The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery.

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Endothelial function in obesity and effects of bariatric and metabolic surgery.

INTRODUCTION: Due to the lifestyle changes and the on-going urbanization waves there is obesity pandemic. The visceral fatty tissue of patients with obesity, in comparison with subcutaneous fat, has more gene expression related to inflammation, oxidative stress, cytokine production, and angiogenesis. The abovementioned leads to a decrease in arteriolar function and also an impaired endothelial vasodilatation and eventually endothelial dysfunction. AREAS COVERED: This review aims to provide an overview of the pathophysiology of obesity and endothelial dysfunction and the effects after bariatric and metabolic surgery and the consequences of surgery for the endothelial function. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date of each database until February 2020) regarding endothelial function, obesity, and effects of bariatric and metabolic surgery. EXPERT OPINION: Within cardiovascular research, the endothelium and its function have a prominent role and it is the responsibility of the researchers to unravel the pathophysiological mechanisms and potential new targets for treatment of cardiovascular diseases.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology.

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure.

BACKGROUND: In 2015 our hospital implemented the ERABS protocol. From that moment also morbidly obese patients with end-stage renal disease (ESRD) were enrolled. The objective of this study was to evaluate the potential benefits and safety of the ERABS protocol for ESRD morbidly obese patients compared with patients who are morbidly obese patients undergoing bariatric surgery. METHODS: A retrospective review of a prospectively collected database was conducted for ESRD patients who underwent bariatric surgery according to the ERABS protocol. The primary endpoint was the length of hospital stay in days. Secondary endpoints were the number of re-admissions, re-operations, length of renal replacement therapy, and complications during admission and within 30 days after surgery. Propensity score matching was used to compare groups. RESULTS: From 2015 onward 1199 non-ESRD patients and 21 with ESRD were operated. Propensity score matching resulted in two groups of 19 patients. In terms of comorbidities, both groups presented typical components of metabolic syndrome. In the ESRD group, one patient had serious complications (rated as Clavien-Dindo IIIb and IVb) at the first postoperative day after OAGB. The overall complication rate was comparable and not significantly different compared with the non-ESRD group. CONCLUSION: Our study shows that ERAS in this population has overall minimal adverse events and lack of any ERAS-related complications.

The RAQET Study: the Effect of Eating a Popsicle Directly After Bariatric Surgery on the Quality of Patient Recovery; a Randomised Controlled Trial.

Quality of recovery could be influenced positively if there is less postoperative sore throat (POST). Eating a popsicle might attenuate this sore throat. Especially for bariatric surgery, early recovery is important. Adding popsicles to the postoperative protocol could be beneficial. Our hypothesis is that offering a popsicle in the recovery room to patients after bariatric surgery will decrease POST and will increase quality of postoperative recovery. Patients undergoing elective bariatric surgery, between the 23 February 2015 and 3 April, were randomised to either the popsicle group or control group. Primary endpoint was the incidence of POST and secondly if a reduction in POST influences quality of recovery at the first day postoperative measured with the Bariatric Quality Of Recovery (BQoR) questionnaire. One hundred and thirty-three patients were assessed for eligibility. For the final analysis, 44 patients in the intervention and 65 in the control group were available. Eating a popsicle after bariatric surgery had no significant effect on the incidence of POST. Significant effects (in favour of the popsicle group) were seen in muscle pain score (p = 0.047) and sore mouth score (p = 0.012). Popsicle intragroup analysis revealed that eating the whole popsicle (compared to partially eating the popsicle) has positive effects on nausea (p = 0.059), feeling cold (p = 0.008), and mean total comfort score (p = 0.011). Of the patients who became nauseous and/or had to vomit because of the popsicle, n = 4 had more severe pain (p = 0.04) and the mean pain score was higher (p = 0.09). The present study demonstrates that offering a popsicle early during recovery after bariatric surgery is feasible without adverse effects, although eating popsicle did not reduce postoperative sore throat. There are possible beneficial effects, such as reduced muscle pains and less sore mouth, that may enhance the quality of recovery. More research is necessary to further substantiate the effect of eating popsicles on the quality of recovery in this patient population. TRIAL REGISTRATION: Registration number: NTR4943 (http://www.trialregister.nl).

