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  • 1.
    Pösö, Tomi
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Kesek, Doris
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Aroch, Roman
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Morbid obesity and optimization of preoperative fluid therapy2013In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 23, no 11, p. 1799-1805Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Preoperative venous return (VR) optimization and adequate blood volume is essential in management of morbidly obese patients (MO) in order to avoid perioperative circulatory instability. In this study, all subjects underwent a preoperative 3-week preparation by rapid-weight-loss-diet (RWL) as part of their treatment program for bariatric surgery.

    METHODS: This is a prospective, observational study of 34 morbidly obese patients consecutively scheduled for bariatric surgery at Sunderby County Hospital, Lulea, Sweden. Preoperative transthoracic echocardiography (TTE) was performed in the awake state before and after intravascular volume challenge (VC) of 6 ml colloids/kg ideal body weight (IBW). Effects of standardized VC were evaluated by TTE. Dynamic and non-dynamic echocardiographic indices for VC were studied. Volume responsiveness and level of VR before and after VC were assessed by TTE. An increase of stroke volume >/=13 % was considered as a volume responder.

    RESULTS: Twenty-nine out of 34 patients were volume responders. After VC, a majority of patients (23/34) were euvolemic, and only 2/34 were hypovolemic. Post-VC hypervolemia was observed in 9/34 of patients.

    CONCLUSIONS: The IBW-based volume challenge regime was found to be suitable for preoperative rehydration of RWL-prepared MO. Most of the patients were volume responders. Preoperative state of VR was not associated with volume responsiveness. IBW estimates and appropriate monitoring avoids potential hyperhydration in MO. For VC assessment, conventional Doppler indices were found to be more suitable compared to tissue Doppler, giving sufficient information on pressure-volume correlation of the left ventricle in morbidly obese.

  • 2.
    Pösö, Tomi
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Kesek, Doris
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Aroch, Roman
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Rapid weight loss is associated with preoperative hypovolemia in morbidly obese patients2013In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 23, no 3, p. 306-313Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In morbidly obese patients (MO), adequate levels of venous return (VR) and left ventricular filling pressures (LVFP) are crucial in order to augment perioperative safety. Rapid weight loss (RWL) preparation with very low calorie diet is commonly used aiming to facilitate bariatric surgery. However, the impact of RWL on VR and LVFP is poorly studied.

    METHODS: In this prospective, controlled, single-center study, we hypothesized that RWL-prepared MO prior to bariatric surgery can be hypovolemic (i.e., low VR) and compared MO to lean controls with conventional overnight fasting. Twenty-eight morbidly obese patients were scheduled consecutively for bariatric surgery and 19 lean individuals (control group, CG) for elective general surgery. Preoperative assessment of VR, LVFP, and biventricular heart function was performed by a transthoracic echocardiography (TTE) protocol to all patients in the awake state. Assessment of VR and LVFP was made by inferior vena cava maximal diameter (IVCmax) and inferior vena cava collapsibility index- (IVCCI) derived right atrial pressure estimations.

    RESULTS: A majority of MO (71.4 %) were hypovolemic vs. 15.8 % of lean controls (p < 0.001, odds ratio = 13.3). IVCmax was shorter in MO than in CG (p < 0.001). IVCCI was higher in MO (62.1 +/- 23 %) vs. controls (42.6 +/- 20.8; p < 0.001). Even left atrium anterior-posterior diameter was shorter in MO compared to CG.

    CONCLUSIONS: Preoperative RWL may induce hypovolemia in morbidly obese patients. Hypovolemia in MO was more common vs. lean controls. TTE is a rapid and feasible tool for assessment of preload even in morbid obesity.

  • 3.
    Pösö, Tomi
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Aroch, Roman
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Kesek, Doris
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Perioperative fluid guidance with transthoracic echocardiography and pulse-contour device in morbidly obese patients2014In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 24, no 12, p. 2117-2125Article in journal (Refereed)
    Abstract [en]

    Background

    In bariatric surgery, non-or mini-invasive modalities for cardiovascular monitoring are addressed to meet individual variability in hydration needs. The aim of the study was to compare conventional monitoring to an individualized goal-directed therapy (IGDT) regarding the need of perioperative fluids and cardiovascular stability. 

    Methods

    Fifty morbidly obese patients were consecutively scheduled for laparoscopic bariatric surgery (ClinicalTrials.gov Identifier: NCT01873183). The intervention group (IG, n=30) was investigated preoperatively with transthoracic echocardiography (TTE) and rehydrated with colloid fluids if a low level of venous return was detected. During surgery, IGDT was continued with a pulse-contour device (FloTrac (TM)). In the control group (CG, n=20), conventional monitoring was conducted. The type and amount of perioperative fluids infused, vasoactive/inotropic drugs administered, and blood pressure levels were registered. 

