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Page 4 of 10 Mohan et al. Hepatoma Res 2020;6:13 I http://dx.doi.org/10.20517/2394-5079.2019.53
[20]
surgery, Nakajima et al. reported improvements in serum albumin levels and reduction in hospital stay
length but no difference in complication rates. Low serum albumin is associated with increased morbidity in
[21]
[22]
elective and emergency procedures . In 40 patients undergoing pancreaticoduodenectomy, Ausania et al.
reported improvement in delayed gastric emptying but not in post-operative complications such as post-
operative pancreatic fistula. Most studies do not report significant negative outcomes even though some
trials fail to demonstrate benefit.

Outcomes of success of prehabilitation program are multifaceted: (1) mortality/morbidity related outcomes:
disease progression during prehabilitation, infectious morbidity during prehabilitation; (2) resource
related outcomes: total cost of care, value driven outcomes; and (3) efficacy related outcomes: length of
stay, admission to rehabilitation unit, morbidity/mortality post operatively, long term disease progression,
acceptance of chemotherapy and adjunct therapy post operatively.

Most trials report clinical outcomes through careful patient selection and elimination of emergent
[23]
cases and those in need of urgent intervention. Janssen et al. has reported single centre uncontrolled
before and after study including 627 patients aged 70 years and older and undergoing elective abdominal
surgery for colorectal carcinoma or aortic aneurysm. The prehabilitation group received interventions to
improve patients’ physical health, nutritional status, frailty and anaemia prior to surgery. With a mean
prehabilitation of 39 days duration, they showed that the incidence of delirium was reduced significantly
[24]
from 11.7% to 8.2% (OR = 0.56, 95%CI: 0.32-0.98, P = 0.043). Some studies such as that by Nielsen et al.
report that even though intervention costs increase, overall costs reduce by about 15%; however, this
remains to be validated for liver resection.

Prehabilitation has also shown improved outcomes in patients with liver resection. For most of these
patients the effects of ageing are compounded by ongoing cirrhosis and oncological burden. A prospective
study including 104 patients treated with elective liver resection showed reduced overall complication rates
[25]
by up to 22.9% and median length of hospital stay by 2.5 days less . The authors also highlighted social
benefits of prehabilitation. These included less social issues that may delay discharge, increased quality
[25]
of life and reduced median cost by up to 16.5% . Though this study was not randomized and included
small sample, it sets the precedent for positive outcomes of prehabilitation. Another trial by Dunne et al.
[26]
on 35 randomized patients undergoing liver resection for colorectal liver metastases, reported significant
preoperative score increase in both mental and physical aspects of the Short Form Health Survey 36.
This supports the idea of both quality of life and physical fitness improvement due to prehabilitation. In
[27]
a review by Tandon et al. , elderly patients with cirrhosis have shown improvements in muscle mass,
strength and functional capacity. They have also reported reduction in hepatic venous gradient and hepatic
steatosis. These results were replicated in a review by Locklear et al. which showed such decreases in
[28]
hepatic venous gradient and increased scores on 6-min walk tests for patients with end stage liver disease.
Prehabilitation includes components of ERAS and more comprehensive preoperative strategy. ERAS
[29]
has shown lower major complication rates and reduced cost in patients undergoing liver resection . A
systemic review on ERAS application in liver surgery by Brustia et al. suggests positive outcomes such as
[30]
reduced time taken for functional recovery by 2.5 days. Similar to ERAS, the American College of Surgeons
[31]
have implemented a program called strong for surgery , which is aimed at identifying and evaluating
evidence-based practices to optimize the health of patients before surgery. It includes optimisation of
nutrition, smoking cessation, pain control and prehabilitation. We have started ROSE program at Tan Tock
Seng Hospital, Singapore to improve outcomes of elderly patients undergoing elective liver resection. In
this paper we shall discuss our protocol of implementation of ROSE program.

ROSE
In Singapore, a population health strategy is designed to meet evolving healthcare needs for ageing society
and “future ready”. National Healthcare Group is the central cluster serving a population of 1.4 million