Canadian consensus statement: enhanced recovery after surgery in bariatric surgery.

BACKGROUND: In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. METHODS: A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. RESULTS: Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks. CONCLUSIONS: The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.

Symptomatic spinal arachnoid cysts: report of two cases with review of the literature.

STUDY DESIGN: Two unusual cases of intradural extramedullary noncommunicating arachnoid cysts are presented, with a review of literature. OBJECTIVE: To assess surgical excision results in the reversal of symptoms and neurologic deficits. SUMMARY OF BACKGROUND DATA: Most patients harboring arachnoid cysts are asymptomatic. Noncommunicating intradural extramedullary arachnoid cysts are more rare than communicating intradural extramedullary cysts. Noncommunicating intradural extramedullary arachnoid cysts are a very rare cause of spinal cord compression. Rarely, these cysts can present with bizarre symptoms, such as angina. MATERIALS AND METHODS: The first case, a 75-year-old woman, presented with progressive paraparesis. The second case, a 40-year-old man, presented with signs and symptoms of angina, with mild spasticity in the lower limbs. In both cases, magnetic resonance imaging revealed compression of the spinal cord as the etiology of presentation. The first patient is the second oldest patient in the literature with an idiopathic spinal arachnoid cyst. The second case has an unusual presentation that has not previously been reported in the literature. RESULTS: Both cases underwent surgical excision of the arachnoid cyst, with resolution of symptoms and reversal of neurologic deficit. CONCLUSIONS: Our experience indicates that complete recovery from an arachnoid cyst is possible after surgical excision, even when symptoms are present for a long duration, even in the elderly.

Treatment of chronic pain with spinal cord stimulation versus alternative therapies: cost-effectiveness analysis.

OBJECTIVE: There is limited available research measuring the cost-effectiveness of spinal cord stimulation (SCS), compared with best medical treatment/conventional pain therapy (CPT). The purpose of this study was to tabulate the actual costs (in Canadian dollars) for a consecutive series of patients treated with SCS in a constant health care delivery environment and to compare the costs with those for a control group treated in the same controlled environment. METHODS: We present a consecutive series of 104 patients with failed back syndrome. Within this group, 60 patients underwent SCS electrode implantation, whereas 44 patients were designated as control subjects. We monitored these patients for a 5-year period and tabulated the actual costs incurred in diagnostic imaging, professional fees paid to physicians, implantation (including the costs for hardware), nursing visits for maintenance of the stimulators, physiotherapy, chiropractic treatments, massage therapy, and hospitalization for treatment of breakthrough pain. From these data, the cumulative costs for each group were calculated for a 5-year period. An analysis of Oswestry questionnaire results was also performed, to evaluate the effects of treatment on the quality of life. RESULTS: The actual mean cumulative cost for SCS therapy for a 5-year period was $29,123/patient, compared with $38,029 for CPT. The cost of treatment for the SCS group was greater than that for the CPT group in the first 2.5 years. The costs of treating patients with SCS became less than those for CPT after that period and remained so during the rest of the follow-up period. In addition, 15% of SCS-treated patients were able to return to employment, because of superior pain control and lower drug intake. No patients in the control group were able to return to employment of any kind. CONCLUSION: SCS is cost-effective in the long term, despite the initial high costs of the implantable devices.