Prospective analysis of convalescence and early pain after uncomplicated laparoscopic fundoplication

Preoperative Anxiolysis and Treatment Expectation (PATE Trial): open-label placebo treatment to reduce preoperative anxiety in female patients undergoing gynecological laparoscopic surgery - study protocol for a bicentric, prospective, randomized-controlled trial

One of the most common concerns of patients undergoing surgery is preoperative anxiety, with a prevalence of up to 48%. The effects of preoperative anxiety continue beyond the preoperative period and are associated with more severe postoperative pain and poorer treatment outcomes. Treatment options for preoperative anxiety are often limited as sedatives cause side effects and their efficacy remains controversial. Placebo research has shown that optimization of positive treatment expectations, as can be achieved through placebo administration and education, has clinically relevant effects on preoperative anxiety, pain and treatment outcomes. As the administration of masked placebos raises ethical questions, clinical studies have increasingly focused on the use of open, non-deceptive placebo administration (open-label placebo, OLP). The use of OLPs to reduce preoperative anxiety and modify clinically relevant postoperative outcomes has not yet been investigated. This bicentric, prospective, randomized-controlled clinical trial (PATE Trial; German Registry for Clinical Studies DRKS00033221), an associated project of the Collaborative Research Center (CRC) 289 "Treatment Expectation", aims to alleviate preoperative anxiety by optimizing positive treatment expectations facilitated by OLP. Furthermore, this study examines a potential enhancement of these effects through aspects of observational learning, operationalized by a positive expectation-enhancing video. In addition, patient's perspective on the self-efficacy and appropriateness of OLPs prior to surgery will be assessed. To achieve these objectives, female patients will be randomized into three groups before undergoing gynecological laparoscopic surgery. One group receives the OLP with a positive rationale conveyed by a study physician. A second group receives the same intervention, OLP administration and rationale provided by a physician, and additionally watches a video on OLP presenting a satisfied patient. A third group receives standard treatment as usual (TAU). Outcome measures will be effects on preoperative anxiety and postoperative experience, particularly visceral and somatic postoperative pain. As the non-deceptive administration of placebos; when indicated; may yield positive outcomes without side effects, and as current treatment of preoperative anxiety is limited, evidence from clinical placebo research has the potential to improve outcomes and patient experience in the surgical setting.

Oxycodone versus morphine for analgesia after laparoscopic endometriosis resection

Background

The objective of this study was to compare the analgesic potency of oxycodone versus morphine after laparoscopic deep infiltrating endometriosis resection.

Methods

Fifty patients undergoing laparoscopic deep infiltrating endometriosis resection were randomized to receive oxycodone or morphine intravenous-PCA after surgery. The primary outcome was opioid consumption during the 24 h after surgery. Secondary outcomes included time to first request for analgesia, the number of bolus, pain, sedation, nausea, vomiting, respiratory depression, and bradycardia. The prominent pain that caused patients to press the analgesic device was also recorded.

Results

Oxycodone consumption (14.42 ± 2.83) was less than morphine consumption (20.14 ± 3.83). Compared with the morphine group, the total number of bolus (78 vs 123) was less and the average time to first request for analgesia (97.27 ± 59.79 vs 142.17 ± 51) was longer in the oxycodone group. The incidence of nausea was higher in the morphine group than in the oxycodone group at 0–2 h (45.45% vs 17.19%), 2–4 h (50% vs 17.19%),12–24 h (40.91% vs 13.04%) and 0–24 h (39.17% vs 19.13%). The overall incidence of vomiting was higher in the morphine group (27.27% vs 13.92%). There was no difference in visual analogue scale score, the incidence of respiratory depression, and bradycardia between groups. Of the three types of pain that prompted patients to request analgesia, the incidence of visceral pain was highest (59.9%, P < 0.01).

Conclusion

Oxycodone was more potent than morphine for analgesia after laparoscopic endometriosis resection, and oxycodone has fewer side effects than morphine.

Name of the registry: Chinese Clinical Trial Registry

Trial registration number: ChiCTR1900021870

URL of trial registry record:http://www.chictr.org.cn/edit.aspx?pid=35799&htm=4

Date of registration: 2019/3/13 0:00:00

Short-term parent reported recovery following open and laparoscopic fundoplication

BACKGROUND

It is assumed that children recover faster after laparoscopic (LF) than after open fundoplication (OF). As this has not been confirmed in any randomized study (RCT), we have in a subsection of a larger RCT compared parent reported recovery of children after LF and OF.

