Recovery of surgery in the elderly (ROSE) program: The efficacy of a multi-modal prehabilitation program implemented in frail and pre-frail elderly undergoing major abdominal surgery.

BACKGROUND: Major abdominal surgery is associated with a high rate of post-operative complications with increased risk of adverse surgical outcomes due to the presence of frailty. This study aims to evaluate the effectiveness of the multimodal Recovery of Surgery in the Elderly (ROSE) prehabilitation program with supervised exercise in mitigating postoperative functional decline when compared to standard care. METHOD: The ROSE program enrolled ambulant patients who were 65 years and above, had a Clinical Frailty Scale score of 4 or more and were planned for major abdominal surgery. Participation in supervised exercise sessions before surgery were compared with standard physiotherapy advice. The primary outcome was 6-min walk test (6MWT) distance assessed at baseline, after prehabilitation and 30 days follow-up after surgery. Secondary outcomes included physical performance, length of hospital stay and postoperative morbidity. RESULTS: Data from 74 eligible patients, 37 in each group, were included. Median age was 78 years old. Forty-two patients (22 in Prehab group and 20 in control group) with complete 6MWT follow-up data at 30 days follow-up were analysed for outcomes. Most patients underwent laparoscopic surgery (63.5%) and almost all of the surgeries were for abdominal malignancies (97.3%). The Prehab group had an increase in 6MWT distance at the 30-day follow up, from a baseline mean (SD) of 277.4 (125) m to 287.6 (143.5) m (p = 0.415). The 6MWT distance in the control group decreased from a baseline mean (SD) of 281.7 (100.5) m to 260.1 (78.6) m at the 30-day follow up (p = 0.086). After adjusting for baseline 6MWT distance and frailty score, the Prehab group had significantly higher 6MWT distance at 30-day follow-up than control (difference in adjusted means 41.7 m, 95% confidence interval 8.7-74.8 m, p = 0.015). There were no significant between-group differences in the secondary outcomes. CONCLUSION: A multimodal prehabilitation program with supervised exercise within a short time frame can improve preoperative functional capacity and maintain baseline functional capacity in frail older adults undergoing major abdominal surgery.

Before and after COVID-19 pandemic: impact on hepatobiliary and pancreatic surgical services in a Singapore Tertiary Hospital.

BACKGROUND: Reallocation of healthcare resources to prioritize the COVID-19 pandemic-related incremental healthcare needs resulted in longer waiting times for routine elective clinical services. AIMS: We aimed to analyze the effects of the pandemic on the hepatopancreatobiliary (HPB) unit's surgical workload. METHODS: The HPB unit's surgical workload for the months of January-June from 2019 to 2022 was extracted, retrospectively compared, and analyzed. This study was registered in ClinicalTrials.gov (NCT05572866) and complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS: Benign elective surgeries were impacted adversely, with elective gallbladder operations decreasing by 45.2% (146 in 2019 vs 80 in 2020, p = 0.89) before slowly increasing to 120 cases in 2021 and rebounding to 179 cases in 2022 (p = 0.001). Elective oncology operations paradoxically increased, with liver resections rising by 12.9% (31 in 2019 vs 35 in 2020, p = 0.002) and maintaining 37 cases in 2021 (p = 0.0337) and 34 cases in 2022 (p = 0.69). Elective pancreatic resections increased by 171.4% (7 in 2019 vs 19 in 2020, p < 0.0001) and were maintained at 15 cases in 2021 (p = 0.013) and 18 cases in 2022 (p = 0.022). The overall emergency workload decreased from 2019 (n = 198) to 2020 (n = 129) to 2021 (n = 122) before recovering to baseline in 2022 (n = 184). The month-on-month volume generally showed similar trends compared to the other years except for February 2022 and May 2021. CONCLUSION: This audit shows that despite large-scale disruption of the local healthcare system, essential surgeries can still proceed with careful resource planning by steadfast and vigilant clinical teams.

Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review.

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.

The Impact of the COVID-19 Pandemic on Hepatobiliary and Pancreatic Surgical Services in Singapore: Retrospective Quantitative Study.

BACKGROUND: At the height of the COVID-19 pandemic, the hepatopancreatobiliary (HPB) unit had to reorganize its surgical case volume due to the rationing of health care resources. We report on a local audit evaluating the impact of COVID-19 on the HPB unit and the HPB surgical oncology practice. OBJECTIVE: The aim of this study was to review the impact of the COVID-19 pandemic on the HPB unit's elective and emergency surgical cases. The secondary aims were to investigate the impact on the HPB surgical oncology operative case volume. METHODS: We performed a comparative audit of the HPB unit surgical case volume for January-June 2019 (baseline) and 2020 (COVID-19). Elective and emergency cases performed under general anesthesia were audited. Elective cases included hernia and gallbladder operations and liver and pancreatic resections. Emergency cases included cholecystectomies and laparotomies performed for general surgical indications. We excluded endoscopies and procedures done under local anesthesia. The retrospective data collected during the 2 time periods were compared. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000040265). RESULTS: The elective surgical case volume decreased by 41.8% (351 cases in 2019 compared to 204 cases in 2020) during the COVID-19 pandemic. The number of hernia operations decreased by 63.9% (155 in 2019 compared to 56 in 2020; P<.001) and cholecystectomies decreased by 40.1% (157 in 2019 compared to 94 in 2020; P=.83). The liver and pancreatic resection volume increased by 16.7% (30 cases in 2019 compared to 35 cases in 2020; P=.004) and 111.1% (9 cases in 2019 compared to 19 cases in 2020; P=.001), respectively. The emergency surgical workload decreased by 40.9% (193 cases in 2019 compared to 114 cases in 2020). The most significant reduction in the emergency workload was observed in March (41 to 23 cases, a 43.9% reduction; P=.94), April (35 to 8 cases, a 77.1% reduction; P=.01), and May (32 to 14 cases, a 56.3% reduction; P=.39); however, only April had a statistically significant reduction in workload (P=.01). CONCLUSIONS: The reallocation of resources due to the COVID-19 pandemic did not adversely impact elective HPB oncology work. With prudent measures in place, essential surgical services can be maintained during a pandemic. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2000040265); https://tinyurl.com/ms9kpr6x.