Bernhard Riedel

• MB.ChB., M.Med., FCA., FASE., FANZCA., GrChPeriopMed. MBA., PhD.
• Head of Department at Peter MacCallum Cancer Centre

Background Evidence to support the effectiveness of intrathecal morphine in patients undergoing minimally invasive abdominal surgery is largely based on small, single-centre studies. We therefore designed a large, multi-centre clinical trial to investigate the effect of intrathecal morphine with local anaesthetic on patient postoperative quality of...

Background/Objective: Despite surgery being the primary curative treatment for cancer, patients with compromised preoperative physical, nutritional, and psychological status are often at a higher risk for complications. While various screening tools exist to assess physical, nutritional, and psychological status, there is currently no standardised...

Background Recovery from major surgery can be difficult to predict given the many factors involved in treating disease and restoring preoperative function. Postoperative recovery metrics such as length of stay, complications, and mortality are typically described. However, large data quantities for patient‐reported recovery are scarce. In this retr...

Perioperative Medicine: A Problem-Based Learning Approach provides a unique learning opportunity for the busy perioperative clinician who wants to read how others approach a case and for clinicians in training who need to learn the basics. Each chapter starts with a stem case, followed by a comprehensive, up-to-date discussion on the topic to make...

Preoperative assessment of functional capacity with the six-minute walk test (6MWT) allows for estimation of surgical risk and targeted triage to prehabilitation services. Patient with abdominal and pelvic cancers have worse preoperative function compared with the general population. However, six-minute walk distance (6MWD) reference values from ca...

BACKGROUND The objective of this systematic review and meta-analysis was to update the body of evidence on the efficacy of prehabilitation with exercise interventions, in reducing postoperative complications and length of hospital stay after cancer surgery. METHODS A comprehensive literature search was conducted on MEDLINE, Embase, The Cochrane Li...

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, l...

Introduction: The views of patients and carers are important for the development of research priorities. This study aimed to determine and compare the top research priorities of cancer patients and carers with those of multidisciplinary clinicians with expertise in prehabilitation. Materials and methods: This cross-sectional study surveyed patie...

BACKGROUND Colorectal cancer (CRC) is the second most frequent cause of global cancer mortality. Most patients with CRC require surgical tumour resection, with certain stages of CRC (Stage II/III) also requiring postoperative chemotherapy. The timing of postoperative chemotherapy is largely determined by postoperative recovery. Delayed return to in...

Background Surgery is essential for curative treatment of solid tumors. Evidence from recent retrospective clinical analyses suggests that use of propofol-based total intravenous anesthesia during cancer resection surgery is associated with improved overall survival compared to inhaled volatile anesthesia. Evaluating these findings in prospective c...

Background: Colorectal cancer is a major cause of morbidity and mortality in Australia. Following colorectal cancer surgery, although systemic opioids are often first-line analgesia, they may be associated with various adverse effects. Intrathecal morphine (ITM) has been shown to provide good analgesia with a safe side effect profile. This study as...

Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However,...

Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO 2), with significant prognostication for postoperative complications. However...

Background Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery. Methods The Delphi methodolog...

Background Thoracic epidural analgesia is commonly used for upper gastrointestinal surgery. Intrathecal morphine is an appealing opioid-sparing non-epidural analgesic option, especially for laparoscopic gastrointestinal surgery. Methods Following ethics committee approval, we extracted data from the electronic medical records of patients at Royal...

Background: Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendat...

Background: Mortality, morbidity, and organ failure are important and common serious harms after surgery. However, there are many candidate measures to describe these outcome domains. Definitions of these measures are highly variable, and validity is often unclear. As part of the International Standardised Endpoints in Perioperative Medicine (StEP...

Background: Cardiopulmonary exercise testing (CPET) objectively informs preoperative risk stratification prior to major surgery. CPET facilities are resource intensive and therefore more cost-effective triage methods are desirable for scalability. We tested two dynamic CPET parameters (end-tidal CO2 (PetCO2) and heart rate (HR)) to early phase exe...

Introduction Prehabilitation is increasingly recognised as a therapeutic option to reduce postoperative complications. Investigating the beneficial effects of exercise on cellular mechanisms, we have previously shown that a single episode of exhaustive exercise effectively stimulates endothelial progenitor cells (a cell population associated with v...

Background Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery. Methods Eligible patie...

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse ep...

Background: Preoperative risk stratification is used to derive an optimal treatment plan for patients requiring cancer surgery. Patients with reversible risk factors are candidates for prehabilitation programmes. This pilot study explores the impact of preoperative covariates of comorbid disease (Charlson Co-morbidity Index), preoperative serum bio...

Background Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients’ fitness during the preoperative period may enhance postoperative recovery. Thus, th...

Background Reproducible assessment of postoperative complications is essential for reliable evaluation of quality of care to enable comparison between healthcare centres and ensure transparent patient counselling. Currently, significant discrepancies exist in complication reporting and grading due to heterogeneous definitions and methodologies. Ob...

