Juan Carlos Molina, MD, Ana-Maria Misariu, Ioana Nicolau, Jonathan Spicer, MD, PhD, Carmen Mueller, Lorenzo Ferri, MD, PhD. McGill University Health Centre
Advances in minimally invasive surgery and the development of enhanced recovery pathways has favored the spread of day-surgery programs. Despite laparoscopic approaches being accepted as the standard of care for benign hiatal diseases, the safety and feasibility of same-day discharges for laparoscopic hiatal surgeries other than fundoplication has yet to be established.
This study aimed to assess the feasibility of same-day discharge for laparoscopic hiatal surgeries including paraesophageal hernia repairs(PEHR), Fundoplication for reflux, and Heller myotomy (+/-diverticulectomy).
A retrospective cohort study was performed for patients who underwent laparoscopic hiatal procedures between 4/2011 and 8/2016 at a Canadian academic tertiary hospital. Patients were discharged home the same day if they met pre-specified discharge criteria. Planned day-surgery(DAYCASE) were compared to planned inpatient(INPT) cohort and the achieved same-day discharges with the unplanned admission group. Primary outcomes were unplanned admissions and readmissions. Demographic, clinical and perioperative variables were assessed. Data are presented as median(IQR), Mann-Whitney U test and Fisher’s exact test determined significance (*p,0.05).
208 patients were identified, 126 female (61%); median age of 64(20.5). The case distribution was: PEHR (112:54%), Heller myotomy (76;20%, 7 Diverticulectomy), and fundoplication(20:10%). Of these, 18 patients had revisional procedures (8,6%). Same-day discharge was planned in over 1/3rd of cases (73) and was successful in 63(86,3%). The proportion of DAYCASE patients increased from the beginning of the study period to the end (2011-13=19/88(22%) vs 2014-16 54/120(45%))*. Ten DAYCASE patients (13,7%) underwent unplanned admission; 7 because they did not achieve discharge criteria and 3 for social issues. INPTs were older (66(17)vs56(27))*, and had a higher proportion of PEHR(89/135:65%vs23/73:32%)*. DAYCASE and INPT cohorts were comparable in gender proportion, ASA classification, length of surgery, intra and postoperative complications, and emergency visits. Complications, the majority of which were minor (Clavien-Dindo 1-2), did not differ (DAYCASE=10vsINPT=20%) and there was no post-operative mortality. As would be expected, the length of stay was significantly lower in DAYCASE 0(0-3) compared to INPATIENT 1 day(1-22)*. Readmission rates (DAYCASE=2/73(3%) vs INPT 6/135(4%)) and emergency visits (DAYCASE=3/73(4%) vs INPT 6/135(4%)) did not differ between the two cohorts. In the multivariate analysis, older age and surgery performed after noon were predictors of unplanned admission.
Day-case surgery for laparoscopic hiatal procedures including paraesophageal hernia repair and Heller myotomy is feasible and can be achieved in a significant number of patients without compromising safety. Age and surgery performed after noon predicted higher risk of unplanned admission in patients undergoing outpatient laparoscopic hiatal surgery.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79302
Program Number: S098
Presentation Session: Foregut 2
Presentation Type: Podium