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(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Multimodal preoperative prehabilitation has been shown to be effective in improving the functional capacity of cancer patients, reducing postoperative complications and the length of hospital and ICU stay after surgery. The availability of prehabilitation units that gather all the professionals involved in patient care facilitates the development of integrated and patient-centered multimodal prehabilitation programs, as well as patient adherence. This article describes the process of creating a prehabilitation unit in our center and the role of perioperative nursing. Initially, the project was launched with the performance of a research study on prehabilitation for gastrointestinal cancer surgery. The results of this study encouraged us to continue the implementation of the unit. Progressively, multimodal prehabilitation programs focusing on each type of patient and surgery were developed. Currently, our prehabilitation unit is a care unit that has its own gym, which allows supervised training of cancer patients prior to surgery. Likewise, the evolution of perioperative nursing in the unit is described: from collaboration and assistance in the integral evaluation of the patient at the beginning to current work as a case manager; a task that has proven extremely important for the comprehensive and continuous care of the patient.

Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required.To assess health outcomes and cost of prehabilitation.Prospective cohort study with a control group built using propensity score matching techniques.Prehabilitation unit in a Tertiary-care University hospital.Candidates for major digestive, cardiac, thoracic, gynecologic or urologic surgeries.Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization and psychological support.The comprehensive complication index, hospital and intensive care unit length of stay and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis.The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay (9.9 (7.2) vs. 12.8 (12.4) days; P=0.035). Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay (2.3 (2.7) vs. 3.8 (4.2) days; P=0.021) and generated mean cost savings per patient of 3,092€ (32% cost reduction) (P=0.007). Five priority areas for action to enhance service efficiencies were identified.The study indicates low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance effectiveness of prehabilitation.

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Recipient hepatectomy during liver transplantation can be a challenging operation and can increase cold ischaemic time. The aim of this study is to assess factors associated with prolonged recipient hepatectomy. From 2005 to 2015, 930 patients were submitted to liver transplantation in our hospital. Prolonged hepatectomy time was defined as operative time >180 min (from knife on skin to total hepatectomy). Patients undergoing early liver retransplantation and living donation were excluded. A total of 715 patients were included in our study. Median age at transplantation was 53 (18–70) years, and median BMI was 26.2 (16–40). Median hepatectomy time was 131 min. Prolonged hepatectomy time occurred in 89 (12.4%) patients. At univariate analysis, previous decompensated cirrhosis with variceal bleeding and/or ascites, higher BMI and previous abdominal surgery were associated with prolonged operating time. Higher surgeon experience and acute liver failure were associated with shorter hepatectomy time. At multivariate analysis, previous episodes of variceal bleeding (p = 0.027, OR 1.78), BMI > 27 (p = 0.01, OR 1.75), previous abdominal surgery (p = 0.04, OR 1.68) and surgeon experience (p = 0.007, OR 2.04) were independently associated with operating time. Prolonged hepatectomy time was significantly associated with cold and total ischaemic time and intraoperative bleeding (p

Purpose The feasibility and effects of multimodal prehabilitation in patients with advanced ovarian cancer (AOC) undergoing a cytoreductive surgery are unknown. We aimed to evaluate the feasibility of a multimodal prehabilitation program in patients with AOC and its impact on postoperative outcomes.Methods We prospectively compared 15 patients with AOC stage scheduled to undergo a citorreductive surgery between December 2019 and January 2021 after a multimodal prehabilitation program consisting of supervised exercise training, nutritional optimization and psychological preparation versus a control cohort of 19 patients matched according to clinical and surgical characteristics who underwent surgery without prehabilitation between January 2018 and November 2019. In both groups, the enhanced recovery after surgery guidelines were followed. We analyzed adherence to the program, comprehensive complication index (CCI), hospital length of stay, and time to starting chemotherapy. Results Overall adherence to the multimodal prehabilitation program was 80%, with 86.7% adherence to exercise training, 100% adherence to nutritional optimization, and 80% adherence to psychological preparation. Median hospital stay was shorter in the prehabilitation cohort [5 days (IQR, 4-6) vs. 7 days (IQR,5-9) in the control cohort, p=0.04]. CCI score in the prehabilitation cohort was 9.3 (SD 12.12) vs. 16.61 (SD 16.89) in the control cohort, p=0.2. Median time to starting chemotherapy was shorter in the prehabilitation cohort compared to control cohort [25 days (IQR, 23-25) vs. 35 days (IQR 28-45), p=0.03]. Conclusion Multimodal prehabilitation is feasible and safe in patients with AOC. This study found significantly shorter hospital stays and time to starting chemotherapy in the multimodal prehabilitation cohort.

Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery.A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence.The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P 0.01) were negatively associated with adherence.Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.