METHODS

Postoperative symptoms, use of analgesics, overall well-being, and time to return to school/day-care were recorded in a subsection of children enrolled in a RCT comparing LF and OF. Ethical approval and parental consent were obtained.

RESULTS

Fifty-five children (LF: n = 27, OF: n = 28) of the 88 enrolled in the RCT, were included in the short term follow up on parent reported recovery. Caregivers were interviewed median 28 days [interquartile range (IQR) 22-36] postoperatively. There was no significant difference regarding improvement in overall well-being (LF: 63%, OF: 68%, p = 0.70), new-onset dysphagia (LF: 30%, OF: 18%, p = 0.08), use of analgesics (LF: 15%, OF: 14%, p = 1.00), or time to return to school/day-care (LF: median 7 days [IQR 5-14] vs. OF: 12 days [IQR 7-15], p = 0.35).

CONCLUSION

We could not demonstrate faster recovery after LF than after OF. Most children had returned to school/day-care after 2 weeks and had improved overall well-being 1 month after surgery.

TYPE OF STUDY

Randomized controlled trial.

LEVEL OF EVIDENCE

Level II.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

The Effect of Perioperative E-Health Interventions on the Postoperative Course: A Systematic Review of Randomised and Non-Randomised Controlled Trials

BACKGROUND

E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course.

METHODS

We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system.

FINDINGS

A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13), 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9) or orthopedic surgery (n = 7). All studies focused on replacing (n = 11) or complementing (n = 15) perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7%) reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6%) reported at least an equal (n = 8) or positive (n = 17) effect of the e-health intervention compared to usual care. In two studies (7.4%) a positive effect on any outcome was found in favour of the control group.

CONCLUSION

Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution.

Pain Characteristics after Total Laparoscopic Hysterectomy

Background. Total laparoscopic hysterectomy (TLH) causes various types of postoperative pain, and the pain pattern has not been evaluated in detail to date. This prospective observational study investigated the types of postoperative pain, intensity in the course of time, and pain characteristics during the first postoperative 72 hr after TLH. Methods. Sixty four female patients undergoing TLH were enrolled, which finally 50 patients were included for the data analyses. The locations of pain included overall pain, abdominal visceral and incisional pains, shoulder pain, and perineal pain. Assessments were made at rest and in motion, and pain level was scored with the use of the 100 mm visual analog scale. The pain was assessed at baseline, and at postoperative 30 min, 1 hr, 3 hr, 6 hr, 24 hr, 48 hr, and 72 hr. Results. Overall, visceral, and incisional pains were most intense on the day of operation and then decreased following surgery. In contrast, shoulder pain gradually increased, peaking at postoperative 24 hr. Shoulder pain developed in 90% of all patients (44/50). It was not more aggravated in motion than at rest, in comparison with other pains, and right shoulder pain was more severe than left shoulder pain (p=0.006). In addition, the preoperative exercise habit of patients increased the threshold of shoulder pain. Most patients (46/50) had perineal pain, which was more severe than abdominal pain in approximately 30% of patients (17/50). Conclusion. Pain after TLH showed considerably different duration, severity, and characteristics, compared with other laparoscopic procedures. Shoulder pain was most intense at postoperative 24 hr, and the intensity was associated with the prior exercise habit of patients and the high level of analgesic request.

Patient-specific Immune States before Surgery Are Strong Correlates of Surgical Recovery

BACKGROUND

Recovery after surgery is highly variable. Risk-stratifying patients based on their predicted recovery profile will afford individualized perioperative management strategies. Recently, application of mass cytometry in patients undergoing hip arthroplasty revealed strong immune correlates of surgical recovery in blood samples collected shortly after surgery. However, the ability to interrogate a patient's immune state before surgery and predict recovery is highly desirable in perioperative medicine.

METHODS

To evaluate a patient's presurgical immune state, cell-type-specific intracellular signaling responses to ex vivo ligands (lipopolysaccharide, interleukin [IL]-6, IL-10, and IL-2/granulocyte macrophage colony-stimulating factor) were quantified by mass cytometry in presurgical blood samples. Selected ligands modulate signaling processes perturbed by surgery. Twenty-three cell surface and 11 intracellular markers were used for the phenotypic and functional characterization of major immune cell subsets. Evoked immune responses were regressed against patient-centered outcomes, contributing to protracted recovery including functional impairment, postoperative pain, and fatigue.

