451
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Souwer E, Bastiaannet E, de Bruijn S, Breugom A, van den Bos F, Portielje J, Dekker J. Comprehensive multidisciplinary care program for elderly colorectal cancer patients: “From prehabilitation to independence”. Eur J Surg Oncol 2018; 44:1894-1900. [DOI: 10.1016/j.ejso.2018.08.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/10/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023] Open
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452
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Luther A, Gabriel J, Watson RP, Francis NK. The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review. World J Surg 2018; 42:2781-2791. [PMID: 29546448 DOI: 10.1007/s00268-018-4569-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite advances in perioperative care, post-operative clinical and functional outcomes after major abdominal surgery can be suboptimal. Prehabilitation programmes attempt to optimise a patient's preoperative condition to improve outcomes. Total body prehabilitation includes structured exercise, nutritional optimisation, psychological support and cessation of negative health behaviours. This systematic review aims to report on the current literature regarding the impact of total body prehabilitation prior to major abdominal surgery. METHODS Relevant studies published between January 2000 and July 2017 were identified using MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, PubMed, and the Cochrane Database. All studies published in a peer-reviewed journal, assessing post-operative clinical and functional outcomes, following a prehabilitation programme prior to major abdominal surgery were included. Studies with less than ten patients, or a prehabilitation programme lasting less than 7 days were excluded. RESULTS Sixteen studies were included, incorporating 2591 patients, with 1255 undergoing a prehabilitation programme. The studies were very heterogeneous, with multiple surgical sub-specialties, prehabilitation techniques, and outcomes assessed. Post-operative complication rate was reduced in six gastrointestinal studies utilising either preoperative exercise, nutritional supplementation in malnourished patients or smoking cessation. Improved functional outcomes were observed following a multimodal prehabilitation programme. Compliance was variably measured across the studies (range 16-100%). CONCLUSIONS There is substantial heterogeneity in the prehabilitation programmes used prior to major abdominal surgery. A multimodal approach is likely to have better impact on functional outcomes compared to single modality; however, there is insufficient data either to identify the optimum programme, or to recommend routine clinical implementation.
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Affiliation(s)
- Alison Luther
- Department of General Surgery, Dorset County Hospital NHS Foundation Trust, Williams Avenue, Dorchester, DT1 2JY, UK
| | - Joseph Gabriel
- Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Castle Lane East, Bournemouth, BH7 7DW, UK
| | - Richard P Watson
- University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
| | - Nader K Francis
- Clinical Research Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK. .,University of Bath, Wessex House 3.22, Bath, BA2 7JU, UK.
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453
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Carli F, Feldman LS. From preoperative risk assessment and prediction to risk attenuation: a case for prehabilitation. Br J Anaesth 2018; 122:11-13. [PMID: 30579388 DOI: 10.1016/j.bja.2018.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada.
| | - L S Feldman
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
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454
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Prehabilitation Prior to Major Cancer Surgery: Training for Surgery to Optimize Physiologic Reserve to Reduce Postoperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0300-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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455
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Beekman L, Berzigotti A, Banz V. Physical Activity in Liver Transplantation: A Patient's and Physicians' Experience. Adv Ther 2018; 35:1729-1734. [PMID: 30328060 PMCID: PMC6223989 DOI: 10.1007/s12325-018-0797-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation has become a highly standardized, acceptable option for selected patients with end-stage liver disease and/or hepatocellular carcinoma in the setting of cirrhosis. Both conditions are associated with loss of skeletal muscle mass (sarcopenia) and physical deconditioning. Both conditions result in a dramatic decrease in the patients’ quality of life, negatively impacting on the pre- and post-transplant prognosis. In this context, awareness of the advantages of physical activity in both the pre- and post-transplant setting is key. However, the importance of regular, individualized and patient-adapted physical activity is still understudied and underestimated. This article describes a three-sided perspective on the importance of physical activity in the setting of liver transplantation, including a patient's, transplant surgeon's and hepatologist’s point of view.
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456
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Gagné S, McIsaac DI. Modifiable risk factors for patients undergoing lung cancer surgery and their optimization: a review. J Thorac Dis 2018; 10:S3761-S3772. [PMID: 30505563 DOI: 10.21037/jtd.2018.10.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Enhanced recovery after surgery (ERAS) programs include a variety of pre-, intra- and post-operative interventions that seek to decrease the stress response to surgery and facilitate the recovery of surgical patients. There are a number of patient factors that may increase the risk of postoperative complications (POC) after lung cancer surgery and delay recovery. Some of these factors may be amenable to optimization preoperatively and potentially decrease the incidence of these complications. We have chosen to discuss the incidence and complications associated with factors we felt were both relatively common and significant contributors to POCs. For each of these factors we discuss potential avenues for optimization and the evidence for the resulting decrease in complications.
