Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. METHODS: A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. RESULTS: A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. CONCLUSIONS: The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Cardiorespiratory fitness predicts mortality and hospital length of stay after major elective surgery in older people.

OBJECTIVE: This study aimed to define the relationship between cardiorespiratory fitness and age in the context of postsurgery mortality and morbidity in older people. BACKGROUND: Postsurgery mortality and morbidity increase with age. Cardiorespiratory fitness also declines with age, and the independent and linked associations between cardiorespiratory fitness and age on postsurgical mortality and morbidity remain to be determined. METHODS: An unselected consecutive group of 389 adults with a mean age of 66 years (range 26-86 years) underwent cardiorespiratory exercise testing before major hepatobiliary surgery at a single center. Mortality and critical care unit and hospital lengths of stay were collected from patient records. Primary outcomes were in-hospital all-cause mortality after surgery and hospital and critical care lengths of stay. RESULTS: Anaerobic threshold was the most significant independent predictor for postoperative mortality (P = 0.003; ß = -0.657 and odds ratio = 0.52) in 18 of 389 (4.6%) patients who died during their in-hospital stay. Age was not a significant predictor in this model. Older people with normal cardiorespiratory fitness spent the same number of days in the hospital or critical care unit as younger people with similar cardiorespiratory fitness (13 vs 12; P = 0.08 and 1 vs 1; P = 0.103). Patients older than 75 years with low cardiorespiratory fitness spent a median of 11 days longer in hospital (23 vs 12; P < 0.0001) and 2 days longer in critical care (2.9 vs 0.9; P < 0.0001) when compared with patients with adequate cardiorespiratory fitness. CONCLUSIONS: Cardiorespiratory fitness is an independent predictor of mortality and length of hospital stay and provides significantly more accurate prognostic information than age alone. Clinicians should consider both the prognostic value of cardiorespiratory testing and techniques to preserve cardiorespiratory function before elective surgery in older people.

Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation.

Liver transplantation has a significant early postoperative mortality rate. An accurate preoperative assessment is essential for minimizing mortality and optimizing limited donor organ resources. This study assessed the feasibility of preoperative submaximal cardiopulmonary exercise testing (CPET) for determining the cardiopulmonary reserve in patients being assessed for liver transplantation and its potential for predicting 90-day posttransplant survival. One hundred eighty-two patients underwent CPET as part of their preoperative assessment for elective liver transplantation. The 90-day mortality rate, critical care length of stay, and hospital length of stay were determined during the prospective posttransplant follow-up. One hundred sixty-five of the 182 patients (91%) successfully completed CPET; this was defined as the ability to determine a submaximal exercise parameter: the anaerobic threshold (AT). Sixty of the 182 patients (33%) underwent liver transplantation, and the mortality rate was 10.0% (6/60). The mean AT value was significantly higher for survivors versus nonsurvivors (12.0 ± 2.4 versus 8.4 ± 1.3 mL/minute/kg, P < 0.001). Logistic regression revealed that AT, donor age, blood transfusions, and fresh frozen plasma transfusions were significant univariate predictors of outcomes. In a multivariate analysis, only AT was retained as a significant predictor of mortality. A receiver operating characteristic curve analysis demonstrated sensitivity and specificity of 90.7% and 83.3%, respectively, with good model accuracy (area under the receiver operating characteristic curve = 0.92, 95% confidence interval = 0.82-0.97, P = 0.001). The optimal AT level for survival was defined to be >9.0 mL/minute/kg. The predictive value was improved when the ideal weight was substituted for the actual body weight of a patient with refractory ascites, even after a correction for the donor's age. In conclusion, the preoperative cardiorespiratory reserve (as defined by CPET) is a sensitive and specific predictor of early survival after liver transplantation. The predictive value of CPET requires further evaluation.

Submaximal exercise testing predicts perioperative hospitalization after aortic aneurysm repair.

BACKGROUND: Aortic aneurysm repair is a high-risk surgical procedure. Patients are often elderly, with multiple comorbidities that predispose them to perioperative morbidity. Use of endovascular aneurysm repair (EVAR) has increased due to reduced early perioperative risk. This study assessed whether preoperative cardiopulmonary exercise testing (CPET) could be used to predict morbidity and hospital length of stay (LOS) after aortic aneurysm repair. METHODS: A total of 185 patients underwent surgical repair (84 open repairs, 101 EVAR) and had adequate determination of a submaximal CPET parameter (anaerobic threshold). RESULTS: Patient comorbidities and cardiorespiratory fitness, derived from CPET, were similar between surgical procedures. Patients undergoing EVAR had fewer complications (10% vs 32%; P<.0001) and shorter mean (standard deviation [SD]) hospital LOS of 5.7 (9.3) days vs 14.4 (10.9) days compared with open repair (P<.0001). The hospital LOS was significantly increased in patients with one or more complications in both groups compared with those with no complications. In the open repair group, the level of fitness, as defined by anaerobic threshold, was an independent predictor of postoperative morbidity and hospital LOS. When the optimal anaerobic threshold (10 mL/min/kg) derived from receiver operator curve analysis was used as a cutoff value, unfit patients stayed significantly longer than fit patients in critical care (mean, 6.4 [SD, 6.9] days vs 2.4 [SD, 2.9] days; P=.002) and in the hospital (mean, 23.1 [SD, 14.8] days vs 11.0 [SD, 6.1] days; P<.0001). In contrast, fitness in the EVAR group was not predictive of postoperative morbidity but did have predictive value for hospital LOS. CONCLUSIONS: Cardiorespiratory fitness holds significant clinical value before aortic aneurysm repair in predicting postsurgical complications and duration of critical care and hospital LOS. Preoperative measurement of fitness could then direct clinical management with regard to operative choice, postoperative resource allocation, and informed patient decision making.