IntroductionPrehabilitation programmes that combine exercise training, nutritional support and emotional reinforcement (multimodal prehabilitation) have demonstrated efficacy reducing postoperative complications in the context of abdominal surgery. However, such programmes have seldom been studied in cardiac surgery, one of the surgeries associated with higher postoperative morbidity and mortality. This trial will assess the feasibility and efficacy in terms of reduction of postoperative complications and cost-effectiveness of a multimodal prehabilitation programme comparing to the standard of care in cardiac surgical patients.Methods and analysisThis is a single-centre, randomised, open-label, controlled trial with a 1:1 ratio. Consecutive 160 elective valve replacement and/or coronary revascularisation surgical patients will be randomised to either standard of care or 4–6 weeks of multimodal prehabilitation that will consist in (1) two times/week supervised endurance and strength exercise training sessions, (2) promotion of physical activity and healthy lifestyle, (3) respiratory physiotherapy, (4) nutrition counselling and supplementation if needed, and (5) weekly mindfulness sessions. Baseline, preoperative and 3-month postoperative data will be collected by an independent blinded evaluator. The primary outcome of this study will be the incidence of postoperative complications.Ethics and disseminationThis study has been approved by the Ethics Committee of Clinical investigation of Hospital Clinic de Barcelona (HCB/2017/0708). The results will be disseminated in a peer-reviewed journal.Trial registration numberNCT03466606.

Introduction: Enhancement of exercise capacity (EC) and physical activity (PA) are core components of preoperative programs for optimization of multimorbid patients undergoing major surgery. However, the relationship between these 2 components has never been explored in this population. Aim: To explore baseline relationship of EC & PA in multimorbid patients included in a preoperative optimization program. Methods: Main inclusion criteria: 1) Undergoing major surgery; 2) High-risk for surgical complications defined by age≥70 and/or American Society of Anesthesiologists risk scale 3-4. Six-minute walk distance Results: 106 patients were included in the study. Main univariate analysis results are shown in table 1. Multivariate analysis results, taking fit & active as a reference group, are shown in table 2. Conclusions: Age, morbidity and frailty are factors associated to EC and PA in multimorbid elderly patients undergoing major surgery. These findings may contribute to enhance personalisation of preoperative optimization programs.

Introduction: Preoperative optimization programs are effective interventions to improve postoperative outcomes in patients undergoing major surgery. However, customization of these programs to multimorbid patients’ is an unmet need. The current study aims to identify factors associated to program completion, and to postoperative complications, in multimorbid patients undergoing major surgery. Methods: Inclusion criteria: 1) Undergoing to major surgery; 2) high-risk for surgical complications defined by age≥ 70 and/or American Society of Anesthesiologists risk scale 3-4. The program included 6 interventions: 1) Cardiorespiratory training; 2) Promotion of physical activity; 3) Volumetric inspirometer teaching; 4) Cognitive behavioural therapy; 5) Nutritional optimization; 6) Mindfulness. Program completion was defined as attending ≥80% of appointments. Results: From 200 patients, 120 (60%) completed the program. Among completers, 62 did not suffer from postoperative complications (52%). Undergoing oncologic surgery (24.5[3.9-153.8];p=0.001), suffering from endocrine and metabolic diseases (3.8[1.2-12.3];p=0.025) and willingness to participate in mindfulness sessions (3.1[1.03-9.15];p=0.044) were associated with program completion, while being older (0.93[0.88-0.97];p=0.002) was related to lower probability of completion. Among completers, higher baseline fitness (Duke Activity Status Index) (0.95[0.91-0.999];p=0.019) and higher risk of malnutrition (Malnutrition Universal Screening Tool) (1.8[1.1-3.1];p=0.023) were related to postoperative morbidity. Conclusions: The current study identifies actionable factors useful to personalize these programs which may facilitate its effectiveness.

Background Multimodal prehabilitation is a preoperative intervention with the objective to enhance cancer patients’ functional status which has been showed to reduce both postoperative morbidity and hospital length of stay in digestive oncologic surgery. However, in lung cancer surgery patients further studies with higher methodological quality are needed to clarify the benefits of prehabilitation. The main aim of the current protocol is to evaluate the cost-effectiveness of a multimodal prehabilitation program supported by information and communication technologies in moderate-to-high risk lung cancer patients undergoing thoracic surgery. Methods A Quadruple Aim approach will be adopted, assessing the prehabilitation program at the following levels: i) Patients’ and professionals’ experience outcomes (by means of standardized questionnaires, focus groups and structured interviews); ii) Population health-based outcomes (e.g. hospital length of stay, number and severity of postoperative complications, peak oxygen uptake and levels of systemic inflammation); and, iii) Healthcare costs. Discussion This study protocol should contribute not only to increase the scientific basis on prehabilitation but also to detect the main factors modulating service adoption. Trial registration NCT04052100 (August 9, 2019).

