Patients who underwent laparoscopic sleeve gastrectomy (LSG) with Nissen Fundoplication (NF) had a higher prevalence of comorbidities and a longer hospital length of stay, according to researchers from the University of Toledo Medical Center, Toledo, OH. However, there was no statistically significant difference found in the rates of readmission within 30 days when compared to the LSG-alone.
Although LSG is one of the most effective surgical options for weight loss, some studies have reported the procedure is associated with higher gastroesophageal reflux disease (GERD) than laparoscopic Roux-en-Y gastric bypass, particularly during the first year following the procedure in some patients. However, there is no clear consensus on whether LSG increases the incidence of GERD or decreases its prevalence.
It has been shown that adding an antireflux procedure to the LSG can help alleviate the symptoms of GERD, but this adds complexity and surgical risk to a relatively simple procedure. The study researchers noted that NF has been shown to be an effective treatment choice for GERD with minimal complications and has been proven to be safe and effective when combined with LSG.
Therefore, their study sought to determine the difference in complications, length of hospital stay and readmission rates between patients who underwent LSG without NF and those who underwent LSG with NF.
Using records from the Nationwide Readmissions Database (NRD) from 2016 to 2019, the researchers identified a total of 236,111 patients were identified that underwent LSG with and without NF. After 2:1 matching, 1644 patients (1096 who underwent LSG without NF and 548 who underwent LSG with NF) were identified.
Outcomes
The median age of patients was 47 years and 1,382 (84%) were female. There were no others statistically significant differences between the two groups for age, sex, BMI or for certain comorbidities including chronic obstructive pulmonary disease (COPD), cardiac arrhythmias, hypothyroidism, diabetes, hypertension, morbid obesity due to excess calories, sleep apnoea, nicotine dependence history.
Other comorbidities were higher in the LSG with NF group including (LSG without NF vs. LSG with NF): Gastro-oesophageal reflux disease (GERD) (40.3%, 68.6%, p<0.001), liver disease (10.8%, 21.0%, p<0.001), diaphragmatic hernia (28.6%, 81.0%, p<0.001), Hyperlipidemia (25.2%, 36.1%, p<0.01), Gastritis (1.6%, 6.0%, p<0.001), anaemia (2.6%, 8.4%, p<0.001), metabolic syndrome (1.5%, 5.1%, p<0.001), polyneuropathy (1.3%, 2.9%, p<0.05), long-term (current use) of anti-coagulants (2.6%, 0.9%, p<0.05).
Patients who underwent LSG with NF had a longer length of stay (median, 1 days; p<0.01), and higher total charges (median, US$62,300 vs. US$46,704, p<0.001). There was no significant difference in 30 days readmissions between the two groups: LSG with NF (3.6%) VS LSG without NF (2.4%) (p=0.19).
Causes of readmission were similar between the two groups including: post-operative hematoma and seroma of a digestive system organ or structure, hematemesis, melena, gastrointestinal haemorrhage-unspecified, pulmonary embolism, acute embolism and deep vein thrombosis, post-operative complications and disorders of digestive system, infection following a procedure-initial encounter, generalised (acute) peritonitis, peritoneal abscess, dehydration, nausea/vomiting, acute kidney failure, myocardial infarction, dysphagia and sepsis.
To determine the effect of preoperative BMI on readmission, the groups were subdivided into three subgroups (BMI<40, 27.2%; BMI 40–50, 52.7%; and BMI > 50, 20.1%). Preoperative BMI played a minor role in the readmission between both groups. In patients with BMI less than 40, the readmission was higher in patients who underwent both LSG and NF (5.8% vs. 1.7%, p<0.05), otherwise there was no significant difference in the readmission among all other subgroups in patients with or without NF.
“This is the largest and first study to investigate the 30-day readmission rates and to compare reasons for readmissions after LSG with or without NF,” the authors stated. “Based on current literature, the differences in short term complication rates between LSG with NF and LSG without NF seem to be small.”
They add that their findings emphasise the importance of considering the patient's BMI and the need for a shared decision-making between patients and their surgeons when deciding on LSG with NF as a surgical procedure, as a lower BMI may increase potential short-term complications after surgery in comparison to LSG without NF.
“The reasons for the difference in short-term readmission rates for those with a BMI of less than 40 between patients who underwent LSG with NF compared to those who underwent LSG alone are uncertain and require more exploration. These findings demonstrate that LSG with NF shows a similar safety profile to LSG without NF but has an increased cost and hospital stay,” the study authors concluded. “The study results also highlight the need for more long-term studies to determine if there is a difference in complication and readmission rates for patients undergoing LSG with NF compared to LSG alone.”
The findings were reported in the paper, ‘Comparative analysis of readmission rates and outcomes: Sleeve gastrectomy with versus without Nissen fundoplication using a National Database’, published in Obesity Reviews. To access this paper, please click here
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