Effective pain control enhances patient recovery after surgery. Laparoscopic techniques for major abdominal surgery are increasingly utilised to reduce surgical trauma. Intrathecal morphine is an attractive analgesic option that is gaining popularity. However, limited evidence guides its use in the setting of laparoscopic surgery. In addition, enha...

Purpose of Review This review aims to provide an overview of the current evidence for prehabilitation in frail, older surgical patients and to provide a pragmatic approach for implementation into routine perioperative care. Recent Findings There is increasing evidence for the use of prehabilitation strategies to improve postoperative outcomes. How...

Background In the recent years, an increasing number of patients with multiple comorbidities (e.g. coronary artery disease, diabetes, hypertension) presents to the operating room. The clinical risk factors are accompanied by underlying vascular-endothelial dysfunction, which impairs microcirculation and may predispose to end-organ dysfunction and i...

Background: The endothelial glycocalyx, a carbohydrate-rich layer coating all endothelial surfaces, plays a fundamental role in the function of microcirculation. The primary aim of this study was to evaluate the feasibility of using dexamethasone and albumin to protect the endothelial glycocalyx in patients undergoing abdominal surgery. Secondary...

Prehabilitation in conjunction with the Enhanced Recovery After Surgery (ERAS) program aims to promote earlier return to baseline function and reducing postoperative complications. This is particularly important in managing gastrointestinal cancer (GI) patients undergoing surgery. An evidence-based critique will be made in regard to the prehabilita...

Autologous free-flap reconstructive surgery has become an integral part of surgical oncology. It allows for more aggressive and definitive resection of solid tumors and the repair of defects left by nonsurgical therapies. The current anesthetic practice is variable, reflecting a paucity of high-level evidence guiding best practice in this field. De...

Background Prehabilitation services assist patients in preparing for surgery, yet access to these services are often limited by geographical factors. Enabling rural and regional patients to access specialist surgical prehabilitation support with the use of telehealth technology has the potential to overcome health inequities and improve post-operat...

Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation s...

Purpose of review: Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term...

Objectives: This systematic review set out to identify, evaluate and synthesise the evidence examining the effect of prehabilitation including exercise on postoperative outcomes following abdominal cancer surgery. Methods: Five electronic databases (MEDLINE 1946-2020, EMBASE 1947-2020, CINAHL 1937-2020, PEDro 1999-2020, and Cochrane Central Registr...

PurposePrehabilitation programs are effective in optimising patient’s functional reserve prior to surgery and increasingly associated with reduced postoperative complications. However, acceptability of programs among patients is largely unknown. This study set out to explore the acceptability of prehabilitation from the perspective of patients awai...

Published data suggest that the type of general anaesthesia used during surgical resection for cancer may impact on patient long-term outcome. However, robust prospective clinical evidence is essential to guide a change in clinical practice. We explored the feasibility of conducting a randomised controlled trial to investigate the impact of total i...

Background: Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of...

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesi...

Background Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of s...

Peptide receptor radionuclide therapy (PRRT) is an effective treatment for metastatic carcinoid tumours but can precipitate a carcinoid crisis through release of stored bioamines. Cardiac arrest is an uncommon manifestation of carcinoid crisis and has never been reported as a complication of PRRT. We report a case of a 58-year old female who suffer...

Practising anaesthetists who are Fellows of the Australian and New Zealand College of Anaesthetists were surveyed with the objective of gaining insight into current analgesic preferences, with particular regard to neuraxial techniques, when managing patients having major open and laparoscopic abdominal surgery. Major abdominal surgery is common and...

Background Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. Methods In this secondary cross-sectional analysis of the...

To the Editor We would like to congratulate Carli et al¹ for exploring multimodal prehabilitation in frail patients prior to colorectal cancer resection. Before perioperative clinicians abandon prehabilitation in frail patients as a preemptive strategy to engender good postsurgical outcomes, we would like to draw attention to the necessity of optim...

Efforts to reduce postoperative venous thromboembolism are challenging due to heterogeneity in thromboprophylaxis practice. As a result, a 'one-size-fits-all' approach that accounts for surgery-specific risk, but fails to account for patient-level variation, is often adopted by healthcare networks. Updated clinical practice guidelines have advocate...

Background International normalized ratio (INR) is used as a marker of the haemostatic status following liver resection. However, the impact of liver resection on haemostasis is complex and beyond what can be measured by INR. This study aimed to prospectively assess haemostatic profile following liver resection and determine if INR measurement can...

Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra‐abdominal pressure. Studies are conflicting on whether meaningful improvements in quality of recovery occur beyond emergence, and whether lower intra‐abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adu...

Background: The Duke Activity Status Index (DASI) questionnaire might help incorporate self-reported functional capacity into preoperative risk assessment. Nonetheless, prognostically important thresholds in DASI scores remain unclear. We conducted a nested cohort analysis of the Measurement of Exercise Tolerance before Surgery (METS) study to char...

