Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care.

BACKGROUND: Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC). METHODS: This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates. RESULTS: Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. CONCLUSIONS: The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain.

OBJECTIVE: In this post hoc observational study, we investigated psychological predictors of outcome after radiofrequency and injection treatments, commonly performed in the management of chronic low back pain (CLBP). DESIGN & SETTING: Data, comprising 161 patients (29 eventually lost to follow-up), were obtained from two randomized controlled trials on efficacy of radiofrequency treatment for back pain and sciatica. Subsequently patients were additionally treated in an open prospective follow-up period. Although all groups presented a significant visual analog scale reduction after 3 and 12 months, no additional pain relief after radiofrequency compared with injection treatment was found. Both trial populations showed sufficient similarities. A principal component (factor) analysis was performed on baseline psychometric tests, SF-36, and physical activity variables. We constructed five clinically relevant psychological profiles: "psychologically negative,""adaptive manager,""rigid qualities,""supporting partner," and "strong ego." These were examined as possible predictors of significant pain relief using logistic regression analysis. RESULTS: The "psychologically negative" dimension showed a negative and the "adaptive manager" dimension a positive prognostic effect on outcome. CONCLUSIONS: Minimally invasive treatment for CLBP leads to significant pain reduction, including potential placebo effects. However, psychologically vulnerable patients, characterized by, among others, reduced life control, disturbed mood, negative self-efficacy, catastrophizing, high anxiety levels, inadequacy, and poor mental health, tend not to respond to this treatment. Patients characterized by a.o. reduced pain and interference levels, positive expectations, and reasonable physical and social functioning, react more favorably. From both a clinical and a financial perspective, psychosocial evaluation and selection of patients seems appropriate, before applying minimally invasive procedures for CLBP.

Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial.

OBJECTIVES: Radiofrequency facet joint denervation procedures have been common practice for 2 decades in treatment of chronic low back pain. We designed this multicenter, randomized, double-blind, sham treatment controlled trial to determine the efficacy of radiofrequency facet joint denervation, as it is routinely performed. METHODS: Inclusion criteria were low back pain, duration more than 6 months, and >or=50% Visual Analog Scale (VAS) reduction on diagnostic block. Exclusion criteria were prior radiofrequency treatment, radicular syndrome, coagulopathies, specific allergies, cancer, and pregnancy. A total of 81 out of 462 patients were randomized to undergo radiofrequency facet joint denervation or sham treatment. The first evaluation was carried out 3 months after treatment. Primary outcome was determined with a combined outcome measure comprising VAS, physical activities, and analgesic intake, from a twice-weekly recorded diary. Secondary outcome measures were the separate diary parameters, global perceived effect (complete relief, >50% relief, no effect, pain increase), and SF-36 Quality of Life Questionnaire. RESULTS: There were no dropouts before the first evaluation. The combined outcome measure showed no differences between radio- frequency facet joint denervation (n=40; success 27.5%) and sham (n=41; success 29.3%) (P=0.86). The VAS in both groups improved (P<0.001). Global perceived effect improved after radiofrequency facet joint denervation (P<0.05). The other secondary outcome parameters showed no significant differences. Relevant costs were evaluated. DISCUSSION: The combined outcome measure and VAS showed no difference between radiofrequency and sham, though in both groups, significant VAS improvement occurred. The global perceived effect was in favor of radiofrequency. In selected patients, radiofrequency facet joint denervation appears to be more effective than sham treatment.

Radiofrequency lesioning of dorsal root ganglia for chronic lumbosacral radicular pain: a randomised, double-blind, controlled trial.

BACKGROUND: Results of observational studies have shown pain reduction with percutaneous radiofrequency lesioning of dorsal root ganglia for lumbosacral radicular pain, but there are few randomised controlled trials. We aimed to assess the efficacy of radiofrequency lesioning of dorsal root ganglia for lumbosacral radicular pain. METHODS: We screened 1001 patients, who were mostly referred by their family doctor, in four hospitals for a double-blind randomised trial. 83 patients met inclusion criteria and thus were randomly assigned to receive a radiofrequency lesion or control treatment of the involved dorsal root ganglion. Control treatment was done in the same way as radiofrequency lesioning, but without radiofrequency current. Preoperatively and during 3-month follow-up, patients reported visual analogue leg-pain and back-pain scores, physical impairment, and use of analgesics in a diary. Primary outcome was success or failure of treatment, defined by a multidimensional decision rule, which included median outcome variables from the diary. Post-hoc analysis for possible covariate interference with outcome variables was done. Primary outcome data were analysed on an intention-to-treat basis. FINDINGS: 45 patients were assigned radiofrequency lesioning and 38 control treatment. Three patients dropped out before 3 months. After 3 months, seven (16%) of 44 patients treated with radiofrequency lesioning and nine (25%) of 36 in the control group had successful treatment (difference -9.1% [95% CI -33.0 to 12.0], p=0.43). No differences between groups in side-effects were seen. INTERPRETATION: Lumbosacral radiofrequency lesioning of dorsal root ganglia failed to show advantage over control treatment with local anaesthetics. Thus, its use as routine treatment in lumbosacral radicular pain should not be advocated.