Use of an intraoperative checklist to decrease the incidence of re-exploration for postoperative bleeding after cardiac surgery.

OBJECTIVES: We have implemented an intraoperative checklist aiming to reduce the incidence of re-exploration for bleeding after cardiac surgery. The present report addresses the results of adopting such a checklist regarding the incidence of postoperative bleeding. METHODS: The checklist was implemented by presenting it in several staff meetings of the Catharina Heart Center. Copies of the checklist were presented in every operating room. Data were collected by the Catharina Heart Center, aligned with the 'Meetbaar Beter' data manual and validated by 'Meetbaar Beter' through their data quality system. The incidence of re-exploration for bleeding was analysed in a variable life-adjusted display curve. The patient population operated after the implementation of the checklist was compared with a recent historical population before its implementation. RESULTS: From January 2013 through April 2016, 4817 cardiac surgical procedures were performed in our institution. Before May 2015, 3210 procedures were performed (Group 1), complicated by 112 re-exploration for bleeding (3.5%). The 'reoperation for bleeding checklist' was implemented on 1 May 2015. After this date, the number of re-explorations for bleeding decreased to 29 (1.8%) of the 1607 cardiac surgical procedures (Group 2) (P < 0.05). CONCLUSIONS: An intraoperative checklist is feasible to implement, low cost, quick and simple to measure with a significant reduction in the incidence of re-exploration for bleeding. This report shows an example of the positive effects of transparency in publishing outcomes' data in cardiac surgery.

Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol.

BACKGROUND: With the increasing prevalence of morbid obesity and healthcare costs in general, interest is shown in safe, efficient, and cost-effective bariatric care. This study describes an Enhanced Recovery After Bariatric Surgery (ERABS) protocol and the results of implementing such protocol on procedural times, length of stay in hospital (LOS), and the number of complications, such as readmissions and reoperations. METHODS: Results of implementing an ERABS protocol were analyzed by comparing a cohort treated according to the ERABS protocol (2012-2014) with a cohort treated before implementing ERABS (2010-2012). Differences between both cohorts were analyzed using independent t tests and chi-squared tests. RESULTS: A total of 1.967 patients (mean age 43.3 years, 80% female) underwent a primary bariatric procedure between 2010 and 2014, of which 1.313 procedures were performed after implementation of ERABS. A significant decrease of procedural times and a significantly decreased LOS, from 3.2 to 2.0 nights (p < 0.001), were seen after implementation of ERABS. Significantly more complications were seen post-ERABS (16.1 vs. 20.7%, p = 0.013), although no significant differences were seen in the number of major complications. CONCLUSION: Implementation of ERABS can result in shorter procedural times and a decreased LOS, which may lead to more efficient and cost-effective bariatric care. The increase in complications was possibly due to better registration of complications. The main goal of an ERABS protocol is efficient, safe, and evidence-based bariatric care, which can be achieved by standardization of the total process.

STOP-Bang and the effect on patient outcome and length of hospital stay when patients are not using continuous positive airway pressure.

