Predictors for Extended Length of Stay, 30-day Readmission and Clinical Outcome After Fundoplication

Yalini Vigneswaran, MD¹, Matt Gitelis², Brandon Johnson², Brittany Lapin², JoAnn Carbray², Michael B Ujiki, MD². ¹University Of Chicago, ²Northshore University HealthSystem

Introduction: The purpose of this study was to identify the risk factors for an extended length of stay, 30-day readmission or failed clinical outcome after laparoscopic fundoplication.

Methods: All patients at our institution undergoing fundoplication were identified between 2009 and 2014. Data related to patient demographics, presenting symptoms, diagnostic studies, preoperative quality of life, intraoperative variables, postoperative care, discharge, readmission and follow up were collected through retrospective review of electronic medical records. Patients requiring Heller myotomy were excluded. Independent predictors for postoperative proton pump inhibitor (PPI) use, extended length of stay or 30-day readmission were identified in a multivariate analysis using a logistic regression model with manual backward selection. Odds ratios were considered significant for p value less than 0.05.

Results: At our institution 146 patients underwent fundoplication with mean age 65.4 years, mean body mass index 29.5 kg/m2 and 30% male gender. Of these cases, 138 cases (94%) were elective operations. All patients either underwent a Nissen (84.3%), Toupet (14.4%) or Dor (1.4%) fundoplication. A total of 136 patients (90.9%) had a paraesophageal hernia seen intraoperatively and 97 of these patients (71.5%) were repaired with mesh.

Patients had a median length of stay of 2.0 days (IQR 1.0, 3.0 days) where 32 patients (21.9%) had LOS greater than 3 days. The most common reason for extended length of stay was a pulmonary or cardiac complication (56.3%). Most patients were discharged home but 12 patients (8.2%) required discharge to an assisted living facility. The independent predictors for extended length of stay were age (odds ratio 1.06, p=0.01) and an operative time greater than 3 hours (odds ratio 11.08, p=0.003).

Of the patients in our series, 7.6% (11/146) were readmitted within 30 days. The median time to readmission was 3 days (range 1-20 days). Readmission occurred due to cardiac or pulmonary complaints (6/11), treatment of esophageal leak (2/11) and obstructive symptoms (3/11). The only independent predictor for 30-day readmission was occurrence of an intraoperative complication (odds ratio 83.8, p=0.006). Age was not a predictor for readmission in this multivariate analysis.

At an average follow up of 21.2 months, 21.4% of patients were restarted on postoperative PPI, however 97.0% patients reported resolution of reflux when compared to preoperative symptoms. The only independent positive predictor for postoperative PPI use was performance of a Toupet fundoplication (odds ratio 5.24, p= 0.002).

Conclusions: Pulmonary and cardiac complications after fundoplication appear to be the greatest reasons for extended length of stay and 30-day readmission. In our series, factors predictive of extended length of stay were related to the severity of disease (prolonged operative time) and age. As expected, an intraoperative complication was strongly predictive of 30-day readmission. Additionally, performing a Toupet fundoplication was strongly predictive of postoperative PPI use. However despite this known incidence of postoperative PPI use, we conclude that almost all patients will experience improved reflux postoperatively and a successful outcome.