Technical and Physiologic Analysis of a Laparoscopic Fundoplication Learning Curve.

Antonio Ramos-De la Medina, MD, Carmina Diaz-Zorrilla, MD, Roberto Lagunes, PhD, Jose M Remes-Troche, MD, Maria F Gonzalez-Medina, MD, Miguel A Zavala, MD

Veracruz Regional Hospital

Laparoscopic Nissen Fundoplication (LNF) is a technically demanding procedure that has a defined learning curve. Most studies dealing with LNF learning curves analyze operation time, hospital stay and complications as surrogates of improved performance without taking into account patient characteristics and physiologic variables.

We conducted a prospective analysis of the first 25 LNF of a single surgeon between August 2009 and January 2011. Patient demographics, clinical, technical and physiologic variables associated with the learning curve phenomenon were recorded and analyzed. Before surgery, all subjects underwent a symptomatic evaluation using a 5 point type Likert scale for esophageal symptoms, stationary esophageal manometry using a solid state catheter and a 24-h pH-multichannel intraluminal impedance (MII-pH) using a six impedance 1-pH catheter . All patients underwent LNF in a standard fashion using 5 upper abdominal ports. A 2-cm loose fundoplication calibrated over a 36 French bougie was performed with extensive transhiatal mobilization of the esophagus and division of short gastric vessels. MII-pH and esophageal manometry was performed 1, 3 and 6 months after LNF.

There were 18 females and 7 males, mean age 47.2 ± 11.09 years. Mean operative time was 168 ± 43 minutes. The mean hospital stay was 3 days (range:1-4 days), mean preoperative lower esophageal sphincter resting pressure (LESRP) was 13.1 ± 6.3 mmHg and mean postoperative LESRP was 27.7 ± 7.7 mmHg. We calculated the moving average of the operative time which showed a clear tendency to diminish as more procedures were performed. A multiple linear regression showed that the order in the sequence of the surgical procedure was predictive of decreased surgical time (p = 0.006, R2 = 0.526, P = 0.039). In contrast, the moving average of the postoperative LESRP did not differ as more experience was gained and a multiple logistic regression was non-significant (R2=0.07). Mean estimated blood loss was 69 ± 73 cc. There were no conversions to an open procedure and the complication rate was 4% (1 pneumothorax that required placement of a chest tube). Three patients (12%) complained of dysphagia more than six weeks after the procedure, but only 2 required dilation. Ninety-six percent of patients (24) reported successful symptom control after the procedure. The 24-h MII-pH confirmed the postoperative reduction of acid and non-acid reflux episodes at 1, 3 and 6 months.

The improvement in performance during the learning curve of LNF is reflected in a decrease in operative time, however, other parameters like hospital stay, complications, estimated blood loss, clinical improvement, dysphagia and LESRP do not significantly change from the early phase of the learning curve as experience is acquired during the first 25 cases. Adequate preoperative patient selection and careful surgical technique can lead to good outcomes even at the beginning of the learning curve of LNF.

Session: Poster Presentation

Program Number: P220

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