James M. Prentis

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 ≤1 complication (26 vs. 10 days; P < 0.001). Anaerobic threshold (AT) was higher in the group with ≤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.

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

BackgroundEnhanced 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.MethodsA 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.ResultsA 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.ConclusionsThe 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; &bgr; = −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 donors 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. Liver Transpl 18:152–159, 2012.

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.

Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy

Postoperative complications are increased in patients with reduced cardiopulmonary reserve undergoing major surgery. Pancreatic leak is an important contributor to postoperative complications and death following pancreaticoduodenectomy. The aim of this study was to determine whether reduced cardiopulmonary reserve was a risk factor for pancreatic leak.

Impaired cardiopulmonary reserve in an elderly population is related to postoperative morbidity and length of hospital stay after radical cystectomy

To determine the relationship of preoperatively measured cardiorespiratory function, to the development of postoperative complications and length of hospital stay (LOS) in a cohort of patients undergoing radical cystectomy (RC), as RC and conduit formation is curative but is associated with significant postoperative morbidity and mortality.

Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome.

INTRODUCTION Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with high risk of postoperative complications. The aim of this study was to identify pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome. METHODS Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and cardiopulmonary exercise testing (CPET) were collected. RESULTS Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39–79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p=0.005 and p=0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p=0.003, odds ratio: 3.261). CONCLUSIONS P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.

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.

P75 Impaired cardiorespiratory reserve in primary biliary cirrhosis patients undergoing liver transplant assessment

Introduction It has been previously shown that PBC patients have bioenergetic abnormality in both peripheral and cardiac muscle. In particular they exhibit significantly lower cardiac muscle phosphocreatine-to-ATP ratio (measure of cardiac bioenergetic integrity) compared with control subjects. In other disease settings, such as cardiac failure, changes of this type have been associated with impaired cardiac function and increased risk of cardiac death. Aim The objective of the present study was to examine whether these changes are reflected in systemic measurements of cardiopulmonary reserve determined by a non-invasive cardiopulmonary exercise test (CPET). Method Consecutive PBC patients being assessed for liver transplantation underwent CPET. The test was conducted in a consistent environment and reviewed by a trained physician to determine objective measures of cardiorespiratory reserve. A control group of consecutive patients with primary sclerosing cholangitis (PSC), also being assessed for liver transplantation was also tested. We compared the results of CPET of all patients with a diagnosis of PBC with those with PSC. Patient demographics and MELD scores at assessment were also collected. A non-paired t test was used to determine group differences. Results In total, 38 patients had a diagnosis of either PBC or PSC. Three patients (2 PBC and 1 PSC) did not exercise sufficiently to gather meaningful results and were excluded from the analysis. The PSC patients assessed for transplantation had significantly worse liver disease as assessed by the MELD score. However, all measures of cardiorespiratory reserve derived from CPX testing were significantly lower in the PBC group. There was no statistical difference between the two groups with respect to age, thus excluding age as the underlying factor in decreasing their fitness. Conclusion In this cohort, patients with PBC, despite having lower MELD scores and equivalent age at transplantation assessment, had significantly impaired cardiorespiratory reserve, when compared to patients with PSC. The results add to the evidence that there is a specific PBC-related bioenergetic effect due to the immunology of PBC that is absent in PSC. This finding could have significant relevance on both future studies and treatment regimes to improve cardiovascular fitness.Abstract P75 Table 1 PBC PSC p Value Number 24 11 Age yrs mean (SD) 56.1 (8.9) 56.1 (12.9) 0.999 MELD mean (SD) 13.0 (6.60) 18.8 (4.15) 0.004 AT mean (SD) 10.7 (2.8) 13.3 (3.0) 0.017 Peak VO2 mean (SD) 13.6 (3.4) 17.9 (4.7) 0.004 OEUS/kg mean (SD) 18.7 (4.5) 22.8 (4.5) 0.018 VO2/HR mean (SD) 7.6 (2.7) 9.7 (1.5) 0.022