤.05), were more likely to be under a high-volume surgeon (high versus low volume, 86.36% versus 32.14%; P≤.05), and were more likely to be on a mane list (mane versus p.m., 82.72% versus 29.63%; P≤.05) (Table 1).

No association between cases planned as day case and inpatient was found for geographical remoteness as measured by time and distance from the patients' home to the hospital site or for the length of the surgery.

Successful day-case discharge was achieved in 71 cases (83.5%). There was no difference in gender, age, distance, journey time, surgeon volume, or length of surgery between achieving successful day-case discharge and unplanned inpatient stay (Table 2). Patients were more likely to need unplanned admission if their ASA grade was 2, if they were redo surgical procedures, and if surgery was completed after 13.00 hours.

Table 2.

Patient and Operative Factors Comparing Successful Day-Case Surgery or Unplanned Admission for Cases Undergoing Planned Day-Case Laparoscopic Antireflux Surgery

Factor	Successful day case	Unplanned admission	P value
Gender			.92^a
Male	44	9
Female	27	5
Age (years) [mean (95% CI)]	45.91 (42.8–49.1)	50.40 (41.7–59.1)	.87^b
ASA			.029^a
Grade 1	35	2
Grade 2	30	10
Distance (miles) from home to hospital [mean (95% CI)]	10.18 (7.5–12.9)	9.03 (2.4–15.6)	.263^b
Travel time (minutes) from home to hospital [mean (95% CI)]	18.04 (14.9–21.2)	15.43 (8.0–22.9)	.25^b
Primary			.017^a
Yes	70	12
Redo	1	2
High-volume surgeon			.184^a
≥20 cases	63	14
<20 cases	8	0
Length of surgery (minutes) [mean (95% CI)]	56.91 (49.6–62.6)	67.17 (48.64–77.14)	.95^b
Operating theater list			.01^a
Mane	58	9
p.m.	4	4

By chi-squared test.

By Student's t test.

ASA, American Society of Anesthesiologists; CI, confidence interval.

After stepwise multivariate logistic regression analysis to control for confounding, there was a significant association between increased rates of planned day-case surgery and male sex (odds ratio [OR] 5.35, 95% CI 1.43–19.99, LR P<.05), primary surgery (OR 15.89, 95% CI 1.18–213.54, LR P<.05), and a mane operating theater list (OR 11.26, 95% CI 2.62–48.38, LR P<.05). An inverse association between planned day case was seen for ASA grade 2 (OR 0.86, 95% CI 0.21–3.47, LR P<.05). For the multivariate regression analysis comparing successful day of surgery discharge and unplanned admission, only operation completion time remained significant (OR 0.15, LR P<.05).

Causes of unplanned admission were intraoperative (n=3), nausea (n=2), pain (n=4), social (n=1), or other (n=1).

Unplanned re-admission was required in 4 patients (two men, two women). The median time after discharge was 3 days (range, 2–6 days). All of the cases had been planned day cases, although 1 had required unplanned admission. The median length of stay after re-admission was 3 days (range, 1–7 days). All of the cases were primary, undertaken by a high-volume surgeon, and ASA grade 1 or 2. The reasons for unplanned re-admission were nausea/bloating (n=2), vomiting (n=1), and vasovagal (n=1); consequently the unplanned re-admission related to surgery was 3/126 (2.38%).

There was no mortality and no complications within the study period.

Discussion

We have confirmed the suitability and safety of day-case laparoscopic antireflux surgery. We found no difference in unplanned admission rates when cases were compared by age, gender, or distance to the hospital. Higher rates of unplanned admission were seen in patients with an ASA grade of 2, in cases completed after 1 p.m., and in revisional surgical cases.

