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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 remodelling and mortality. In the past years several high quality multicentre randomised 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. The majority 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 are in need of 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 remodelling. One of the hypothesis 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 summarise the effects of GLP-1 on cardiovascular morbidity, mortality and remodelling 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.

BackgroundMinimally invasive surgery requires surgeons to allocate more attention and efforts than open surgery. A surgeon’s pool of resource is affected by the multiple occurrences of interruptions and distractions in the operating room. Surgical flow disruption has been addressed from a quantitative perspective. However, little is known on its impact on the surgeons’ physiological resources.MethodsThree physiological markers, heat flux (HF), energy expenditure in metabolic equivalent of tasks and galvanic skin response were recorded using body sensor monitoring during the 21 surgical operations. The three markers, respectively, represent: stress, energy mobilization and task engagement. A total of 8 surgeons with different levels of expertise (expert vs. novice) were observed performing 21 surgical procedures categorized as short versus long. Factors of distractions were time-stamped, and triangulated with physiological markers. Two cases illustrate the impact of surgical flow disruptions on the surgeons.ResultsThe results indicate that expert surgeons’ mental schemata are better organized than novices. Additionally, the physiological markers indicate that novice surgeons display a higher HF at the start (tendency p = .059) and at the end of procedures (p = .001) when compared to experts. However, during longer procedures, expert surgeons have higher HF at the start (p = .041) and at the end (p = .026), than at the start and end of a short procedure.ConclusionData collected during this pilot study showed that interruptions and disruptions affect novice and expert surgeons differently. Surgical flow disruption appears to be taxing on the surgeons’ mental, emotional and physiological resources; as a function of the length and nature of the disruptions. Several training curricula have incorporated the use of virtual reality programs to train surgeons to cope with the new technology and equipment. We recommend integrating interruptions and distractions in virtual reality training programs as these impact the surgeons’ pool of resources.

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.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.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.

Summary Introduction Being obese has a significant impact on the quality of life limiting physical condition, life and professional activity, causing lack of acceptance from the environment, and a disturbing self-esteem. The main aim of this study is to identify which factors contribute to changes of self-esteem and satisfaction of female patients' body image perception as well as their correlation during the various stages of bariatric therapy. Methods This prospective observational study included 438 bariatric female patients and a control group that consisted of 127 female subjects with reference body weight and BMI. Parametric data were collected in all the subgroups; anthropometric measurements and subjective assessment of body image were checked depending on the stage of bariatric treatment. Results The body image and self-esteem of bariatric patients is changing according to the stage of bariatric treatment. At the beginning of the bariatric pathway, patients are characterized by a negative body image and low self-esteem. Women undergoing contour lifting surgery got the highest score, even higher than women from the control group. The lowest scores are in the group entering the therapy and 24 h after surgery. A more favorable body image and a higher self-esteem were presented by patients with higher education and a better financial situation. Conclusion For female bariatric patients, the body image and self-esteem scores are higher with the consecutive stages of treatment. A more favorable body image and higher self-esteem is demonstrated with patients having a higher education and a better financial situation.

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.

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.

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). ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12262-016-1560-4) contains supplementary material, which is available to authorized users.

Introduction Computer simulation is used to evaluate use of dedicated operating rooms (ORs) for urgent and emergency (add-on) surgical cases versus the same amount of OR time interspersed throughout the day in many ORs and/or at the end of the day. Simulations are limited because of absence of prior quantitative data on the relative incidence of surgeon, equipment, and anesthesiologist availability as a constraint influencing when cases start. Methods We prospectively obtained a series of 6 weeks ( N =30 days) of add-on cases announced (submitted) in the period 7:30 a.m. through 4:59 p.m. Monday through Friday at an 18 OR Level 1 trauma teaching hospital in The Netherlands. When an urgent or emergency case (add-on) was announced, the OR scheduler evaluated which of the ORs were both clinically suitable for the procedure and either currently open or would be open within 30 min. Results The ratio of mean cases per day with surgeon versus OR availability as a constraint was 96.1% (99% confidence interval 64.6% to 127.8%). The ratio can be considered (in simulation) as equaling 1.0 ( P =0.83, mean 1.02±0.10 [SE], median 1.00, N =30 days). The ratios of mean cases each day with equipment as constraint (e.g., C-arm) versus OR availability as a constraint was negligible (mean 0.03±0.02, median 0.00, P P Conclusions Surgeon and OR availability can be equally (1:1) limiting when cases start. Before individual hospitals apply current papers that are based on ORs being constraints, some hospitals may need also to consider surgeon availability as limiting.

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. 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. 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. Our study shows that ERAS in this population has overall minimal adverse events and lack of any ERAS-related complications.

While the demand for bariatric surgery is increasing, hospital capacity remains limited. The ERABS (Enhanced Recovery After Bariatric Surgery) protocol has been implemented in a number of bariatric centers. We retrospectively compared the operating room logistics and postoperative complications between pre-ERABS and ERABS periods in an academic hospital. The primary endpoint was the length of stay in hospital. The secondary endpoints were turnover times—the time required for preparing the operating room for the next case, induction time (from induction of anesthesia until a patient is ready for surgery), surgical time (duration of surgery), procedure time (duration of stay in the operating room), and the incidence of re-admissions, re-operations and complications during admission and within 30 days after surgery. Of a total of 374 patients, 228 and 146 received surgery following the pre-ERABS and ERABS protocols, respectively. The length of hospital stay was significantly shortened from 3.7 (95 % confidence interval [CI] 3.1–4.7) days to 2.1 (95 % CI 1.6–2.6) days (P

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.

