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Mohan et al. Hepatoma Res 2020;6:13 I http://dx.doi.org/10.20517/2394-5079.2019.53 Page 7 of 10

Nutritional supplementation and monitoring pre and post-operatively: supplementation could include
Branch chain amino acids for protein and glycogen synthesis promotion and for the regulation of immune
[40]
system .
Glutamine is a conditionally essential amino acid and is a fuel for neutrophils, lymphocytes and
[43]
[42]
enterocytes . A Cochrane review reporting 4671 patients with critical illness or elective major surgery
showed that glutamine supplementation reduced infection rates by 21% and days on mechanical ventilation
by 0.69 days.

Physiotherapist
To assess objective and subjective markers of functional capacity pre and post-operatively: 6-min walk
test, sit to stand test, Gait speed test and balance tests. Structured exercise program, either inpatient or
[44]
outpatient is essential to prehabilitation , these show improved outcomes such as in functional physical
tests such as the 6MWT.

To conduct physiotherapy sessions pre operatively to increase functional capacity, respiratory function and
[45]
mobility training in preparation for post-operative period: in a review by Guinan et al. on patients who
underwent esophagectomies, it was reported that inspiratory muscle training conducted by physiotherapists
may improve post-operative outcomes such as lowering hospitalization by 4.5 days and reducing the rate of
high grade post-operative pulmonary complications.

To conduct physiotherapy as required to rehabilitate to baseline fitness post operatively.

Nurse
Modified Barthel Index assessment pre and post operatively: this is to ascertain patients pre and post-
operative baselines and ensure return to function. In a study by Fortinsky et al. on 89 chronically ill
[46]
patients, the Modified Barthel Index was able to reliably measure and track patient’s ability to perform
activities of daily living effectively. Furthermore, the Modified Barthel Index was easy to administer without
[47]
much variability in reporting activities of daily living .
Geriatric surgery service
Peri-operative medicine aims to provide high quality evidence based cross-specialty multidisciplinary
[48]
care for surgical patients. Partridge et al. has reported a prospective randomized controlled study
including 176 patients aged 65 years and older undergoing elective aortic aneurysm repair or lower-limb
arterial surgery comparing standard preoperative assessment with preoperative comprehensive geriatric
assessment and optimization. They reported lower incidence of delirium (11% vs. 24%, P = 0.018), cardiac
complications (8% vs. 27%, P = 0.001) and bladder/bowel complications (33% vs. 55%, P = 0.003) in the
intervention group. We have a geriatric surgical service capability with a consultant lead team and includes
geriatric trained nursing staff. The team assists in managing diverse care needs upon referral: (1) optimize
medical co-morbidity and assist with peri-operative care; (2) combined care provided by the geriatrician,
[49]
anesthesiologist and surgeon is pivotal in the functioning of the prehabilitation program .

Financial counselor
Finance is an important element of health care and often considered less important in context of public
healthcare as treatment/intervention is “paid for” by the state in many high income countries. In Singapore,
patient co-share the cost burden and hence it is imperative to appropriately counsel patients with estimated
bill size and how does it vary based on different choices of therapy, e.g., open surgery vs. laparoscopic
surgery, etc. A trained professional supplements the multidisciplinary team for this task and the role is: (1)
to ensure financial security and if needed to counsel patients on financial aid programs pre operatively; (2)