BackgroundOutcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.MethodsPatients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.ResultsSeven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien–Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.ConclusionsVO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.Clinical trial registrationNCT03637647.

Shared decision making is a collaborative process between clinicians and patients, which aims to select the most suitable management option based on both best available evidence and patient preferences. This article looks at the role of shared decision making in perioperative medicine.

British Journal of Hospital MedicineVol. 79, No. 10 RegularsCardiopulmonary exercise testing: valuable stratification tool or waste of time?David Timbrell, Pradeep PrabhuDavid TimbrellSearch for more papers by this author, Pradeep PrabhuSearch for more papers by this authorDavid Timbrell; Pradeep PrabhuPublished Online:5 Oct 2018https://doi.org/10.12968/hmed.2018.79.10.598AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Levett DZH, Jack S, Swart M et al.; Perioperative Exercise Testing and Training Society (POETTS). Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth. 2018 Mar;120(3):484–500. https://doi.org/https://doi.org/10.1016/j.bja.2017.10.020 Crossref, Medline, Google ScholarMoran J, Wilson F, Guinan E, McCormick P, Hussey J, Moriarty J. Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review. Br J Anaesth. 2016 Feb;116(2):177–191. https://doi.org/https://doi.org/10.1093/bja/aev454 Crossref, Medline, Google ScholarReeves T, Bates S, Sharp T et al.; Perioperative Exercise Testing and Training Society (POETTS). Cardiopulmonary exercise testing (CPET) in the United Kingdom—a national survey of the structure, conduct, interpretation and funding. Perioper Med (Lond). 2018 Dec;7(1):2. https://doi.org/https://doi.org/10.1186/s13741-017-0082-3 Crossref, Medline, Google ScholarYoung EL, Karthikesalingam A, Huddart S et al.. A systematic review of the role of cardiopulmonary exercise testing in vascular surgery. Eur J Vasc Endovasc Surg. 2012 Jul;44(1):64–71. https://doi.org/https://doi.org/10.1016/j.ejvs.2012.03.022 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 October 2018Volume 79Issue 10ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 5 October 2018 Published in print 2 October 2018 Information© MA Healthcare LimitedPDF download

Decision making through multidisciplinary teams offers an opportunity to improve perioperative care for high-risk surgical patients. While multidisciplinary team decision making is commonplace in the NHS, involvement of perioperative physicians including anaesthetists and intensivists in this process is not well established. This article presents an exemplar of anaesthetic and intensivist involvement in a joint perioperative upper gastrointestinal cancer multidisciplinary team meeting at the Royal Surrey County Hospital in Guildford, UK. It is hoped that this model example and critical analysis will assist others who are interested in improving perioperative shared decision making in their units.

Tracheostomy is a procedure that has evolved over many hundreds of years. In the 21st century, the majority of tracheostomies are now inserted by intensivists in the intensive care unit (ICU). Commonly performed to assist in weaning patients from mechanical ventilation, the procedure is performed using a percutaneous dilatational technique. Percutaneous tracheostomy can generally be performed safely in the ICU, although a number of contra-indications and complications do exist. Recent publications have highlighted weaknesses in the quality of care both in the immediate and longer term. Consequently, a number of organizations, based in the UK and internationally, have turned the focus in recent years to improving the quality of care delivered to these patients. Clinicians caring for patients with tracheostomies should not only be familiar with the indications, anatomy and insertion techniques, but also current guidance on routine care and the emergency management of complications.

Objectives: Improving outcomes for high risk surgical patients has formed the basis for the rapid emergence of perioperative medicine as a subspecialty of anaesthesia.1 It has been suggested that a multidisciplinary team (MDT) approach – “the Perioperative MDT” - may provide a useful forum to coordinate these efforts.2 While MDT decision-making is already well established in many areas of the NHS, involvement of anaesthetists is often ad-hoc at best. In 2015, a joint anaesthetic & surgical ‘Perioperative’ MDT meeting (MDTM) was introduced at our institution for Upper Gastrointestinal (UGI) cancer patients. We report our findings of the workload and outcomes of this exemplar Perioperative MDT.

Abstract Background Cardiopulmonary exercise testing (CPEX) is an objective measure of functional capacity adapted to predict post-operative morbidity. CPEX may also identify optimisable cardio-respiratory comorbidity, prompting treatment modification or specialist referral. The role of CPEX in patient optimisation before oesophago-gastrectomy is yet to be evaluated. This study aims to assess the utility of CPEX in altering management and optimising patients prior to oesophago-gastrectomy. Methods All patients who underwent pre-operative CPEX testing and two phase oesophago-gastrectomy (January 2012 to January 2018) were included. All changes in patient management brought about by CPEX findings were evaluated. In addition, the role of validated risk-stratifying CPEX parameters (anaerobic threshold (AT), VO2 peak and FEV1) in predicting post-operative complications was assessed. Results 236 patients underwent surgery. Median AT and VO2 peak were 11.95(7–24)ml/kg/min and 773(403–1552)ml/min/m2 respectively. 46% (109/236) of patients (VO2 peak > 800ml/min/m2) were graded ‘low risk’, 42% (99/236) ‘intermediate risk’ (VO2 peak = 600–800ml/min/m2), and 12% (28/236) ‘high risk’ (VO2 peak < 600ml/min/m2) for developing post-operative cardio-pulmonary complications. Based on CPEX findings, management plans were altered in 84 patients (36%). Cardiac comorbidity was identified in 55 patients (23%) with immediate alteration of cardiac medications in 9% (21/236) and another 11% (27/236) requiring specialist cardiology review. Medication for respiratory optimisation was initiated in 3% (7/236) and formal respiratory review sought in 5% (12/236). ‘Intermediate’ and ‘high risk’ patients had similar rates of overall complication (63% vs 63%, P = 1.00), cardio-pulmonary complication (48% vs 47%, P = 0.17), anastomotic leak (11% vs 15%, P = 0.33) and 90-day mortality (6% vs 4%, P = 0.40) compared with ‘low risk’ groups. CPEX variables (AT, VO2 peak, FEV1) did not predict complications, length of critical care or overall stay on Receiver Operating Characteristic curves (AUROC < 0.5) and multivariate logistic regression models. Conclusion CPEX findings changed management in 36% of patients, enabling optimisation before oesophago-gastrectomy. ‘Confounding by intention’ is a bias reducing the strength of association between test results and post-operative complications due to the propensity to medically intervene on the basis of the test findings. This study highlights the possibility that the high intervention rate may explain the poor correlation between test results and post-operative outcome. Disclosure All authors have declared no conflicts of interest.

Objectives: Impaired functional exercise capacity, measured by cardiopulmonary exercise testing (CPET), is associated with increased postoperative morbidity and mortality.1 Haemoglobin concentration is an important determinant of blood oxygen-carrying capacity and is commonly measured in surgical patients as preoperative anaemia is well known to be associated with poorer postoperative outcomes.2 Reduced haemoglobin concentration has previously been shown to reduce functional exercise capacity.3 We, therefore, sought to identify whether a correlation exists between haemoglobin concentration and CPET variables.