[No abstract available]

The use of sedation for diagnostic procedures including gastrointestinal endoscopy is rapidly growing. Recovery of cognitive function after sedation is important because it would be important for most patients to resume safe, normal life soon after the procedure. Computerized tests have shown being accurate descriptors of cognitive function. The purpose of the present study was to evaluate the time course of cognitive function recovery after sedation with propofol and remifentanil. A prospective observational double blind clinical study conducted in 34 young healthy adults undergoing elective outpatient colonoscopy under sedation with the combination of propofol and remifentanil using a target controlled infusion system. Cognitive function was measured using a validated battery of computerized cognitive tests (Cogstate™, Melbourne, Australia) at different predefined times: prior to starting sedation (Tbaseline), and then 10 min (T10), 40 min (T40) and 120 min (T120) after the end of colonoscopy. Tests included the assessment of psychomotor function, attention, visual memory and working memory. All colonoscopies were completed (median time: 26 min) without significant adverse events. Patients received a median total dose of propofol and remifentanil of 149 mg and 98 µg, respectively. Psychomotor function and attention declined at T10 but were back to baseline values at T40 for all patients. The magnitude of psychomotor task reduction was large (d = 0.81) however 100% of patients were recovered at T40. Memory related tasks were not affected 10 min after ending sedation. Cognitive impairment in attention and psychomotor function after propofol and remifentanil sedation was significant and large and could be easily detected by computerized cognitive tests. Even though, patients were fully recovered 40 min after ending the procedure. From a cognitive recovery point of view, larger studies should be undertaken to propose adequate criteria for discharge after sedation.

Introduction Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimise these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimisation programmes. Objective To characterise surgical population in a university hospital. Methods All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. Results One hundred and forty patients were included (60 ± 15 yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/ IV , sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. Conclusions The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Resumen Introduccion Una baja reserva cardiorrespiratoria, un bajo nivel de actividad fisica y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria. Implementar medidas para optimizar estos aspectos es clave para mejorar el pronostico. Es fundamental conocer la magnitud del problema para dimensionar los programas de optimizacion preoperatoria. Objetivo Caracterizar la poblacion quirurgica de un hospital universitario de nivel terciario. Metodos Se incluyeron prospectivamente todos los pacientes sometidos a evaluacion preoperatoria para cirugia digestiva con ingreso durante 3 meses. Se evaluo el nivel de actividad fisica, la capacidad funcional, la fragilidad y el estado emocional, y se realizo un test de medicion del estado fisico (5 Times Sit-to-Stand Test). Se recogieron datos demograficos, clinicos y relacionados con la cirugia. Resultados Se incluyeron 140 pacientes (60 ± 15 anos, 56% varones, 25% ASA III o IV ). El 49% estaban propuestos para cirugia oncologica y un 13% habia recibido neoadyuvancia. El 70% de los pacientes presentaban una capacidad funcional reducida y eran sedentarios. Un 18% fueron considerados fragiles y mas de un 50% completaron el 5 Times Sit-to-Stand Test en un tiempo superior a los valores de referencia. La edad avanzada, el ASA III / IV , el sedentarismo, la fragilidad y un nivel de ansiedad/depresion elevado se relacionaron con una menor capacidad funcional. Conclusiones La poblacion quirurgica de nuestro entorno tiene una baja reserva funcional y un elevado indice de sedentarismo y fragilidad, factores asociados a un peor pronostico quirurgico. Urge implementar medidas preoperatorias para identificar la poblacion de riesgo y programas de prehabilitacion considerados estrategias de optimizacion preoperatoria con gran potencial.

The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery.Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients.This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise.We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity [ΔET 135 (218) %; P0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3-0.8; P = 0.001) and the rate of complications [1.4 (1.6) and 0.5 (1.0) (P = 0.001)] as compared with controls.Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.

Purpose Frailty and poor functional performance are associated with worse outcomes after heart transplantation (HT). Prehabilitation performed to improve patients preoperatively has been shown to improve surgery outcomes in other high-risk patients, but there is no experience in patients prior to HT. We postulate that a combined prehabilitation program in patients on the waiting list for HT may improve short-term outcomes after HT, reduce hospitalization days and be cost-effective. Methods All patients entering the waiting list from July 2017 to July 2020 were offered to join an 8 weeks prehabilitation program consisting in 2 hours/week personalized moderate-high-intensity exercise training, nutritional optimization and mindfulness sessions. Patients completing a minimum of 12 sessions (6 weeks) were included as Prehab-Group (Prehab-G). Patients who decline to participate or underwent HT before starting the program were included as controls (Contr-G). Urgent HT and multiorgan transplants were excluded. Primary endpoints were total length of stay (LOS) and cost of HT hospitalization. Secondary endpoints were hours of mechanical ventilation, intensive care LOS and 30 days re-hospitalization. Results We enrolled 49 patients, from them 28 pat. entered the program. 18 patients in the Prehab-G and 17 patients in the Contr-G reached transplantation. There were no adverse events during the exercise sessions. Baseline characteristics show no differences between groups except for higher ratio of males (89% vs 47%, p=0.01) and longer median time on waiting list for the Prehab-G (242±228 vs 92±56 days, p Conclusion A prehabilitation program for patients awaiting HT is feasible and safe. Patients completing at least 6 weeks of training had shorter LOS and lower total and direct cost for the HT admission compared to patients without prehabilitation.

