A. Bhama1, V. Wu1, B. Nardy1, H. Chong1 1University Of Iowa Hospitals And Clinics,General Surgery,Iowa City, IA, USA
Introduction: Laparoscopic Nissen fundoplication (LNF) is commonly performed for medically refractory gastroesophageal reflux disease and in conjunction with symptomatic hiatal hernia repairs. Though associated with a low incidence of postoperative complications, it may be still be a common practice to obtain postoperative upper gastrointestinal contrast studies (UGI) in the immediate postoperative setting. Extensive literature search did not reveal any literature regarding the use of routine UGI following LNF. The aim of this study is to evaluate the postoperative utility of UGI following uncomplicated LNF in leak assessment.
Methods: A single institution, retrospective review was performed of adult patients who underwent LNF from 2006 to 2012. Indications for LNF were refractory GERD or hiatal hernia repair. 171 patients were identified. Those undergoing reoperative surgery or Collis gastroplasty with LNF were excluded. Ten were excluded for reoperative surgery, and 19 were excluded for undergoing Collis gastroplasty. The final study comprised of 142 patients. UGI and postoperative outcomes were assessed from this group of patients. All UGI were obtained between postoperative days one through three and interpreted by staff radiologists. The cost of study was obtained from the radiology billing department.
Results: Of the 142 patients reviewed, the mean age of patients undergoing surgery was 56.9 years, with a female predominance 72%. Indication for operation was refractory GERD in 58% (n=83) of patients, paraesophageal hernia repair in 42 %(n=59) of patients. UGI studies were obtained in 94% (n=134) of patients. Of the 134 UGI studies, no leaks were identified; however, one was a false negative study, and the patient required emergent reoperation for gastric perforation found on CT. There was no clinical suspicion for leaks in those who did not undergo UGI. Negative predictive value of UGI for leak was found to be 99.3%. Sensitivity, specificity and PPV are unable to be calculated given that no tests were positive for leak. Cost of each UGI and CT scan with interpretation was $816 and $4020 respectively.
Conclusion: This study suggests that there is little utility of UGI in the early postoperative period following uncomplicated LNF for refractory GERD and paraesophageal hernia repairs. If clinical suspicion of leak arises, a CT scan with oral contrast should be obtained in lieu of an UGI study.