BACKGROUND: In patients undergoing surgical interventions under general anesthesia, obstructive sleep apnea syndrome (OSA) can cause serious perioperative cardiovascular or respiratory complications leading to fatal consequences, even sudden death. In this study we test the hypothesis that morbidly obese patients diagnosed by a polysomnography test and using continuous positive airway pressure (CPAP) therapy have fewer and less severe perioperative complications and a shorter hospital stay than patients who have a medical history that meets at least three STOP-Bang criteria and are not using CPAP therapy. METHODS: Postoperative hospital stay and pulmonary complications were analyzed in three groups of morbidly obese patients undergoing bariatric surgery (Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy) between January 2009 and November 2013 (n = 693). Group A comprised 99 patients who were preoperatively diagnosed with OSA based on polysomnography results. These patients used CPAP therapy before and after surgery. Group B consisted of 182 patients who met at least three STOP-Bang criteria but who were not diagnosed with OSA based on polysomnography results. These patients did not use CPAP. Group C, the reference group, comprised 412 patients who scored one to two items on the STOP-Bang. RESULTS: During the perioperative period, Group B patients had a significantly (p < 0.001) higher cumulative rate of pulmonary complications, worse oxygen saturation, respiratory rates, and increased length of stay in hospital. There was also two cases of sudden death in this group. CONCLUSION: Based on these results, we conclude that patients meeting at least three STOP-BANG criteria have higher postoperative complications and an increased length of hospital stay than patients using CPAP.

Improving the efficiency of the cardiac catheterization laboratories through understanding the stochastic behavior of the scheduled procedures.

BACKGROUND: In this study, we sought to analyze the stochastic behavior of Catherization Laboratories (Cath Labs) procedures in our institution. Statistical models may help to improve estimated case durations to support management in the cost-effective use of expensive surgical resources. METHODS: We retrospectively analyzed all the procedures performed in the Cath Labs in 2012. The duration of procedures is strictly positive (larger than zero) and has mostly a large minimum duration. Because of the strictly positive character of the Cath Lab procedures, a fit of a lognormal model may be desirable. Having a minimum duration requires an estimate of the threshold (shift) parameter of the lognormal model. Therefore, the 3-parameter lognormal model is interesting. To avoid heterogeneous groups of observations, we tested every group-cardiologist-procedure combination for the normal, 2- and 3-parameter lognormal distribution. RESULTS: The total number of elective and emergency procedures performed was 6,393 (8,186 h). The final analysis included 6,135 procedures (7,779 h). Electrophysiology (intervention) procedures fit the 3-parameter lognormal model 86.1% (80.1%). Using Friedman test statistics, we conclude that the 3-parameter lognormal model is superior to the 2-parameter lognormal model. Furthermore, the 2-parameter lognormal is superior to the normal model. CONCLUSIONS: Cath Lab procedures are well-modelled by lognormal models. This information helps to improve and to refine Cath Lab schedules and hence their efficient use.

Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.

BACKGROUND: Bariatric surgery durations vary considerably because of differences in surgical procedures and patient factors. We studied the effects on patient outcomes, teamwork and safety climate, and procedure durations resulting from working with operating room (OR) teams that remain fixed for the day instead of OR teams that vary during the day. METHODS: Data were collected in 2 general teaching hospitals, consisting of patientrelated demographic and intraoperative data and of staffrelated survey data on team work and safety climate. The procedure durations of fixed and conventional OR teams were analyzed by comparison of means tests and by regression methods to control for the effects of surgeon, surgical experience, and procedure type. RESULTS: For both hospitals, we obtained the following 4 results for working on bariatric procedures with OR teams that remained fixed for the day. First, patient outcomes did not worsen. Second, teamwork and safety climate (both measured on a 5-point scale) improved significantly, for teamwork + 0.86 (95% confidence interval [CI], 0.54 to 1.18) and for safety climate + 0.75 (95% CI, 0.40 to 1.11). Third, the procedures were performed significantly faster, as both the mean and the SD of procedure durations decreased. After correcting for learning effects, the average reduction of durations was 10.8% (99% CI, 5.0% to 15.3%, or 4 to 13 minutes). This gain was mainly realized for surgical time (12%; 99% CI, 5% to 18%, or 3 to 11 minutes). The effect on peripheral time, defined as procedure time minus surgical time, is not significant (3%; 99% CI, -6% to 12%, or -1 to 3 minutes). Fourth, additional gains were obtained by performing the same type of procedure multiple times within the same day (5% per every next procedure of the same type; 99% CI, 3% to 7%, or 3 to 6 minutes). CONCLUSIONS: Working with fixed teams in bariatric surgery reduced procedure durations and improved teamwork and safety climate, without adverse effects on patient outcomes.