Background Patients undergoing liver transplantation (LT) have a high risk of bleeding. The goal of this study was to assess whether the first derivative of the velocity waveform (V-curve) generated by whole blood rotation thromboelastometry (ROTEM®) can predict blood loss during LT. Methods Preoperative V-curve parameters were retrospectively evaluated in 198 patients. Patients were divided into quartiles based on blood loss: low (LBL) in the first quartile and high (HBL) in the higher quartiles. A subgroup analysis was performed with patients stratified according to cirrhosis aetiology. A logistic regression model and receiver operator characteristics (ROC) curve were used to test the capacity of the V-curve, to discriminate between LBL and HBL. Results In the HBL group, the V-curve showed a lower maximum velocity of clot generation (MaxVel), a lower area under maximum velocity curve (AUC), and a higher time-to-maximum velocity (t-MaxVel) than in the LBL group. t-MaxVel was the only parameter showing a capacity to discriminate between the two groups, with a ROC area of 0.69 (95% CI; 0.62-0.74). The ROC area was 0.78 (95% CI; 0.75-0.83) for the 148 patients with cirrhosis, 0.73 (0.60-0.82) for patients with viral hepatitis and 0.83 (0.78-0.96) for patients with alcoholic hepatitis, the group that showed the best discriminative capacity. Moderate but significant correlations were found between all parameters of V-curve and BL. Conclusions Pre-transplant V-curve obtained from ROTEM is a promising tool for predicting BL risk during LT, particularly in patients with cirrhosis.

Background Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016–2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011–2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). Methods The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. Discussion The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. Trials registration NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018). Electronic supplementary material The online version of this article (10.1186/s12913-019-4174-2) contains supplementary material, which is available to authorized users.

BACKGROUND: Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the only curative option. However, postoperative complications occur in up to 50% of patients and are associated with higher morbidity and mortality rates, lower health related quality of life (HRQoL) and increased expenditure in health care. The number and severity of complications are closely related to preoperative functional capacity, nutritional state, psychological state, and smoking behavior. Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes. However, recent evidence shows that the preoperative period might be the optimal moment for intervention. This study will determine the impact of multimodal prehabilitation on patients' functional capacity and postoperative complications.METHODS/DESIGN: This international multicenter, prospective, randomized controlled trial will include 714 patients undergoing colorectal surgery for cancer. Patients will be allocated to the intervention group, which will receive 4 weeks of prehabilitation (group 1, prehab), or the control group, which will receive no prehabilitation (group 2, no prehab). Both groups will receive perioperative care in accordance with the enhanced recovery after surgery (ERAS) guidelines. The primary outcomes for measurement will be functional capacity (as assessed using the six-minute walk test (6MWT)) and postoperative status determined with the Comprehensive Complication Index (CCI). Secondary outcomes will include HRQoL, length of hospital stay (LOS) and a cost-effectiveness analysis.DISCUSSION: Multimodal prehabilitation is expected to enhance patients' functional capacity and to reduce postoperative complications. It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer.TRIAL REGISTRATION: Trial Registry: NTR5947 - date of registration: 1 August 2016.

Background Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. Methods A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. Results We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4–30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% –878 – 2642; P=0.365). Conclusions Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. Clinical trial registration NCT02024776.

Background & Aims: Surgery in cirrhosis is associated with a high morbidity and mortality. Retrospectively reported prognostic factors include emergency procedures, liver function (MELD/Child-Pugh scores) and portal hypertension (assessed by indirect markers). This study assessed the prognostic role of hepatic venous pressure gradient (HVPG) and other variables in elective extrahepatic surgery in patients with cirrhosis. Methods: A total of 140 patients with cirrhosis (Child-Pugh A/B/C: 59/37/4%), who were due to have elective extrahepatic surgery (121 abdominal; 9 cardiovascular/thoracic; 10 orthopedic and others), were prospectively included in 4 centers (2002–2011). Hepatic and systemic hemodynamics (HVPG, indocyanine green clearance, pulmonary artery catheterization) were assessed prior to surgery, and clinical and laboratory data were collected. Patients were followed-up for 1 year and mortality, transplantation, morbidity and post-surgical decompensation were studied. Results: Ninety-day and 1-year mortality rates were 8% and 17%, respectively. Variables independently associated with 1-year mortality were ASA class (American Society of Anesthesiologists), high-risk surgery (defined as open abdominal and cardiovascular/thoracic) and HVPG. These variables closely predicted 90-, 180- and 365-day mortality (C-statistic >0.8). HVPG values >16 mmHg were independently associated with mortality and values ≥20 mmHg identified a subgroup at very high risk of death (44%). Twenty-four patients presented persistent or de novo decompensation at 3 months. Low body mass index, Child-Pugh class and high-risk surgery were associated with death or decompensation. No patient with HVPG 0.63 developed decompensation. Conclusions: ASA class, HVPG and high-risk surgery were prognostic factors of 1-year mortality in cirrhotic patients undergoing elective extrahepatic surgery. HVPG values >16 mmHg, especially ≥20 mmHg, were associated with a high risk of post-surgical mortality. Lay summary: The hepatic venous pressure gradient is associated with outcomes in patients with cirrhosis undergoing elective extrahepatic surgery. It enables a better stratification of risk in these patients and provides the foundations for potential interventions to improve post-surgical outcomes.