RESULTS

Evoked signaling responses varied significantly and defined patient-specific presurgical immune states. Eighteen signaling responses correlated significantly with surgical recovery parameters (|R| = 0.37 to 0.70; false discovery rate < 0.01). Signaling responses downstream of the toll-like receptor 4 in cluster of differentiation (CD) 14 monocytes were particularly strong correlates, accounting for 50% of observed variance. Immune correlates identified in presurgical blood samples mirrored correlates identified in postsurgical blood samples.

CONCLUSIONS

Convergent findings in pre- and postsurgical analyses provide validation of reported immune correlates and suggest a critical role of the toll-like receptor 4 signaling pathway in monocytes for the clinical recovery process. The comprehensive assessment of patients' preoperative immune state is promising for predicting important recovery parameters and may lead to clinical tests using standard flow cytometry.

Clinical recovery from surgery correlates with single-cell immune signatures

Delayed recovery from surgery causes personal suffering and substantial societal and economic costs. Whether immune mechanisms determine recovery after surgical trauma remains ill-defined. Single-cell mass cytometry was applied to serial whole-blood samples from 32 patients undergoing hip replacement to comprehensively characterize the phenotypic and functional immune response to surgical trauma. The simultaneous analysis of 14,000 phosphorylation events in precisely phenotyped immune cell subsets revealed uniform signaling responses among patients, demarcating a surgical immune signature. When regressed against clinical parameters of surgical recovery, including functional impairment and pain, strong correlations were found with STAT3 (signal transducer and activator of transcription), CREB (adenosine 3',5'-monophosphate response element-binding protein), and NF-κB (nuclear factor κB) signaling responses in subsets of CD14(+) monocytes (R = 0.7 to 0.8, false discovery rate <0.01). These sentinel results demonstrate the capacity of mass cytometry to survey the human immune system in a relevant clinical context. The mechanistically derived immune correlates point to diagnostic signatures, and potential therapeutic targets, that could postoperatively improve patient recovery.

Pain after laparoscopic antireflux surgery

INTRODUCTION

The benefits of antireflux surgery are well established. Laparoscopic techniques have been shown to be generally safe and effective. The aim of this paper was to review the subject of pain following laparoscopic antireflux surgery.

METHODS

A systematic review of the literature was conducted using the PubMed database to identify all studies reporting pain after laparoscopic antireflux surgery. Publications were included for the main analysis if they contained at least 30 patients. Operations in children, Collis gastroplasty procedures, endoluminal fundoplication and surgery for paraoesophageal hernias were excluded. The frequency of postoperative pain was calculated and the causes/management were reviewed. An algorithm for the investigation of patients with pain following laparoscopic fundoplication was constructed.

RESULTS

A total of 17 studies were included in the main analysis. Abdominal pain and chest pain following laparoscopic fundoplication were reported in 24.0% and 19.5% of patients respectively. Pain was mild or moderate in the majority and severe in 4%. Frequency of pain was not associated with operation type. The authors include their experience in managing patients with persistent, severe epigastric pain following laparoscopic anterior fundoplication.

CONCLUSIONS

Pain following laparoscopic antireflux surgery occurs in over 20% of patients. Some have an obvious complication or a diagnosis made through routine investigation. Most have mild to moderate pain with minimal effect on quality of life. In a smaller proportion of patients, pain is severe, persistent and can be disabling. In this group, diagnosis is more difficult but systematic investigation can be rewarding, and can enable appropriate and successful treatment.

Early pain after laparoscopic inguinal hernia repair. A qualitative systematic review

BACKGROUND

Early post-operative pain after laparoscopic groin hernia repair may, as in other laparoscopic operations, have its own individual pain pattern and patient-related predictors of early pain. The purpose of this review was to characterise pain within the first post-operative week after transabdominal pre-peritoneal repair (TAPP) and total extraperitoneal repair (TEP), and to identify patient-related predictors of early pain.

METHODS

A qualitative systematic review was conducted. Pubmed, Embase, CINAHL, and the Cochrane database were searched for studies on early pain (first week) after TAPP or TEP.

RESULTS

We included 71 eligible studies with 14,023 patients. Post-operative pain is most severe on day 0 and mainly on a level of 13-58 mm on a visual analogue scale and decreases to low levels on day 3. There seems to be no difference in pain intensity and duration when TEP and TAPP are compared. Deep abdominal pain (i.e. groin pain/visceral pain) dominates over superficial pain (i.e. somatic pain) and shoulder pain (i.e. referred pain) after TAPP. Predictors of early pain are young age and pre-operative high pain response to experimental heat stimulation. Furthermore, evidence supported early pain intensity as a predictive risk factor of chronic pain after laparoscopic groin hernia repair.

