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Mohan et al. Hepatoma Res 2020;6:13 I http://dx.doi.org/10.20517/2394-5079.2019.53 Page 5 of 10

and embraces the concept of “River of Life”. This defines five segments of care - Living Well, Living with
Illness, Crisis and Complex Care, Living with Frailty and Leaving Well - rooted by strong partnerships
amongst care providers. Six population care streams feed into “River of Life” - Preventive Care, Primary
Care, Hospital Care, Intermediate Care, Transitional and Community Care, End-of-Life and Long-Term
Care. With the increasing burden of chronic diseases, primary care will take on an even bigger role in the
community. Though there are reports of safe surgery with acceptable outcomes in elderly as compared
to non-elderly [32,33] ; elderly do have additional needs to ensure comparable outcomes. Hence, additional
resources have to be invested to achieve good outcomes. ROSE program was initiated in 2018 by a
multidisciplinary group of healthcare professionals who recognized the need for our elderly patients to be
optimized prior to major abdominal oncology surgery. It aims to identify elderly (> 65 years old) and frail
patients and our discussion in this chapter is relevant to elective liver resection.

CURRENT IMPLEMENTATION OF ROSE
Target population
Not all elderly patients are the same and hence patient selection is essential to streamline the resources.
One method of patient selection is by virtue of risk prediction. Various risk prediction models are reported in
diverse pathologies and surgeries to enhance resource allocation [18,34,35] . A prospective study on 162 patients
[36]
undergoing hepatopancreaticobiliary surgery by van der Windt et al. , showed that scoring systems such
as the Risk Analysis Index, was able to accurately predict post-operative outcomes in patients. The study
further elaborates on the possible use of such a scoring system to identify target groups for prehabilitation
to optimise outcomes. Tan Tock Seng Hospital Nutrition Screening Tool is a locally developed tool which
[37]
is validated against subjective global assessment in a cohort of elderly patients . In a local study including
281 acute admissions with age range of 61-102 years, Tan Tock Seng Hospital Nutrition Screening Tool
predicted risk of malnutrition with high accuracy (area under the curve 0.87) and malnutrition predicted
[37]
6-month mortality (adjusted OR = 2.2; P = 0.05) and hospital length of stay (P < 0.05).

Currently ROSE program is piloted for patients who undergo liver, pancreas and colorectal surgeries.
Initially, patients (≥ 65 years old) are screened for frailty and malnutrition. Those at risk will be enrolled
into ROSE program [Figure 2].

Multidisciplinary team
Upon decision for liver resection, an assessment of frailty and nutrition is done by consultant surgeon.
Patient who fulfil the criteria are then sent to allied healthcare members to be enrolled and seen as part of
the ROSE program. Members of the program and their role are as follows (further details on workflow in
Appendix 1).

Dietician
Nutritional counseling pre and post operatively: the role of the dietician has been studied in multimodal
[38]
care teams such as in Poindessous et al. which demonstrates the benefit in a dietician functioning as an
educator as well, with decreased recidivism and increased return to independence.

To obtain initial anthropometric and to conduct subjective global assessment: this is especially important
[39]
in context of liver resection as malnutrition is very common in patients with cirrhosis and to add to this,
[40]
precise evaluation of their nutrition status is difficult with the presence of ascites and edema . A review
[41]
by Doherty et al. identifies intra hepatic fat as an independent risk factor for post-operative morbidity
following hepatic resection. Dietary interventions such as calorie restriction, carbohydrate restriction or a
[40]
Mediterranean diet have shown reductions in pre-operative intra hepatic fat by up to 55% .