There are relatively few other series reporting ambulatory care after antireflux surgery, particularly in the United Kingdom. Our planned day-case rate of 68.55% compares favorably with Mariette et al.,⁷ who reported day-case LF in 32.2% of patients (49/152) among all cases undergoing LF in a university tertiary-care center between September 2003 and January 2007. Agrawal et al.¹¹ (2009) report a rate of 79.2% (103/130) in a United Kingdom–based series of Lind fundoplications performed by a single surgeon at a tertiary referral center.

In the present study 83.5% (71/85) of day surgery patients were discharged on the same day. Published rates of successful day-case discharge vary from 77.3% to 100%.^10–16

We did not exclude patients with an ASA grade of 3 or higher from the day-case group, although no cases were deemed suitable. Several other studies excluded patients with ASA grade 3 from day-case selection.^8,10,11,16 Khan and Stephens¹³ reported higher rates of unplanned admission in patients with an ASA grade of 3. We found higher rates of unplanned admission for revisional cases. Revisional surgery was an exclusion criteria for consideration of day-case fundoplication in several other series.^8,11 Cases completed after 1300 hours (1 p.m.) had a 50% chance of needing admission, and after multivariate analysis only the end time of surgery was independently significant.

Unplanned re-admissions were required in 2.38% of cases and were not related to early discharge. Other studies have reported rates of re-admission of between 0% to 12.2%.^7,8,10,13 Ng et al.⁵ reported dysphagia as a principal reason for re-admission in their systemic review; however, in our series the principal symptoms were bloating and nausea. There was no significant morbidity associated with day of surgery discharge.

The approach to day-case surgery is very much multidisciplinary. Achieving successful day-case discharge begins in presenting planned day-case surgery as the norm when counseling the patient in the outpatient service. This attitude is reinforced on arrival at the day-case unit. The role of the anesthetic department is also crucial. Trondsen et al.¹⁰ described a highly prescriptive anesthetic regimen in their cohort of day-case LF. Although there are no restrictions on anesthetic regimen for the NUGITS group, we recommend avoidance of opioids.

Our patients are given the contact number of an upper gastrointestinal nurse specialist, who is available weekdays 0800–1700 hours. Other studies have described far more intensive follow-up.^10,11,15 Tronsden et al.¹⁰ described contacting the patients the night after surgery, again the following day, by the surgeon and anesthetist, and then when deemed necessary by the patient. Bailey et al.¹⁵ telephoned the patient on the night of surgery and gave the patients the surgeon's phone number. Several groups arranged for the patients to be seen at home the following day.^15,17

Although we have not measured patient satisfaction, the low rates of unplanned admission and re-admission provide a surrogate marker of satisfaction. Trondson et al.¹⁰ reported 75.6% satisfaction among a cohort of 41 patients who had undergone day-case LF. In a small series (n=21), Vlug et al.⁹ reported that two-thirds of patients having day-case LF would have preferred a short hospital stay. However, they did not report how cases were selected for suitability for day-case treatment. Conversely, Victorzon et al.⁸ found that 26/28 (92.9%) of patients who had undergone day-case LF were satisfied, and 28/28 (100%) would recommend the surgery as a day case to a friend or relative.

As a historical cohort study, there are limits in usefulness. However, it is the first study of day-case LF to perform comprehensive analysis of the patient and operative factors that need to be considered when determining a patient's suitability for day-case LF and the setting of a district general means that our results should be widely reproducible.

We recommend that only primary surgery and cases with an ASA grade of 1 or 2 should routinely be considered for day-case LF. Furthermore, all cases should be planned on a mane list. It is interesting that although surgeons performing more than 20 cases over the 2 years were more likely to plan cases as day case, there was no difference in the successful day-case discharge, suggesting that all surgeons should plan straightforward cases as day cases. Age and distance from residency to hospital are not barriers to successful day-case antireflux surgery.

Conclusions

Day-case Nissen LF can be achieved safely in the majority of patients. Unplanned admission is to be expected in approximately 15% of planned cases and cannot be predicted. Cases should be undertaken in the morning and be primary surgical cases, and patient age and distance from the hospital are not barriers to surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

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