Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Anterior 90 degree(s) partial vs Nissen fundoplication-5 year follow-up of a single-centre randomised trial

INTRODUCTION: Nissen fundoplication can be followed by side effects, and this has driven modifications, including partial fundoplications. We previously reported early outcomes from a randomised trial of Nissen vs anterior 90 degrees partial fundoplication. This paper reports 5-year follow-up outcomes to determine whether anterior 90 degrees fundoplication achieves a satisfactory longer-term outcome. METHODS: From February 1999 to August 2003, 79 patients were randomised to Nissen vs anterior 90 degrees fundoplication. Patients were followed yearly using a standardized clinical questionnaire which included symptom scores to assess heartburn, dysphagia, other post-fundoplication side effects and overall satisfaction with the outcome. Five-year clinical outcomes were analysed. RESULTS: Seventy-four patients were available for follow-up at 5 years. There were no significant differences for heartburn or satisfaction, although more patients used antisecretory medication after anterior 90 degrees fundoplication (29.7 vs 8.1 %). Dysphagia was greater after Nissen fundoplication when measured by an analogue score for solid food and a composite dysphagia score. Symptoms of bloating were more common following Nissen fundoplication (80.0 vs 32.4 %), and less patients could eat a normal diet (78.4 vs 94.6 %). Re-operation was undertaken in four patients after Nissen fundoplication (dysphagia, three; hiatus hernia, one) vs three after anterior 90 degrees fundoplication (recurrent reflux, three). CONCLUSIONS: At 5 years, anterior 90 degrees partial fundoplication was associated with less side effects, offset by greater use of antisecretory medication. Reflux symptoms and overall satisfaction were similar to Nissen fundoplication. Laparoscopic anterior 90 degrees partial fundoplication is an effective treatment for gastro-esophageal reflux.David Ian Watson, Peter G. Devitt, Lorelle Smith and Glyn G. Jamieso

Laparoscopic fundoplication in patients with a hypertensive lower esophageal sphincter

Background: A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods: Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results: Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median: follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). Conclusion: Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.Peter J. Lamb, Jennifer C. Myers, Sarah K. Thompson and Glyn G. Jamieso

Early reoperation after laparoscopic fundoplication: The importance of routine postoperative contrast studies

Background: The necessity for routine postoperative contrast studies following laparoscopic fundoplication for either gastroesophageal reflux disease or paraesophageal hernia is unclear. Methods: To determine whether a routine contrast X-ray film influenced surgical decision making following laparoscopic fundoplication, we reviewed records from a prospective database of 1,894 patients who underwent a primary laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia between October 1991 and June 2008, and identified those who underwent early reoperation. The value of early routine postoperative barium swallow examinations in the management of these patients was then determined. Results: The review showed that 53 patients (2.8%) underwent reoperative procedures within seven days of their original operation: 21 had originally undergone surgery for a paraesophageal hernia, and 32 for reflux. Of the 53 patients who underwent reoperaiton, 25 (47.2%) were treated for dysphagia, 17 (32.1%) for acute paraesophageal hernia, 6 (11.3%) for a gastrointestinal leak, and 5 (9.4%) for bleeding or peritonitis. Fifteen of the 17 patients who underwent repair of an acute hiatus hernia (0.8% of all patients) had no symptoms and underwent reoperative surgery because of radiological findings alone. Primary surgery for a large hiatus hernia was associated with a higher incidence of early reoperation (5.2 vs. 2.2%; P = 0.001). Conclusions: Approximately 1 in 125 patients who underwent laparoscopic surgery for reflux or a large hiatus hernia had an important finding on an early postoperative contrast swallow, and benefited from this investigation by undergoing early reoperative intervention.Shigeru Tsunoda, Glyn G. Jamieson, Peter G. Devitt, David I. Watson and Sarah K. Thompso

Outcomes for trainees vs experienced surgeons undertaking laparoscopic antireflux surgery - is equipoise achieved?

BackgroundThere is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication.MethodPatients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared.ResultsOne thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants.ConclusionThe learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.Claire N. Brown, Lorelle T. Smith, David I. Watson, Peter G. Devitt, Sarah K. Thompson, Glyn G. Jamieso

Use of antireflux medication after antireflux surgery

The original publication can be found at www.springerlink.comIntroduction It is claimed that a substantial number of patients who undergo antireflux surgery use antireflux medication postoperatively. This study was aimed to determine the prevalence and underlying reasons for antireflux medication usage in patients after surgery. Materials and Methods A questionnaire on the usage of antireflux medication was sent to 1,008 patients identified from a prospective database of patients who had undergone a laparoscopic antireflux procedure. Results A total of 844 patients (84%) returned the questionnaire. Mean follow-up was 5.9 years after surgery. A single or combination of medications was being taken by 312 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. Fifty-two patients (17%) had never stopped taking medication, whereas 260 patients (83%) restarted medication at a mean of 2.5 years after surgery. Return of the same (31%) or different (49%) symptoms were the commonest reasons for taking medication, whereas 20% were asymptomatic or had other reasons for medication use. Postoperative 24-hour pH studies were abnormal in 16/61 patients (26%) on medication and in 5/78 patients (6%) not taking medication. Conclusions Antireflux medication is frequently taken by many patients for various symptoms after antireflux surgery. Symptomatic patients should be properly investigated before antireflux medications are prescribed.Bas P. L. Wijnhoven, Carolyn J. Lally, John J. Kelly, Jennifer C. Myers and David I. Watso