Fast-track practice in cardiac surgery: results and predictors of outcome.

OBJECTIVES: Various studies have shown different parameters as independent risk factors in predicting the success of fast-track postoperative management in cardiac surgery. In the present study, we evaluated our 7-year experience with the fast-track protocol and investigated the preoperative predictors of successful outcome. METHODS: Between 2004 and 2010, 5367 consecutive patients undergoing cardiac surgery were preoperatively selected for postoperative admission in the postanaesthesia care unit (PACU) and were included in this study. These patients were then transferred to the ordinary ward on the same day of the operation. The primary end-point of the study was the success of the PACU protocol, defined as discharge to the ward on the same day, no further admission to the intensive care unit and no operative mortality. Logistic regression analysis was performed to detect the independent risk factors for failure of the PACU pathway. RESULTS: Of 11,895 patients undergoing cardiac surgery, 5367 (45.2%) were postoperatively admitted to the PACU. The protocol was successful in 4510 patients (84.0%). Using the multivariate logistic regression analysis, older age and left ventricular dysfunction were found to be independent risk factors for failure of the PACU protocol [odds ratio of 0.98/year (0.97-0.98) and 0.31 (0.14-0.70), respectively]. CONCLUSIONS: Our fast-track management, called the PACU protocol, is efficient and safe for the postoperative management of selected patients undergoing cardiac surgery. Age and left ventricular dysfunction are significant preoperative predictors of failure of this protocol.

Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time.

HYPOTHESIS: If variation in procedure times could be controlled or better predicted, the cost of surgeries could be reduced through improved scheduling of surgical resources. This study on the impact of similar consecutive cases on the turnover, surgical, and procedure times tests the perception that repeating the same manual tasks reduces the duration of these tasks. We hypothesize that when a fixed team works on similar consecutive cases the result will be shorter turnover and procedure duration as well as less variation as compared with the situation without a fixed team. DESIGN: Case-control study. SETTING: St Franciscus Hospital, a large general teaching hospital in Rotterdam, the Netherlands. PATIENTS: Two procedures, inguinal hernia repair and laparoscopic cholecystectomy, were selected and divided across a control group and a study group. Patients were randomly assigned to the study or control group. MAIN OUTCOME MEASURES: Preparation time, surgical time, procedure time, and turnover time. RESULTS: For inguinal hernia repair, we found a significantly lower preparation time and 10 minutes less procedure time in the study group, as compared with the control group. Variation in the study group was lower, as compared with the control group. For laparoscopic cholecystectomy, preparation time was significantly lower in the study group, as compared with the control group. For both procedures, there was a significant decrease in turnover time. CONCLUSIONS: Scheduling similar consecutive cases and performing with a fixed team results in lower turnover times and preparation times. The procedure time of the inguinal hernia repair decreased significantly and has practical scheduling implications. For more complex surgery, like laparoscopic cholecystectomy, there is no effect on procedure time.

Modeling procedure and surgical times for current procedural terminology-anesthesia-surgeon combinations and evaluation in terms of case-duration prediction and operating room efficiency: a multicenter study.