Liver transplantation (LT) offers patients with liver disease a real chance for long-term survival. In the past decade, successful survival after LT along with the Model for End-Stage Liver Disease-based allocation policy have increased willingness to accept patients with a higher risk profile and marginal organs and to prioritize the sickest patients on the waiting list. Therefore, the anesthesiologist now deals with very challenging patients. In the present review, we aimed to highlight key aspects of intraoperative LT management in high-risk patients and to place these aspects in the perspective of their impact on perioperative outcomes. Conservative standardized perioperative strategies mandate a switch toward accurate and tailored perioperative anesthetic care to maintain the steady improvement in recipient survival rates after LT. In our opinion, continuous assessment of fluid status and cardiac performance, strategies promoting graft decongestion, rational hemostatic management, and the identification of LT recipients with potential risk of vascular complications should constitute the cornerstone of intraoperative management.

Background Colorectal cancer (CRC) screening programs result in the detection of early-stage asymptomatic carcinomas suitable to be surgically cured. Lymph nodes (LN) from early CRC are usually small and may be difficult to collect. Still, at least 12 LNs should be analyzed from colectomies, to ensure a reliable pN0 stage. Presurgical endoscopic tattooing improves LN procurement. In addition, molecular detection of occult LN tumor burden in histologically pN0 CRC patients is associated with a decreased survival rate. We aimed to study the impact of presurgical endoscopic tattooing on the molecular detection of LN tumor burden in early colon neoplasms. Methods A prospective cohort study from a CRC screening-based population was performed at a tertiary academic hospital. LNs from colectomies with and without preoperative endoscopic tattooing were assessed by two methods, hematoxylin and eosin (HE), and RT-LAMP, to detect tumor cytokeratin 19 (CK19) mRNA. We compared the amount of tumor burden and LN yields from tattooed and non-tattooed specimens. Results HE and RT-LAMP analyses of 936 LNs were performed from 71 colectomies containing early carcinomas and endoscopically unresectable adenomas (8 pT0, 17 pTis, 27 pT1, 19 pT2); 47 out of 71 (66.2 %) were tattooed. Molecular positivity correlated with the presence of tattoo in LN [p

Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.

Background Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability. Methods The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017–2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment. Discussion The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites. Trial registration This study protocol has been registered at ClinicalTrials.org (NCT02976064). Registered November 24th, 2016. Electronic supplementary material The online version of this article (10.1186/s12913-018-3363-8) contains supplementary material, which is available to authorized users.

Our goal was to assess the accuracy of measuring cardiac output (CO) by the FloTrac/Vigileo (CO(V)) device in comparison with thermodilution technique through pulmonary artery catheterization (PAC(TD)) in morbidly obese patients.Cardiac output in 8 morbidly obese patients was assessed twice at upright and lying position breathing ambient air. At least 4 consecutive CO measurements with 10 mL of ice-cold saline injections were performed each time. Simultaneous CO measurements were recorded with both single-bolus thermodilution and CO(V).One hundred thirty-two CO data pairs were collected. The overall mean single-bolus thermodilution 6.2 ± 1.1 L/min was lower than the overall mean CO(V) 7.8 ± 1.6 L/min (P.001). Lin concordance coefficient indicated that overall agreement between PAC(TD) and CO(V) was poor, 0.29. Lin concordance coefficient in sitting position was 0.29, 95% confidence interval (0.17-0.40) and in lying position was 0.30, 95% confidence interval (0.15-0.44). The Bland-Altman plot analysis showed systematically higher values from CO(V) in comparison with PAC(TD). These differences increased in presence of high CO measurements. In 3 of 8 patients, the percentage error was lower than 20%, whereas in the other 5, it was higher than 20%. Of these 5, in 2 cases, the percentage error was greater than 50%.Data obtained using CO(V) vs PAC(TD) measurements showed poor correlation. The results were not interchangeable.