CONCLUSION

Early pain within the first week after TAPP and TEP is most severe on the first post-operative day, and the pain pattern is dominated by deep abdominal pain. Early post-operative pain is most intense in younger patients and can be predicted by pre-operative high pain response to experimental heat stimulation.

Randomized double-blind placebo-controlled study of the efficacy of continuous infusion of local anesthetic to the diaphragm closure following laparoscopic hiatal hernia repair

BACKGROUND

Laparoscopic repair of hiatal hernia can result in significant postoperative pain requiring use of narcotics and patient dissatisfaction. A catheter-based delivery method that has demonstrated effectiveness and safety in other laparoscopic and open procedures (ON-Q, I Flow Corporation) was used to deliver pain medicine. This randomized double-blind, placebo-controlled study evaluated the efficacy of continuous infusion of local anesthetic to the diaphragm closure post laparoscopic hiatal hernia repair.

METHODS

After obtaining Institutional Review Board approval, qualifying patients undergoing laparoscopic repair of hiatal hernia voluntarily consented to the study protocol. Standard techniques for routine closure of hiatal hernia repair were used. The ON-Q pain pump catheter was placed adjacent to the sutures used to repair the hiatal hernia, so that it rested between the diaphragm and the collagen patch used to reinforce the hernia repair. The pump infused either bupivacaine 0.5% or NaCl 0.9% at 2 cc/h for 5 days postoperatively. Patients kept a daily diary for pain scores, number of narcotic pain pills taken, and number of nausea pills taken.

RESULTS

Of the 46 patients enrolled in the study, seven were dropped for adverse events or noncompliance; 20 were given placebo (0.9% NaCl) and 19 were given 0.5% bupivacaine.

CONCLUSION

This randomized double-blind, placebo-controlled trial showed no advantage in using the ON-Q pain pump in terms of providing measurable reduction of pain or concomitant narcotic or nausea medication use. Further studies are indicated to determine alternatives for reducing postoperative pain after laparoscopic hiatal hernia repair.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.

Pain characteristics after laparoscopic inguinal hernia repair

BACKGROUND

Previous studies have shown different pain characteristics in different types of laparoscopic operations, but pain pattern has not been studied in detail after laparoscopic inguinal hernia repair. To optimise preoperative patient information and postoperative analgesic treatment the present study investigated postoperative pain in terms of time course, pain intensity and individual pain components during the first 4 days after transabdominal preperitoneal hernia repair (TAPP).

METHODS

The study was a single-centre prospective trial including 50 consecutive male patients with primary or recurrent inguinal and/or femoral hernia undergoing elective repair. Several pain components (visceral pain, incisional pain and shoulder pain) were studied as well as pain at the three different trocar incisions. Pain was recorded before operation and on a daily basis during the first four postoperative days using a visual analogue and a verbal rating scale. We used 1 × 12 and 2 × 5 mm trocars for TAPP.

RESULTS

A total of 46 patients were available for analyses (age median 58 years, range 27-69 years). Visceral pain dominated significantly compared with incisional pain (P < 0.01), which again dominated over shoulder pain intensity and incidence (P < 0.01). Pain intensity did not significantly differ between different trocar incisions (5 and 12 mm) (P > 0.05). The overall pain intensity (a conglomerate of the different pain components) was most intense 3 h after TAPP and declined to preoperative levels on day 3 (P > 0.5).

CONCLUSION

Pain was most intense 3 h after the operation and declined to low levels within the first 3 days. Visceral pain was by far the dominating pain component compared with incisional and shoulder pain.

Shoulder tip pain after laparoscopic surgery analgesia by collateral meridian acupressure (shiatsu) therapy: a report of 2 cases

OBJECTIVES

This article describes 2 cases of collateral meridian acupressure (shiatsu) therapy (CMAT) for treatment of shoulder tip pain after laparoscopic cholecystectomy (LC). Both cases showed marked pain relief with reduction of skin temperature (1 degrees C) of the affected shoulder after CMAT.

CLINICAL FEATURES

A 32- and a 53-year-old female presented with right shoulder tip pain after LC surgery. The repeated dose of intravenous ketorolac 30 mg and meperidine 50 mg did not improve the pain. Because of persistent pain and episodes of nausea and vomiting after intravenous nonsteroidal anti-inflammatory drugs and opioid medications, patients refused to take more analgesics, and we were consulted for pain management.