BACKGROUND: Gains in operating room (OR) scheduling may be obtained by using accurate statistical models to predict surgical and procedure times. The 3 main contributions of this article are the following: (i) the validation of Strum's results on the statistical distribution of case durations, including surgeon effects, using OR databases of 2 European hospitals, (ii) the use of expert prior expectations to predict durations of rarely observed cases, and (iii) the application of the proposed methods to predict case durations, with an analysis of the resulting increase in OR efficiency. METHODS: We retrospectively reviewed all recorded surgical cases of 2 large European teaching hospitals from 2005 to 2008, involving 85,312 cases and 92,099 h in total. Surgical times tended to be skewed and bounded by some minimally required time. We compared the fit of the normal distribution with that of 2- and 3-parameter lognormal distributions for case durations of a range of Current Procedural Terminology (CPT)-anesthesia combinations, including possible surgeon effects. For cases with very few observations, we investigated whether supplementing the data information with surgeons' prior guesses helps to obtain better duration estimates. Finally, we used best fitting duration distributions to simulate the potential efficiency gains in OR scheduling. RESULTS: The 3-parameter lognormal distribution provides the best results for the case durations of CPT-anesthesia (surgeon) combinations, with an acceptable fit for almost 90% of the CPTs when segmented by the factor surgeon. The fit is best for surgical times and somewhat less for total procedure times. Surgeons' prior guesses are helpful for OR management to improve duration estimates of CPTs with very few (<10) observations. Compared with the standard way of case scheduling using the mean of the 3-parameter lognormal distribution for case scheduling reduces the mean overreserved OR time per case up to 11.9 (11.8-12.0) min (55.6%) and the mean underreserved OR time per case up to 16.7 (16.5-16.8) min (53.1%). When scheduling cases using the 4-parameter lognormal model the mean overutilized OR time is up to 20.0 (19.7-20.3) min per OR per day lower than for the standard method and 11.6 (11.3-12.0) min per OR per day lower as compared with the biased corrected mean. CONCLUSIONS: OR case scheduling can be improved by using the 3-parameter lognormal model with surgeon effects and by using surgeons' prior guesses for rarely observed CPTs. Using the 3-parameter lognormal model for case-duration prediction and scheduling significantly reduces both the prediction error and OR inefficiency.

The effect of the Operating Room Coordinator's risk appreciation on operating room efficiency.

BACKGROUND: The Operating Room Coordinator (ORC) is responsible for filling gaps in every operating room (OR) schedule. We have observed differences among the personalities of the four ORCs with regard to their willingness to agree to assume more risk concerning their daily planning. The hypothesis to be tested is that the relationship between the personality of each of the four ORCs and the risk an ORC is willing to take of cases running late affects OR efficiency. METHODS: In order to judge the personality of an ORC in relation to risk-taking in planning schedules, we applied the Zuckerman-Kuhlman Personality Questionnaire in our study. Seven anesthesiologists were asked to score every ORC on willingness to take risks in planning. To analyze which risk attitude creates more OR efficiency, the daily prognosis of the ORC compared with the actual OR program outcome was registered during a 5-mo period in 2006 and 2007. We analyzed whether, in the opinion of hospital management, the costs of reserving too much OR time balances with the costs of reserving too little OR time, and whether this result is consistent with the assignment of the management tasks of the ORC. RESULTS: Seven anesthesiologists classified the four ORCs into the risk-averse group (n = 2) and the nonrisk-averse group (n = 2). The Zuckerman-Kuhlman Personality Questionnaire results for risk-seeking indicate that there is a difference in risk appreciation among the different ORCs. The main finding in our study is that the nonrisk-averse ORC plans to fill the gaps in more cases in the OR program than the risk-averse ORC does. The number of extra cases performed by the nonrisk-averse ORC as compared to a risk-averse ORC is 188 in 2006 and 174 in 2007. The average end-of-program-time per OR/day for the nonrisk-averse ORC is 34 min (+/-19 min, P = 0.0085) later than for the risk-averse ORC. We find that this hospital on average reserves more OR time for procedures than is actually required. The nonrisk-averse ORC takes more advantage of that extra OR time than the risk-averse ORC does by scheduling extra cases during office hours. The success of the nonrisk-averse ORC can be linked to the fact that there is usually time available due to this over-reserving. CONCLUSIONS: The conclusion of this study is that a nonrisk-averse ORC creates significantly less unused OR capacity without a great chance of running ORs after regular working hours or canceling elective cases scheduled for surgery compared to a risk-averse ORC.