1. Gary Minto Consultant Anaesthetist www.bowelcancerwest.org.uk HOW DO WE ASSESS PATIENTS FOR MAJOR SURGERY?

2. www.bowelcancerwest.org.uk Surgical mortality, UK

3. Why Is Surgery Bad For You?  A Premeditated and Calculated Trauma  Mishaps, bleeding  Systemic Inflammatory Response –Increased VO 2 (Fitness) –Hypercoagulability (Stents, DVT, stroke) –Metabolic Response (Diabetes, Renal)  Psychological (“Sickness”)

4. Complications after Colorectal Surgery

5. Risk Stratification Scoring Systems  ASA  Lee Revised Cardiac Index  APACHE Score  POSSUM Score Anaesthetic Hunch?

6. A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = Outcome Iezzoni, L. I. An introduction to risk adjustment. Am J Med Qual 11, S8-11 (1996).

7. A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = Outcome Comorbidity “aerobic fitness/ functional capacity” Genetics

8. Hammill 2008 Procedure 30d Mortality (%) With CAD With CCF AAA4.85.810.3 Ca Colon 5.46.311.9 Ca Lung 5.16.010.2 THR2.93.88.4

9. Cardio-Pulmonary Exercise Testing (CPET)

11. Clinic No clinic 30 day mortality 2%6% Critical Care 24%12%

12. A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation severity of surgery, urgency what happens during surgery stress response (genetics)

13. A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = intra-op and post op complications response to complications / level of care decision-making process

14. www.bowelcancerwest.org.uk

16. ANY QUESTIONS?