Background: Prehabilitation (PREHAB), including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients. Objective: To assess the impact of personalized PREHAB on postoperative complications in high-risk patients undergoing elective major abdominal surgery. Design: RCT. Subjects were randomized (1:1 ratio) to control (standard care) or PREHAB (standard care + PREHAB). Inclusion criteria: i) aged above 70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Intervention: i) motivational interview; ii) high-intensity endurance training; and, iii) promotion of physical activity. Main study outcome: Proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise. Results: We randomly assigned 71 patients to the control arm and 73 to PREHAB. After excluding 19 patients due to changes in the surgical plan, 63 controls and 62 PREHAB patients were included in the intention-to-treat analysis. The PREHAB group enhanced aerobic capacity after prehabilitation (∆ET 135 (218) %; p-value Conclusions: Personalised PREHAB increased aerobic capacity in high-risk candidates for elective major abdominal surgery which can explain the enhanced clinical outcomes.

Background/Objective To assess the relationship between the presence of ascites detected by endoscopic ultrasonography (EUS) and peritoneal carcinomatosis (PC) in patients with pancreatic adenocarcinoma. Methods Consecutive patients who underwent a EUS for preoperative staging of a pancreatic adenocarcinoma between 1998 and 2014 were retrospectively reviewed. The diagnosis of PC was confirmed by histopathology or peritoneal fluid cytology. The main outcome of the study was the relationship of ascites at EUS and PC in patients with pancreatic cancer. Secondarily, to evaluate the relationship between this finding and survival as well as the development of PC during follow-up. Results A total of 136 patients were included: 30 patients with local unresectable tumor or metastatic disease and 106 potentially-resectable candidates based on CT staging. EUS showed ascites in 27 (20%) patients, of whom 8 (29.6%) had PC. The sensitivity, specificity, PPV, NPV and accuracy of ascites by EUS in the detection of PC in this group of patients were 67%, 85%, 30%, 96% and 83%, respectively. Ascites detected by EUS was the only independent predictive factor of PC with an OR of 11 (CI 95%: 3–40). The detection of ascites by EUS was associated with a shorter survival (median survival time 7,3 months; range 0–60 vs 14.2 months; range 0–140) (p = 0.018) and earlier development of PC during follow-up (median 3.2 months, range 1.4–18.1 vs 12.7 months, range 5.4–54.8; p = 0.003). Conclusion The finding of ascites at EUS in patients with pancreatic adenocarcinoma is highly associated with PC and a poor outcome.

Introduction Prehabilitation programs designed to improve functional status showed efficacy to increase functional capacity and to prevent postoperative complications in selected high-risk surgical populations. Patients awaiting heart transplantation (HT) usually exhibit poor quality of life and this situation usually progresses while waiting for HT. Objective to evaluate the effect of a multimodal prehabilitation program on quality of life and functional capacity in patients waiting HT. Methods Adult patients listed for HT were included. Exclusion criteria were hospitalized patients, clinical instability, refusal to participate and living far away or not availability for transportation to the hospital twice weekly. The prehabilitation program was initiated after baseline assessment and all participants were reassessed after having completed 8 weeks of program. The intervention consisted in exercise training and promotion of physical activity, nutritional counselling and whey protein supplementation when necessary and coping of the psychological stress using mindfulness therapy. The exercise training consisted in 2 sessions of 1 hour per week of personalized monitored supervised moderate to high-intensity interval training and endurance strength training at the hospital's outpatient gym during 8 weeks. All patients were instructed on breathing exercises with an incentive inspirometer. After 8 weeks, and until HT, patients followed a maintenance program consisted in 1 session per week of supervised training and were empowered to maintain their level of physical activity Results 24 patients were included in the study from July 2017 to April 2019 (21 males, Age 56+10). Two patients were transplanted before starting the program and 8 patients before the 8-weeks assessment. None of the patients withdrew from the study. Over the duration of the study, 9 enrolled patients were successfully transplanted. One patient asked to opt out from the HT waiting list after having completed the program. No complications occurred during the program. Discussion This study suggests that a multimodal prehabilitation program in patients awaiting HT is feasible, safe and may increase functional capacity and quality of life.

