Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada.
Surg Endosc. 2018 Feb;32(2):937-944. doi: 10.1007/s00464-017-5769-5. Epub 2017 Aug 4.
Advances in minimally invasive surgery and the development of enhanced recovery pathways have favored the spread of day-surgery programs. Despite laparoscopic approaches being accepted as the standard of care for benign hiatal diseases, 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 primary and revisional laparoscopic hiatal surgeries including paraesophageal hernia repairs (PEHR), fundoplication for reflux, and Heller myotomy (±diverticulectomy).
A retrospective cohort study including all patients undergoing elective laparoscopic hiatal procedures in the division of Thoracic surgery between 2011 and 2016 at McGill University Health Centre was performed. Planned day-surgery (DAYCASE) was compared to planned inpatient (INPATIENT) cohorts with respect to operative and postoperative outcomes, length of stay, readmission, and emergency room visits.
A total of 261 patients were identified, 161 female (62%); median age 62 (20). The case distribution was: PEHR (123; 47.1%), Heller myotomy (94;36%, 7 diverticulectomy), and fundoplication (44; 16.9%). Twenty patients had revisional procedures (7.7%). Same day discharge was planned in 98 cases (38%) and was successful in 80 (81.6%). Proportion of DAYCASE increased form 12% prior to 2013 to 67% in 2016. INPATIENTs were older (median 66 vs. 60 years), and had a higher proportion of PEHR (55 vs. 34%), p < 0.05. Both cohorts were comparable in gender proportion, ASA classification, and length of surgery. Complications, readmission, and emergency visits did not differ between the two cohorts. On multivariate analysis, female gender (OR 37, 95% CI 1.46-936, p = 0.028), surgery beginning after noon (OR 5.4, 95% CI 1.1-26.9, p = 0.038), intraoperative complications (OR 20.4 95% CI 1.5-286, p = 0.025), and postoperative complications (OR 52.1, 95% CI 4.5-602, p = 0.002) were independently associated with unplanned admission.
Day-case surgery for complex laparoscopic hiatal procedures is feasible and can be achieved in a significant number of patients without compromising safety.
微创技术的进步和加速康复途径的发展促进了日间手术计划的普及。尽管腹腔镜方法已被接受为治疗良性食管裂孔疾病的标准方法，但对于除了胃底折叠术以外的腹腔镜食管裂孔手术能否实现当日出院仍有待确定。
本研究旨在评估原发性和复发性腹腔镜食管裂孔手术（包括食管裂孔疝修补术、反流性胃底折叠术和 Heller 肌切开术[±憩室切除术]）当日出院的可行性。
对 2011 年至 2016 年期间在麦吉尔大学健康中心胸外科进行的所有择期腹腔镜食管裂孔手术的患者进行了回顾性队列研究。计划日间手术（DAYCASE）与计划住院治疗（INPATIENT）队列在手术和术后结果、住院时间、再入院和急诊就诊方面进行了比较。
共确定了 261 名患者，其中 161 名女性（62%）；中位年龄为 62（20）岁。病例分布为：食管裂孔疝修补术（123 例；47.1%）、Heller 肌切开术（94 例；36%，7 例合并憩室切除术）和胃底折叠术（44 例；16.9%）。20 例为复发性手术（7.7%）。计划 98 例（38%）当日出院，80 例（81.6%）成功出院。DAYCASE 的比例从 2013 年前的 12%增加到 2016 年的 67%。住院患者年龄较大（中位数 66 岁 vs. 60 岁），食管裂孔疝修补术的比例较高（55% vs. 34%），p<0.05。两组在性别比例、ASA 分级和手术时间方面均相似。两组的并发症、再入院和急诊就诊率无差异。多变量分析显示，女性（OR 37，95%CI 1.46-936，p=0.028）、手术开始于下午（OR 5.4，95%CI 1.1-26.9，p=0.038）、术中并发症（OR 20.4，95%CI 1.5-286，p=0.025）和术后并发症（OR 52.1，95%CI 4.5-602，p=0.002）与非计划入院独立相关。
对于复杂的腹腔镜食管裂孔手术，日间手术是可行的，可以在不影响安全性的情况下为大量患者实现当日出院。
