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Title: Pre-operative cardiopulmonary exercise testing and oesophageal doppler guided fluid therapy in elective colorectal surgery
Author: Challand, Christopher Philip
ISNI:       0000 0004 2730 1911
Awarding Body: Exeter and Plymouth Peninsula Medical School
Current Institution: Exeter and Plymouth Peninsula Medical School
Date of Award: 2013
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Recent advances in peri-operative care and surgical technique have influenced the short-term outcomes for patients undergoing elective major colorectal surgery. Intraoperative Goal Directed fluid Therapy (GDT) has been shown to reduce length of stay and decrease morbidity in elective colorectal resections. Pre-operative Cardiopulmonary Exercise testing (CPET) characterises baseline aerobic fitness and may identify 'high-risk' patients more likely to benefit from GDT. COMPETE-C was a randomised, single-centre trial comparing the effect of oesophageal Doppler guided GDT against standard care in patients stratified by CPET as Unfit (AT 8.0-10.9 mI02/kg/min) or Fit (AT >11.0 mI02/kg/min). There was no observed benefit to administration of GDT, and it was associated with prolonged length of stay in patients classified as aerobically fit (8.8 vs. 6.0 days; p=0.06). PicoPEX was a pilot study to evaluate the effect of mechanical bowel preparation and carbohydrate-loading on aerobic fitness as measured by CPET in healthy volunteers. Neither intervention significantly worsened aerobic fitness but their clinical significance on patients undergoing major colorectal surgery was not addressed. A retrospective analysis of patients who underwent elective colorectal surgery during the study period revealed that decreased aerobic fitness was associated with prolonged total postoperative stay, particularly amongst "Very Unfit" patients with AT <8 mI02/kg/min and those undergoing rectal resections. Inability to pe arm a CPET was associated with significantly worse short- and medium- term mortality compared to those who completed the test. Concerns exist regarding the robustness of the evidence from GOT studies due to heterogeneity in the trial design and as the initial clinical benefits observed may have been offset by advances in surgical techniques and peri-operative care, and the type of resection performed. A meta-analysis was conducted to address whether Doppler guided GOT influenced total postoperative stay and complications rates when stratified according to type of resection performed. GOT did not improve outcome in terms of length stay but there was a reduction in complications suffered by those undergoing rectal surgery (p=O.04). Our results highlight the need for a large multi-centre study into the role of GOT with patients stratified according to aerobic fitness, surgical technique and planned resection.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available