Introduction: The efficacy of prehabilitation (PreHab) to reduce surgical complications, and facilitate postoperative recovery, has been demonstrated (Ann Surg. 2018; 267(1):50-56). Deployment of PreHab as mainstream service at Hospital Clinic de Barcelona (HCB) has been undertaken. However, there is a need for consolidation of modular digital health tools to address two main aspects of service scalability: to empower patients for self-management at community level and to support collaborative work among professionals. Practice change implemented: PreHab has a trimodal approach including: supervised endurance training & promotion of physical activity, nutritional balance and psychological support (mindfulness). Supporting technologies include an adaptive case management platform to enhance collaborative work among health professionals and patients themselves using a mobile application for self-management at community level. Aim and theory of change: A recent design thinking process involving all stakeholders identified that transferability of the PreHab service can improve with modularity of both service workflow and digital health tools. Moreover, service accessibility and sustainability should be enhanced by shared care agreements with community-based services. Targeted population: Effectiveness and sustainability of PreHab is currently being assessed in a real world setting (HCB, 300 patients/yr.). Timeline: The technological support with full integration between community (patient) and health information systems at HCB (professionals) was implemented and is currently being evaluated. Next steps, during 2019, are: i) regional deployment of PreHab; ii) integration of the self-management platform into the regional personal health folder (La Meva Salut© - lamevasalut.gencat.cat), iii) evolution of the service toward a perioperative care program with a population-health approach; iv) refinement of the adaptive case management functionalities using the Camunda© (camunda.org) open source workflow and decision automation platform; and, v) transferability of selected traits of PreHab to rehabilitation of chronic stable patients. Highlights: The supervised endurance training sessions are managed and tracked with the proprietary Technogym® equipment (i.e. Mywellness). Patient self-management is based on MyPathway® (mypathway.healthcare). Integration with hospital information systems is performed using an open source HL7 FHIR API (i.e. HAPI). System usability is planned to be assessed by means of a Net Promoter Score survey in case of patients and the User Experience Questionnaire (UEQ) in case of healthcare professionals. Comments on sustainability: PreHab has shown potential for health value generation, both at provider and at health system levels, indicating that the operational costs can be fully covered by savings generated through adoption of the service. Comments on transferability: Regional transferability of PreHab is planned during 2019 and transferability at International level will be undertaken thereafter. Conclusions: PreHab digital health tools for patient self-management with off-line remote monitoring and access to a case manager are ready to be integrated with provider-specific and regional health information systems for a large scale development. Discussions: Individualized work plans should combine face to face supervised sessions and community-based remotely supervised activities, including access to partnering health/wellness centers. Lessons learned: Personalization and modularization of the service, as well as the supporting digital health tools, were identified as core traits to ensure adoption. Supported by CONNECARE H2020-689802, NEXTCARE COMRDI15-1-0016

The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection.Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved.All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens.This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

In this descriptive study, we examined the role of single-operator cholangioscopy (SOC) in the evaluation of biliary complications after liver transplantation (LT). We prospectively included adult recipients of deceased donor LT who were referred for endoscopic retrograde cholangiopancreatography between June 2009 and July 2011. All patients underwent SOC with biopsy of the biliary anastomosis. Sixteen patients were included: 12 with biliary anastomotic strictures (ASs), 2 with common bile duct stones, 1 with a bile leak, and 1 with sphincter of Oddi dysfunction. Patients with ASs displayed 1 of 2 patterns: (A) mild erythema (n = 9) or (B) edema, ulceration, and sloughing (n = 3). Those without ASs displayed a pale mucosa with mild edema at the anastomosis. Patients with ASs and pattern B required a longer period of stenting than patients with pattern A (457 versus 167 days, P = 0.02). In addition, patients with pattern A had a better response and better resolution of their strictures with endoscopic therapy than those with pattern B (66% versus 33%, P = 0.13). Histological examinations of ASs showed nonspecific intraepithelial inflammation in patients with patterns A and B. Biopsy samples from patients without ASs showed normal columnar epithelial bile duct cells. The total cholangioscopy time for all procedures was 26.8 ± 10.1 minutes. In conclusion, SOC in LT recipients is feasible and allows adequate visualization and tissue sampling of ASs and bile ducts. Two distinct visual patterns that are easily identified with SOC may help to predict the outcomes of endoscopic therapy in patients with biliary complications after LT.

Resumen Objetivos La intubacion con fibrobroncoscopio es la tecnica de eleccion para intubar a pacientes con via aerea dificil prevista y no prevista, que se pueden ventilar correctamente. Nuestro objetivo fue determinar si un curso practico e individualizado con esta tecnica era capaz de proporcionar suficiente entrenamiento y autoconfianza para permitir que los anestesiologos participantes practiquen rutinariamente la intubacion con fibrobroncoscopio tras el curso. Material y metodos En nuestro centro se realiza un curso practico e individualizado de intubacion con fibrobroncoscopio en pacientes con anestesia general, con sedacion en ventilacion espontanea y mediante dispositivos extragloticos. Entre 2005 y 2009 realizamos una encuesta via e-mail entre los participantes para autovalorar la adquisicion de habilidades durante el curso y su grado de satisfaccion. Resultados La encuesta se remitio a 77 alumnos, 6 meses despues de la realizacion del curso, con una respuesta del 61%. Todos los alumnos que respondieron se consideraron habiles con el manejo del fibrobroncoscopio al acabar el curso y, el 97% lo utilizo en su practica habitual en pacientes con via aerea dificil. Conclusion Estos resultados sugieren que la realizacion de cursos de intubacion con fibrobroncoscopio que, ademas de la teoria y la practica en maniquies, incluya pacientes con anestesia general y en ventilacion espontanea, tiene una alta tasa de exito en cuanto a la adquisicion de habilidades y autosuficiencia de los participantes.