    Results

    In the IG, 213 +/- 204 mL colloid fluids were administered as preoperative rehydration vs. no preoperative fluids in the CG (p<0.001). During surgery, there was no difference in the fluids administered between the groups. Mean arterial blood pressures were higher in the IG vs. the CG both after induction of anesthesia and during surgery (p=0.001 and p=0.001). 

    Conclusions

    In morbidly obese patients suspected of being hypovolemic, increased cardiovascular stability may be reached by preoperative rehydration. The management of rehydration should be individualized. Additional invasive monitoring does not appear to have any effect on outcomes in obesity surgery.

  • 4.
    Sun, Sun
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Synergus AB, Kevinge Strand 20, 182 57 Stockholm, Sweden; Health Outcomes and Economic Evaluation Research Group, Center for Healthcare Ethics, Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Borisenko, Oleg
    Spelman, Tim
    Ahmed, Ahmed R.
    Patient Characteristics, Procedural and Safety Outcomes of Bariatric Surgery in England: a Retrospective Cohort Study 2006-20122018In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 28, p. 1098-1108Article in journal (Refereed)
    Abstract [en]

    The objective of the study is to analyze procedural and safety outcomes associated with bariatric surgery and describe the characteristics of patients undertaking bariatric procedures in England between April 2006 and March 2012. This is a retrospective cohort study of all adult patients in England diagnosed with obesity and undergoing bariatric surgery as a primary procedure in NHS-funded sites between April 2006 and March 2012 using data sourced from the Hospital Episode Statistics dataset. Length of stay (LOS), 30-day readmission, and post-surgery complication were analyzed as primary outcomes. Socio-demographic background, provider type, procedure volume, and comorbidities were all analyzed as potential explanatory variables. Gastric bypass (GBP, 12,628) was the most utilized procedure, followed by gastric banding (GB, 6872) and sleeve gastrectomy (SG, 3251). The most prevalent comorbidity was type 2 diabetes (23%). Inpatient mortality was low (≀ 0.15%) for all procedure types. LOS and the risks of both post-operative complication and 30-day readmission were significantly lower for GB, relative to those for GBP and SG. Ethnicity, geographical area, surgery type, and volume were all associated with LOS, risk of readmission, and complication. Provider type and deprivation were further associated with LOS while age correlated with readmission only. An increasing comorbidity burden was associated with an increased risk of both readmission and complication. Gastric bypass was the most frequently reported procedure in England across the observation period. While utilization across all procedure types increased between 2007 and 2010, overall uptake of bariatric surgery in England represents only a small proportion of the eligible population. Readmission and complication rates were lower for gastric banding relative to those for either gastric bypass or sleeve gastrectomy. The observed inpatient mortality rate was low across all procedure types.

  • 5.
    Turkmen, Sahruh
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ahangari, Alebtekin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Bäckström, Torbjörn
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Roux-en-Y Gastric Bypass Surgery in Patients with Polycystic Ovary Syndrome and Metabolic Syndrome2016In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 26, no 1, p. 111-118Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: We aimed to evaluate the impact of Roux-en-Y gastric bypass (RYGB) surgery on metabolic syndrome-related variables in obese women with polycystic ovarian syndrome (PCOS).

    METHODS: Thirteen obese women with PCOS (Rotterdam criteria) who met the International Diabetes Federation criteria for metabolic syndrome and who qualified for RYGB were enrolled. Clinical examinations included ovarian ultrasonography and measurement of waist, hip, body mass index and blood pressure. Venous blood samples were taken at the visit before surgery to measure triglyceride, high-density lipoprotein, low-density lipoprotein, fasting glucose, glycated haemoglobin (HbA1c), serum progesterone, allopregnanolone, total testosterone and sex hormone-binding globulin (SHBG) levels. Six months after surgery, patients underwent the same examinations and provided blood samples to analyse the same variables.

    RESULTS: At 6 months after surgery, the metabolic syndrome-related variables improved in all patients, except in six patients with anovulatory menstrual cycles who still satisfied the criteria for metabolic syndrome. The metabolic variables normalised and serum progesterone and allopregnanolone levels increased in seven patients with ovulatory cycles. Testosterone and SHBG normalised in all patients at 6 months after surgery. Serum HDL and diastolic blood pressure did not change after surgery. Correlations were found among testosterone, progesterone, allopregnanolone, lipoproteins, triglyceride, fasting glucose and HbA1c levels, which was interpreted as progesterone and its metabolite allopregnanolone may contribute to metabolic abnormalities.

    CONCLUSIONS: In PCOS patients, normalisation of metabolic dysfunction may be incomplete by 6 months after RYGB surgery, and the start of ovulatory menstrual cycles may indicate normalisation of metabolic dysfunction.

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