Masterclass 3 - Enhancing Perioperative Care

Pre-operative care makes significant impact on the overall surgical process. With the increasing number of surgical procedures conducted in patients with advanced age and multiple medical co-morbidities, the complexity and risk of procedures are also on the rise, despite technological advancement and introduction of minimally invasive surgery. Well-managed pre-operative care can potentially reduce procedure-related or medically-related complications and positively influence post-operative recovery.
Once the surgical decision is affirmed, comprehensive pre-operative assessment should follow. No dobut the collaborations between the surgical and anaesthetic team are essential but increasingly specialists from other disciplines such as internal medicine and geriatrics are involved. However, since the surgeons hold the primary responsibility to the patients, appropriate general assessment such as the geriatric vulnerabiltiy screens or frailty scoring should be performed by surgeons before consulting colleagues from other specialties.
Risk stratification is important because of its impact on surgical decision-making and how to optimize patients pre-operatively. The availability of more accurate risk prediction could help both the care team and patients (as well as their families) in making decisions on various treatment options. Such risk predictions can be general and procedure-specific.
Patient education and communication are part of our duty of care to patients. Through appropriate risk disclosure and explanations, we can help patients set realistic expectations for the post-operative period, and address their concerns and worries. Such communication can also motivate patients to actively take part in prehabilitation programmes in preparing for the surgical procedures.

With the advances in diagnostic, medical therapy, surgical and anaesthetic care, curative or palliative surgery can be considered in older patients or those having more complicated background medical conditions whom may have been precluded from surgical options by patients himself or the clinical team in the past because of the anticipated high perioperative complication rate. With the introduction of preoperative Cardiopulmonary Exercise testing, we are able to not only evaluate one’s cardiopulmonary reserves and thus fitness to combat the peri-operative stress more precisely and objectively, but also to describe one’s impairment profile that provides a foundation for optimization possible through an integrated prehabilitation programme that involved medical optimization, physical training, nutritional intervention and health behavioural modification.


In our centre, we have pioneered a service model collaborated with the anaesthesiologists and surgeons. Patients planned for high risk non-cardiac surgery are co-evaluated by anaesthesiologists and prehabilitation physicians clinically and by CPET assessment. Patients with borderline performances with low VO2 Peak/ VO2 AT +/- high VE/VCO2 were recruited for a 2 – 4 weeks integrated prehabilitation training with pre-determined goal. Most patients are considered high-exercise risk because of the background comorbidity and required specialist-led training. Different from service models elsewhere, medical review and optimization are provided concurrent to the exercise training under close medical supervision if possible. Surgery will be proceeded as planned once the goal is achieved within the operable time frame. For those performed less favourably, they are counselled preemptively along the prehabilitation “journey” in order to facilitate a final shared decision that is to the best interest of that patient.

Enhanced Recovery After Surgery ("ERAS"), developed about two decades ago, has revolutionised perioperative care. Aiming at improving patient outcomes, it is evidence based but challenges the traditional practices. TKOH was among the first batch of hospitals that implemented ERAS in this locality. In 2015, our multidisciplinary team commenced implementation of ERAS program in colorectal surgeries.


Over the years, we expanded our scopes of ERAS to cover most major surgeries in different surgical stream specialties and our breadth of ERAS by introducing more strategies, including the most notable one, patient blood management.


While implementing ERAS may not be an easy task, sustaining it after implementation, indeed, is considered more challenging. This topic will be specifically discussed in this presentation.

In recent years, there has been a growing emphasis on enhancing healthcare efficiency and patient satisfaction, particularly in the field of day case surgery. This presentation aims to explore strategies for improving day case surgery delivery in Hong Kong, focusing on key areas such as patient selection, preoperative assessment, intraoperative care, and postoperative management.


The evolution of day case surgery in Hong Kong public hospitals represents a significant journey characterized by innovation, adaptation, and the pursuit of enhanced healthcare delivery. In this presentation, I will review the history of day case surgery development within the context of Hong Kong's public healthcare system, explore the initial challenges faced, including infrastructure limitations, cultural perceptions, and workforce readiness, and examine the strategies employed to overcome these obstacles.


Additionally, I will present the current landscape of day case surgery in Hong Kong, including the prevalence of day procedures across different specialties, aiming to identify areas for improvement and opportunities for optimization.


Furthermore, I will highlight best practices and evidence-based interventions that can enhance the efficiency and safety of day case surgery delivery, such as the development of standardized protocols for patient selection and preoperative assessment, the implementation of enhanced recovery pathways, and the utilization of novel surgical techniques to reduce operative time and enhance recovery.


Importantly, I will also address the challenges and barriers that healthcare providers may face in implementing changes to improve day case surgery delivery.


In conclusion, this presentation will discuss the potential impact of improving day case surgery delivery on healthcare outcomes, patient satisfaction, and healthcare system efficiency in Hong Kong. By optimizing the delivery of day case surgery services, we aim to enhance patient access to timely and cost-effective surgical care while maintaining high standards of safety and quality.