INTERVENTION AND OUTCOME

After informed written consent obtained, CMAT was performed using acupoints located on the contralateral (left) kidney meridian to treat affected (right) shoulder pain. Postoperatively, patients' pain intensity was measured using a numeric pain scale. The infrared thermography of shoulder tip was obtained before and after the CMAT. Both patients reported immediate pain relief after the CMAT, with pain scores decreased from 5 to 1 of 10 and 5 to 0 of 10, respectively. Moreover, the local skin temperature of affected shoulders were significantly decreased in both patients after the CMAT. Similarly, the temperature difference between patients' affected and nonpainful shoulders were also significant after the CMAT.

CONCLUSION

The results of these 2 cases suggest that the CMAT may be effective in reducing patients' post-LC shoulder tip pain without medication. An associated reduction of skin temperature of the painful shoulder with CMAT warrants further investigation.

Pain, quality of life and recovery after laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is a well established procedure in the treatment of ventral hernias. It is our clinical experience that patients suffer intense postoperative pain, but this issue and other recovery parameters have not been studied in detail.

METHODS

Thirty-five patients with hernias >3 cm prospectively underwent LVHR using "double-crown" titanium tack mesh fixation. Pre- and postoperative pain was measured on a 0-100-mm visual analogue scale (VAS) and health-related quality of life was measured using the Short Form 36 questionnaire (SF-36). Several other recovery parameters were measured systematically in the 6 months follow-up period.

RESULTS

We observed no recurrences or severe complications in the follow-up period (n = 31 at day 30 and n = 28 after 6 months). The median in-hospital stay was 2 days (range 0-5). Patients reported significantly more pain during activity than at rest at all times (p < 0.05). The median VAS-pain score during activity vs. at rest at discharge was 60 and 31, respectively. The median VAS-pain score during activity on the day of operation (day 0) was 78; it returned to baseline values at day 30 (p = 0.148) and, after 6 months, it was below the preoperative score (p = 0.01). The scores for general well-being and fatigue returned to baseline values at days 3 and 30, respectively, and at 6 months, they had both significantly improved compared with preoperative values (p = 0.005). The SF-36 scores were significantly worse in three domains at day 30 (p < 0.005). After 6 months, the bodily pain score had increased significantly compared with preoperative values (p < 0.005) and all eight scales were comparable to the Danish reference population scores. Patients resumed normal daily activities after a median of 14 days (range 1-38). Smokers and patients with hard physical demands at work took a significantly longer amount of time to resume work compared with non-smokers (30 vs. 9 days, p < 0.005) and patients with light work demands (29 vs. 9 days, p < 0.05), respectively. VAS-pain scores were strongly correlated to general well-being (r = -0.8, p < 0.001), patient satisfaction (r = -0.67, p < 0.001) and quality of life (r = -0.63, p < 0.001). We found no significant correlation between the number of tacks used (median 59) and postoperative pain.

CONCLUSION

LVHR was associated with considerable postoperative pain and fatigue in the first postoperative month, prolonging the time of convalescence and significantly affecting patients' quality of life up to 6 months postoperatively. Mesh fixation with fibrin glue or other non-invasive/degradable products seems promising for reducing pain and it should be investigated in future randomised trials.

Randomized clinical trial and follow-up study of cost-effectiveness of laparoscopic versus conventional Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has essentially replaced its conventional open counterpart (CNF). An economic evaluation of LNF compared with CNF based on prospective data with adequate follow-up is lacking.

METHODS

Data from two consecutive studies (a randomized clinical trial (RCT) of 57 patients undergoing LNF and 46 undergoing CNF that was terminated prematurely, and a follow-up study of 121 consecutive patients with LNF) were combined to determine incremental cost-effectiveness 1 year after surgery.

RESULTS

Mean operating time, reoperation rate and hospital costs of LNF were lower in the second series. The mean overall hospital cost per patient was euro 9126 for LNF and euro 6989 for CNF at 1 year in the initial RCT, and euro 7782 in the second LNF series. The success rate of both LNF and CNF at 1 year was 91 per cent in the RCT, and LNF was successful in 90.1 per cent in the second series. A cost reduction of euro 998 for LNF would cancel out the cost advantage of CNF. Similarly, if the reoperation rate after LNF decreased from 0.05 to below 0.008 and/or if the mean duration of sick leave after LNF was reduced from 67.2 to less than 61.1 days, the procedure would become less expensive than CNF. Complications, reoperation rate and quality of life after both operations were similar.

CONCLUSION

Including reinterventions, the outcome at 1 year after LNF and CNF was similar. In a well organized setting with appropriate expertise, the cost advantage of CNF may be neutralized.