Purpose The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by β-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative β-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the pri...

Background: The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. Methods: We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific...

Background Preoperative anaemia is associated with elevated risks of postoperative complications. This association may be explained by confounding related to poor cardiopulmonary fitness. We conducted a pre-specified substudy of the Measurement of Exercise Tolerance before Surgery (METS) study to examine the associations of preoperative haemoglobin...

There was an isolated error relating to the Oh et al. study (1) within our recurrence-free survival analysis. When the reported estimates for Oh et al. are corrected, the pooled hazard ratio (HR) is now 0.87; 95% confidence interval (CI), 0.66 to 1.15; P=0.32.

Background: Clinical indicators are powerful tools to quantify the safety and quality of patient care. Their validity is often unclear and definitions extremely heterogeneous. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid clinical outcome...

Cancer-related mortality, a leading cause of death worldwide, is often the result of metastatic disease recurrence. Anesthetic techniques have varying effects on innate and cellular immunity, activation of adrenergic-inflammatory pathways, and activation of cancer-promoting cellular signaling pathways; these effects may translate into an influence...

Background Value-based healthcare is strongly advocated to reduce the spiralling rise in healthcare expenditure. Operating room efficiency is an important focus of value-based healthcare delivery due to high costs and associated hospital revenue derived from procedural streams of care. A parallel induction design, utilising induction rooms for anes...

Background: Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clin...

Purpose Preoperative fitness training has been listed as a top ten research priority in anesthesia. We aimed to capture the current practice patterns and perspectives of anesthetists and colorectal surgeons in Australia and New Zealand regarding preoperative risk stratification and prehabilitation to provide a basis for implementation research. Me...

Prevention of cancer-associated thromboembolism (TE) remains a significant clinical challenge and priority world-wide safety initiative. In this prospective non-small cell lung cancer (NSCLC) cohort, longitudinal TE risk profiling (clinical and biomarker) was undertaken to develop risk stratification models for targeted TE prevention. These were co...

Perioperative morbidity and mortality are common following lung resection, with most deaths (>75%) attributed to major adverse pulmonary events (MAPE; including pneumonia, acute lung injury [ALI], and acute respiratory distress syndrome [ARDS]). Perioperative risk can be managed by dividing risk into two broad categories: iatrogenic risk and patien...

Purpose of Review The aging, sedentary global population and associated increasing incidence of cancer calls for increasingly complex surgery. These patients are at particular risk of postoperative complications. This review will explore the redesign of the perioperative care pathway, with emphasis on preoperative risk stratification to identify mo...

Background This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. Methods A wide database search on English literature publications was performed. Studies on ea...

Background: The 6-min walk test (6MWT) is a common means of functional assessment. Its relationship to disability-free survival (DFS) is uncertain. Methods: This sub-study of the Measurement of Exercise Tolerance for Surgery study had co-primary outcome measures: correlation of the preoperative 6MWT distance with 30 day quality of recovery (15-i...

Increasing evidence suggests that total intravenous anaesthesia (TIVA) may be the preferred anaesthetic for cancer resection surgery. To assist the preparation of a randomised controlled trial (RCT) examining Volatile (versus TIVA) Anaesthesia and Perioperative Outcomes Related to Cancer (VAPOR-C) we developed an 18-question electronic survey to in...

Background: Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duk...

Background: The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, g...

Background: The biological perturbation associated with psychological and surgical stress is implicated in cancer recurrence. Preclinical evidence suggests that beta-blockers can be protective against cancer progression. We undertook a meta-analysis of epidemiological and perioperative clinical studies to investigate the association between beta-b...

Global health is a continuously evolving eld of study and practice, and learning materials replete with contemporary examples and a cosmopolitan view of health in all human populations are in high demand. Dr Armstrong-Mensah has broadly succeeded with this ambitious task in the form of her recent textbook, drawn from first-hand experience in both t...

PurposeThe Duke Activity Status Index (DASI), a patient-administered questionnaire, is used to quantify functional capacity in patients undergoing cancer surgery. Methods This retrospective cohort study assessed whether the DASI was accurate in predicting peak oxygen consumption (pVO2) that was objectively measured using cardiopulmonary exercise te...

Cancer, currently the leading cause of death in the population aged less than 85 years, poses a significant global disease burden and is anticipated to continue to increase in incidence in both developed and developing nations. A substantial proportion of cancers are amenable to surgery, with more than 60% of patients undergoing tumour resection. U...

The United States Navy uses a visual feedback system for pilots, named ‘the Greenie Board’, to improve flight manoeuvres on aircraft carriers. Given that increased compliance with enhanced recovery after surgery protocols reduces postoperative complications, we decided to apply a similar feedback system to our institutional enhanced recovery progra...

Background: There is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. Methods: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO...