Laparoscopic Nissen Fundoplication: Analysis of Preoperative Risk Factors and 30-day Morbidity and Mortality Using ACS-NSQIP

E Miller, MD, J O Bader, Phd, D B Holt, MD, FACS. William Beaumont Army Medical Center

INTRODUCTION – Controversy exists whether laparoscopic Nissen fundoplication (LNF) has lower morbidity and mortality when performed in high volume centers as well as whether the procedure should be performed by general surgeons or sub-specialists.   We sought to identify pre-operative risk factors associated with increased 30-day morbidity and mortality for patients undergoing LNF in order to delineate which patients may be better suited for high volume centers and/or sub-specialty care.

METHODS AND PROCEDURES – 16,107 LNF were identified using Current Procedural Terminology (CPT) 43280 from the 2005-2013 National Surgical Quality Improvement Program (NSQIP) database.  Patient demographics, preoperative characteristics, and 30 day morbidity and mortality data were analyzed.  Univariate, chi-squared, and multivariate logistic regression analysis were used to examine the influence of risk factors on 30-day overall complications and mortality.

RESULTS – Overall 30-day morbidity and mortality for LNF was 3.6% and 0.2% respectively.  Unplanned intubation (0.6%), urinary tract infection (0.9%), and pneumonia (0.9%) were the most common complications.   Patients with renal failure on dialysis, ASA 3 or greater,  sepsis within 48 hours prior to surgery, chronic steroid use, and bleeding requiring transfusion had odds ratios of 27.93 (4.44-175.81, p=0.0004), 3.39 (1.18-9.78, p=0.02), 9.89 (2.68-36.49, p=0.0006), 3.62 (1.19-11.07, p=0.02) and 13.54 (4.01-45.65, p=<0.0001) for associated mortality respectively.   Mean operative time was 129.5 ± 63.3 minutes.  Increased operative time greater than 1 standard deviation above the mean was associated with increased complications but not overall mortality on multivariate logistic regression.

CONCLUSION – LNF has a low overall mortality rate.  The general surgeon should be able to safely perform LNF in appropriately selected patients in less than 3.2 hours.  Patients with renal failure, ASA 3, preoperative sepsis, and chronic steroid use should be carefully selected and counselled for the procedure and may be considered for referral to high volume centers.