Y. Vigneswaran1,2, K. Kuchta1, J. G. Linn1,2, S. P. Haggerty1,2, R. Joehl2, E. W. Denham1,2, M. B. Ujiki1,2 2NorthShore University HealthSystem,Surgery,Evanston, IL, USA 1University Of Chicago,Surgery,Chicago, IL, USA
Introduction: Although a common low risk procedure, laparoscopic fundoplication for a small portion of patients can result in a complicated postoperative course. Expected outcomes such as length of stay and unplanned readmissions have not been well studied for this procedure yet payers have decided on certain standard and expected outcomes. We hypothesize certain patient specific factors are associated with extended length of stay and unplanned 30 day readmission. The purpose of this study was to identify these risk factors from a national database and correlate them in a single institution experience.
Methods: American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2013 was queried for elective laparoscopic fundoplication. Patient characteristics, comorbidities and operative details were used to determine predictors for complications, readmission and extended length of stay in a multivariate analysis. These predictors were then retrospectively tested in our single institution cohort from 2009 to 2014.
Results: A total of 9,338 patients underwent laparoscopic fundoplication for reflux (41.0%) or paraesophageal hernia (59.0%). Complications occurred in 319 (3.4%), 972 had length of stay greater than 3 days (10.4%) and 507 had unplanned 30-day readmission (5.4%). Most common complications were urinary tract infection (27.6%) and pneumonia (26.3%). Most common reasons for readmission were related to pulmonary (20.3%) or GI symptoms (14.4%).
From the multivariable analysis, patients at increased risk of complications were aged greater than 80 (OR 2.7, p<0.0001) and higher ASA class (OR 1.7, p <0.0001). Patients at increased risk of extended length of stay were aged greater than 80 (OR 3.9, p<0.0001), higher ASA class (OR 2.0, p <0.0001), black race (OR 1.9, p<0.0001), race listed other/unknown (OR 1.7, p <0.0001), history of pulmonary disease (OR 1.6, p=0.0001) and females (OR 1.3, p=0.004). The odds of unplanned readmission was also significantly increased for age greater than 80 (OR 1.4, p=0.03), higher ASA class (OR 1.6, p<0.0001) and black race (OR 1.8, p<0.001). When these predictors were used to create risk calculators and tested in our single institution cohort of 207 patients, extended length of stay had 72% sensitivity (CI: 66-78%), 45% specificity (CI 38-52%) and readmission had 71% sensitivity (95% CI: 65%-78%), 58% specificity (95% CI 51%-64%).
Conclusion: We have identified several patient dependent characteristics that are associated with increased risk of extended length of stay and unplanned 30-day readmission after laparoscopic fundoplication. We hope these results will allow for better patient counseling and patient selection by surgeons when proceeding with laparoscopic fundoplication. Additionally this data suggests outcomes of extended length of stay and 30-day readmission may not be good markers for the quality of surgical care with fundoplications, as currently used by payers.