Perioperative medicine.

Perioperative medicine delivers patient-centred, multidisciplinary, integrated care for patients from the contemplation of surgery throughout the surgical pathway to recovery. High-quality perioperative care reduces complications, improves outcomes, and leads to improved patient satisfaction and reduced healthcare costs. This article is based on key findings and recommendations from the Getting It Right First Time (GIRFT) national report on perioperative medicine and outlines key concepts of perioperative medicine; exploring how practice can be transformed to improve care. The GIRFT report was produced using information gathered from 72 visits and 119 surveys from NHS trusts in England. It illustrates examples of exemplary perioperative care across the country but also describes variation in access to and provision of perioperative care. To address this unwarranted variation and to tackle the implementation gap, transformation of perioperative care pathways ensuring a patient-centered approach, multi-professional collaboration and widespread adoption of best practice will be required.

Evaluating the feasibility and acceptability of an exercise and behaviour change intervention in socioeconomically deprived patients with peripheral arterial disease: The textpad study protocol.

This pilot randomised controlled trial aims to assess the feasibility and acceptability of a 12-week home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with peripheral artery disease (PAD). The study will also determine the preliminary effectiveness of the intervention for improving clinical and health outcomes. Sixty patients with PAD who meet the inclusion criteria will be recruited from outpatient clinic at the Freeman Hospital, United Kingdom. The intervention group will undergo telehealth behaviour intervention performed 3 times per week over 3 months. This program will comprise a home-based exercise (twice a week) and an individual lifestyle program (once per week). The control group will receive general health recommendations and advice to perform unsupervised walking training. The primary outcome will be feasibility and acceptability outcomes. The secondary outcomes will be objective and subjective function capacity, quality of life, dietary quality, physical activity levels, sleep pattern, alcohol and tobacco use, mental wellbeing, and patients' activation. This pilot study will provide preliminary evidence of the feasibility, acceptability and effectiveness of home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with PAD. In addition, the variance of the key health outcomes of this pilot study will be used to inform the sample size calculation for a future fully powered, multicentre randomized clinical trial.

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme.

BACKGROUND: A key first step in optimising COVID-19 patient outcomes during future case-surges is to learn from the experience within individual hospitals during the early stages of the pandemic. The aim of this study was to investigate the extent of variation in COVID-19 outcomes between National Health Service (NHS) hospital trusts and regions in England using data from March-July 2020. METHODS: This was a retrospective observational study using the Hospital Episode Statistics administrative dataset. Patients aged ≥ 18 years who had a diagnosis of COVID-19 during a hospital stay in England that was completed between March 1st and July 31st, 2020 were included. In-hospital mortality was the primary outcome of interest. In secondary analysis, critical care admission, length of stay and mortality within 30 days of discharge were also investigated. Multilevel logistic regression was used to adjust for covariates. FINDINGS: There were 86,356 patients with a confirmed diagnosis of COVID-19 included in the study, of whom 22,944 (26.6%) died in hospital with COVID-19 as the primary cause of death. After adjusting for covariates, the extent of the variation in-hospital mortality rates between hospital trusts and regions was relatively modest. Trusts with the largest baseline number of beds and a greater proportion of patients admitted to critical care had the lowest in-hospital mortality rates. INTERPRETATION: There is little evidence of clustering of deaths within hospital trusts. There may be opportunities to learn from the experience of individual trusts to help prepare hospitals for future case-surges.

Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery.