The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE).Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d.Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P0.05 and P0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P0.01).Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.

Anastomotic strictures (ASs) of the biliary duct after liver transplantation (LT) are primarily managed with endoscopic retrograde cholangiopancreatography (ERCP), but in some cases, this fails because of difficulties in passing the strictures. The aim of this case-control study was to examine specific risk factors for initial ERCP failure and the outcomes of percutaneous transhepatic cholangiography (PTC) as a second-line approach in LT recipients with ASs. Between January 2002 and December 2010, we identified LT recipients with ASs who experienced initial ERCP failure (which was defined as the inability to traverse the AS with guidewires in 2 or more consecutive procedures). A period-matched control group (ratio = 1:2) with ASs and initial ERCP success was analyzed. Preoperative, intraoperative, postoperative, and endoscopic variables were evaluated as risk factors. The outcomes of PTC and the need for hepaticojejunostomy (HJ) or retransplantation were evaluated. Seventeen cases who experienced initial ERCP failure were compared with 34 controls. The median times from LT to ERCP were similar (8.7 months for cases and 8.6 months for controls, P = not significant). A multivariate analysis revealed that previous bile leaks [odds ratio (OR) = 6.07, 95% confidence interval (CI) = 1.0-36.5] and more than 4 U of intraoperatively transfused red blood cells (OR = 11.51, 95% CI = 1.9-71.2) were independent risk factors for failure. PTC was an effective second-line treatment in only 3 of 12 cases (25%). The need for HJ was more frequent for the cases (13/17 or 76.5%) versus the controls (7/34 or 20.6%, P < 0.001). One patient in each group underwent retransplantation (P = not significant). In conclusion, previous bile leaks and high packed red blood cell transfusion requirements during surgery are risk factors for initial ERCP failure in LT recipients with ASs. A high proportion of these patients will need surgery as their final therapy.

BACKGROUND: Rotation thromboelastometry (TEM) has been proposed as a convenient alternative to standard coagulation tests in guiding the treatment of coagulopathy during orthotopic liver transplantation (OLT). This study was aimed at assessing the value of TEM in monitoring blood coagulation and guide transfusion support in OLT. STUDY DESIGN AND METHODS: Standard coagulation and TEM (EXTEM and FIBTEM) tests were performed at four preestablished intraoperative time points in 236 OLTs and prospectively recorded in a dedicated database together with the main operative and transfusion data. Transfusion thresholds were based on standard coagulation tests. Spearman's rank correlation (ρ), linear regression, and receiver operating characteristic curves were used when appropriate. RESULTS: EXTEM maximum clot firmness (MCFEXTEM) was the TEM variable that best correlated with the platelet (PLT) and fibrinogen levels (ρ = 0.62 and ρ = 0.69, respectively). MCFFIBTEM correlated with fibrinogen level (ρ = 0.70). EXTEM clot amplitude at 10 minutes (A10EXTEM) was a good linear predictor of MCFEXTEM (R2 = 0.93). The cutoff values that best predicted the transfusion threshold for PLTs and fibrinogen were A10EXTEM = 35 mm and A10FIBTEM = 8 mm. At these values, the negative and positive predictive accuracies of TEM to predict the transfusion thresholds were 95 and 27%, respectively. CONCLUSION: A10EXTEM is an adequate TEM variable to guide therapeutic decisions during OLT. Patients with A10EXTEM of greater than 35 mm are unlikely to bleed because of coagulation deficiencies, but using A10EXTEM of not more than 35 mm as the sole transfusion criterion can lead to unnecessary utilization of PLTs and fibrinogen-rich products.

Given the severe shortage of liver donors, a carefully evaluation and selection of patients who are likely to obtain a significant survival benefit from liver transplantation (LT) is imperative in order to attain successful outcomes. Cardiovascular and respiratory events remain one of the leading causes of non-graft-related death in LT. A variety of pre-existing cardiac and pulmonary disorders are commonly identified in LT recipients, more so than in the general population. Uncertainties regarding the optimal assessment of cardiovascular and respiratory function in potential transplant candidates have produced a wide variation in the clinical care of tjis population. There is still no consensus on which assessment algorithm confers the best outcomes. Once the diagnosis has been established, the prognosis should be estimated for risk stratification and to confirm the candidacy for LT. Additionally, the challenge remains in knowing how cardiac or respiratory derangements in candidates affect the long-term outcome after LT and which is the magnitude of risk that we as physicians are willing to accept. This article discusses the cardiac and pulmonary aspects of liver disease that may impact recipient selection. Relevant literature focused upon the most common entities in this field is presented in this review.