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

Wstep: Rozpoznanie po operacjach pierwotnie niedoszczetnych raka brodawkowatego lub pecherzykowego tarczycy wymaga radykalizacji leczenia operacyjnego i usuniecia calego gruczolu tarczowego. W zmienionych przez tkanke bliznowatą warunkach anatomicznych radykalnośc tych zabiegow moze byc niezadowalająca i w konsekwencji wplywac na wyniki tarapii. Celem pracy byla ocena korzyści wynikających z zastosowania recznego gamma nawigatora w zabiegach wtornie calkowitych w przypadkach dobrze zroznicowanych rakow tarczycy. Material i metody: W pracy przedstawiono 75 przypadkow chorych z dobrze zroznicowanymi rakami tarczycy, zakwalifikowanych do radykalizacji leczenia operacyjnego. W 43 przypadkach (grupa I) środoperacyjnie zastosowano reczny gamma nawigator (Navigator GPS), 32 chorych reoperowano bez uzycia wyzej wymienionego urządzenia (grupa II). W celu oceny radykalności wtornie calkowitego zabiegu w obu grupach chorych badano pooperacyjnie stezenie tyreoglobuliny (Tg) oraz oceniano wyniki badania scyntygrafii calego ciala (I131) — jodochwytnośc. W obu grupach porownano rowniez wystąpienie powiklan po zabiegach wtornie radykalnych. Wyniki: Podczas radykalizacji we wszystkich przypadkach wykonano calkowite wyciecie gruczolu tarczowego wraz z wycieciem wezlow chlonnych przedzialu centralnego. Pooperacyjne średnie stezenie Tg oraz jodochwytnośc byly nizsze w grupie I w porownaniu z grupą II: (3,32 ± 2,09 v. 4,58 ± 2,5 ng/ml, [p = 0,021] jodochwytnośc: 6,9 ± 3,38 (grupa I) v. 7,31 ± 2,29 ng/ml (grupa II) [p = 0,187]). Uzycie nawigatora nie mialo wplywu na czestośc wystąpienia pooperacyjnych powiklan w obu grupach chorych (p = 0,109). Wnioski: Ś rodoperacyjne zastosowanie nawigatora moze byc pomocne w osiągnieciu lepszej radykalności pierwotnie nieradykalnych operacji, chociaz obserwowane wyniki pozwalają na stwierdzenie, ze zabieg ten wykonywany przez doświadczonego operatora pozwala na osiągniecie porownywalnej radykalności niezaleznie o d środoperacyjnej detekcji izotopowej. (Endokrynol Pol 2013; 64 (5): 335–339)

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

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. Copyright

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.

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.

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.

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 (

Drs. Fixler and Wright1 should be commended for demonstrating that operating room (OR) performance indicator definitions vary in literature and among children’s hospitals. Unfortunately, I do not agree with their conclusion that the most logical course would be for professional associations to agree upon and develop common metrics and definitions. Their conclusion is based on a limited review of papers that are not always relevant. First, the Procedural Times Glossary has been the leading source for OR definitions since 1997.2 Papers describing operational research in ORs use this glossary.3 A bibliography of papers concerning operational research within the OR can be found online (http://www.franklindexter.net/bibliography_TOC.htm). Based on this evidence, I conclude that there are clear definitions for monitoring OR performance indicators. An additional conclusion is that hospitals continue to use their own definitions. This needs to be solved by sending surgeons, anesthesiologists and managers of ORs to courses where they can learn which indicators to use and how to use them. Fixler and Wright call for us to use the OR resources in both an efficient and effective way. Here they make a mistake. Indeed, monitoring the operational performance of the OR may contribute to the use of OR resources in an efficient way. However, the call to use OR resources in an effective way is a faulty statement. According to the Institute of Medicine’s Committee on Quality Health Care in America, effective care “is based on providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding under-use and overuse, respectively).”4 Here the patient clinical parameters are of interest and not, for example, the utilization rate of the OR. In conclusion, performing an accurate search in PubMed will show that the actual problem of agreed-upon definitions in literature, as described by the authors, does not exist.

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.

Accurate prediction of medical operation times is of crucial importance for cost efficient operation room planning in hospitals. This paper investigates the possible dependence of procedure times on surgeon factors like age, experience, gender, and team composition. The effect of these factors is estimated for over 30 different types of medical operations in two hospitals, by means of ANOVA models for logarithmic case durations. The estimation data set contains about 30,000 observations from 2005 till 2008. The relevance of surgeon factors depends on the type of operation. The factors found most often to be significant are team composition, experience, and daytime. Contrary to widespread opinions among surgeons, gender has nearly never a significant effect. By incorporating surgeon factors, the accuracy of out-of-sample prediction of case durations of about 1,250 surgical operations in 2009 is improved by up to more than 15 percent as compared to current planning procedures.