OBJECTIVE: To investigate the null hypothesis that an objective, noninvasive technique of measuring cardiorespiratory reserve, does not improve the preoperative assessment of patient risk of postoperative complications, when compared with a standard questionnaire-based assessment of functional capacity. SUMMARY BACKGROUND DATA: Postoperative complications may be increased in patients with reduced cardiorespiratory function. Activity questionnaires are subjective, whereas cardiopulmonary exercise testing (CPET) provides an objective definition of cardiorespiratory reserve. The use of preoperative CPET to predict postoperative complications is not fully defined. METHOD: CPET and an algorithm-based activity assessment (Veterans Activity Questionnaire Index [VASI]) were performed on consecutive patients (n = 171) with low subjective functional capacity (metabolic equivalent score [METS] < 7), being assessed for major surgery. A morbidity survey determined postoperative day 7 complications. Logistic regression defined independent predictors of complication group. Receiver-operating curve (ROC) analysis defined the predictive value of CPET to outcome. P < 0.05 value demonstrated significance. RESULTS: Objective cardiorespiratory reserve did not differ between operated (n = 116) and nonoperated patients (n = 55). Median complication rate on postoperative day 7 was 1. Patients with >1 complication had an increase in hospital LOS compared to the group with < or =1 complication (26 vs. 10 days; P < 0.001). Anaerobic threshold (AT) was higher in the group with < or =1 complication (11.9 vs. 9.1 mL/kg/min; P = 0.001) and demonstrated high accuracy (AUC = 0.85), sensitivity (88%), and specificity (79%), at an optimum AT of 10.1 mL/kg/min (defined by the furthest left point on the ROC curve). AT, VASI, and surgical reintervention were independent predictors of complication group. Preoperative AT significantly improved outcome prediction when compared with the use of VASI alone. CONCLUSION: An objective measure of cardiorespiratory reserve was an independent predictor of a major surgical group with increased postoperative complications and hospital LOS. AT measurement significantly improved outcome prediction compared with an algorithm-based activity assessment.

High-intensity interval training (HIT) for effective and time-efficient pre-surgical exercise interventions.

The advancement of perioperative medicine is leading to greater diversity in development of pre-surgical interventions, implemented to reduce patient surgical risk and enhance post-surgical recovery. Of these interventions, the prescription of pre-operative exercise training is gathering momentum as a realistic means for enhancing patient surgical outcome. Indeed, the general benefits of exercise training have the potential to pre-operatively optimise several pre-surgical risks factors, including cardiorespiratory function, frailty and cognitive function. Any exercise programme incorporated into the pre-operative pathway of care needs to be effective and time efficient in that any fitness gains are achievable in the limited period between the decision for surgery and operation (e.g. 4 weeks). Fortunately, there is a large volume of research describing effective and time-efficient exercise training programmes within the discipline of sports science. Accordingly, the objective of our commentary is to synthesise contemporary exercise training research, both from non-clinical and clinical populations, with the overarching aim of informing the development of effective and time-efficient pre-surgical exercise training programmes. The development of such exercise training programmes requires the careful consideration of several key principles, namely frequency, intensity, time, type and progression of exercise. Therefore, in light of more recent evidence demonstrating the effectiveness and time efficiency of high-intensity interval training-which involves brief bouts of intense exercise interspersed with longer recovery periods-the principles of exercise training programme design will be discussed mainly in the context of such high-intensity interval training programmes. Other issues pertinent to the development, implementation and evaluation of pre-operative exercise training programmes, such as individual exercise prescription, training session monitoring and potential barriers and risks to high-intensity exercise are also discussed. The evidence presented suggests that individually prescribed and supervised high-intensity interval training programmes, encompassing a variety of exercise modes represent an effective and safe means of exercise therapy prior to surgery.

Anesthesia for hepatobiliary surgery.

Hepatobiliary surgery outcomes have significantly improved since the early 1970s. Surgical and anesthetic advances related to patient selection, alternative surgical management options, and reduction of operative blood loss have been important. Postoperative analgesic regimens are being modified to include intrathecal opiates and to embrace enhanced recovery regimens.

A small plant-specific protein family of ABI five binding proteins (AFPs) regulates stress response in germinating Arabidopsis seeds and seedlings.

The transcription factor ABA-Insensitive5 (ABI5) is a key regulator of ABA signaling and stress response in Arabidopsis seeds and seedlings. Potential ABI5-interacting proteins were identified by a yeast two-hybrid screen; the most prevalent interactors were a family of four highly conserved plant-specific proteins with no domains of known function, but homology to a previously characterized ABI Five Binding Protein (AFP). This study compares expression and function of the family members. The AFPs are induced by ABA and/or dehydrating stresses in young seedlings, but the developmental timing of their induction differs. Mutations in AFP1 or AFP2 result in increased sensitivity to ABA and salt, whereas afp4 mutants are mildly ABA-resistant. AFP2, like AFP1, acts epistatically to ABI5. Reduced germination or seedling growth of the mutants under stress correlates with a higher level of ABI5 protein when compared to wild-type seedlings, but it is not clear whether this is a cause or effect of the reduced growth. Although both ABI5 and the AFPs are ABA-induced, the ABI5:AFP ratio increases at high ABA concentrations, maintaining growth inhibition under severe stress. An AFP2:GFP fusion, which complements the afp2 mutation, is nuclear-localized in seedlings exposed to stress, but becomes delocalized before being degraded following removal of stress. The AFPs may also interact to varying extents with many ABI5-related bZIP transcription factors. This study suggests that germination and seedling growth are regulated by antagonistic interactions among at least two functionally redundant families, the AFPs and the ABI5-related proteins, providing a mechanism to fine-tune seedling stress responses.