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Affiliation(s)
- Sylvain Gagné
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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457
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Nakajima H, Yokoyama Y, Inoue T, Nagaya M, Mizuno Y, Kadono I, Nishiwaki K, Nishida Y, Nagino M. Clinical Benefit of Preoperative Exercise and Nutritional Therapy for Patients Undergoing Hepato-Pancreato-Biliary Surgeries for Malignancy. Ann Surg Oncol 2018; 26:264-272. [DOI: 10.1245/s10434-018-6943-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Indexed: 12/15/2022]
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458
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Christensen JF, Simonsen C, Banck-Petersen A, Thorsen-Streit S, Herrstedt A, Djurhuus SS, Egeland C, Mortensen CE, Kofoed SC, Kristensen TS, Garbyal RS, Pedersen BK, Svendsen LB, Højman P, de Heer P. Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction. BJS Open 2018; 3:74-84. [PMID: 30734018 PMCID: PMC6354184 DOI: 10.1002/bjs5.50110] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/07/2018] [Indexed: 12/20/2022] Open
Abstract
Background Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro‐oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients. Methods Patients were allocated to a standard‐care control group or an exercise group, who were prescribed standard care plus twice‐weekly high‐intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient‐reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured. Results The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy — Esophageal (FACT‐E) total score compared with the baseline level. Conclusion Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.
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Affiliation(s)
- J F Christensen
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - C Simonsen
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - A Banck-Petersen
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - S Thorsen-Streit
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - A Herrstedt
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - S S Djurhuus
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - C Egeland
- Department of Surgical Gastroenterology C Copenhagen Denmark
| | | | - S C Kofoed
- Department of Surgical Gastroenterology C Copenhagen Denmark
| | | | - R S Garbyal
- Department of Pathology, Rigshospitalet Copenhagen Denmark
| | - B K Pedersen
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - L B Svendsen
- Department of Surgical Gastroenterology C Copenhagen Denmark
| | - P Højman
- Centre of Inflammation and Metabolism/Centre for Physical Activity Research Copenhagen Denmark
| | - P de Heer
- Department of Surgical Gastroenterology C Copenhagen Denmark
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459
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Intensive perioperative rehabilitation improves surgical outcomes after pancreaticoduodenectomy. Langenbecks Arch Surg 2018; 403:711-718. [DOI: 10.1007/s00423-018-1710-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
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460
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Effect of Posthospital Syndrome on Health Care Utilization After Abdominal Contouring Surgery. Ann Plast Surg 2018; 81:e4-e11. [PMID: 30211741 DOI: 10.1097/sap.0000000000001613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Posthospital syndrome (PHS) is a transient condition after acute hospitalizations when patients are physiologically deconditioned. The objective of this study was to determine if having PHS at the time of abdominal contouring surgery increased the incidence of postoperative adverse medical events. METHODS We conducted a retrospective cohort study of patients enrolled in the MarketScan Databases who underwent outpatient functional or cosmetic abdominal contouring surgery (ie, abdominoplasty, liposuction, or panniculectomy) from April 2010 to August 2015. Patients were separated into 2 groups based upon PHS exposure, defined by hospitalization within 90 days before surgery. Differential health care utilization within 30 days after surgery was compared between cohorts. RESULTS Among the 18,947 patients included in the final cohort, 1045 patients (6%) had PHS at the time of abdominal contouring surgery. Patients with PHS experienced more emergency department visits (0.16 vs 0.08 visits; adjusted odds ratio, 1.60; P < 0.001) and more episodes of hospitalization (0.11 vs 0.04 episodes; adjusted odds ratio, 1.70; P < 0.001) within 30 days postoperatively. The mean unadjusted health care utilization after abdominal contouring surgery for patients with PHS was US $7888 (SD, 17,659) versus US $2943 (SD, 9096) in patients without PHS. After controlling for confounders, such as comorbidity burden, PHS was associated with US $3944 greater cost than patients without PHS (P < 0.001). CONCLUSIONS Among patients undergoing outpatient abdominal contouring surgery, having PHS increased the incidence of adverse medical events requiring medical attention in the 30-day postoperative period. These findings support the inclusion of PHS in preoperative evaluation and preparation for patients seeking abdominal contouring surgery.
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461
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Powell A, Coxon AH, Patel N, Chan D, Christian A, Lewis W. Prognostic Significance of Post-Operative Morbidity Severity Score After Potentially Curative D2 Gastrectomy for Carcinoma. J Gastrointest Surg 2018; 22:1516-1527. [PMID: 29766446 PMCID: PMC6132392 DOI: 10.1007/s11605-018-3787-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 04/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Survival and relapse after gastric cancer surgery are largely attributed to tumor biology and surgical radicality; yet, other prognostic factors have been reported, including respiratory sepsis and anastomotic leakage, but not global morbidity severity score (MSS). The hypothesis tested was that MSS would be associated with both disease-free (DFS) and overall survival (OS). METHODS Consecutive 373 patients undergoing potentially curative surgery for gastric adenocarcinoma between 2004 and 2016 in a UK cancer network were studied. Complications were defined prospectively as any deviation from a pre-determined post-operative course within 30 days of surgery and classified according to the Clavien-Dindo severity classification (CDSC). Primary outcome measures were DFS and OS. RESULTS Post-operative complications were identified in 127 (34.0%) patients, which was associated with 9 (2.4%) post-operative deaths. Five-year DFS and OS were 35.9 and 38.5% for patients with a post-operative complication compared with 59.5 and 61.5% in controls (p < 0.001, p = 0.001, respectively). On multivariable DFS analysis, post-operative morbidity [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.06-2.50, p = 0.026] was independently associated with poor survival. On multivariable OS analysis, post-operative morbidity HR 2.25 (95% CI 1.04-4.85, p = 0.039) and CDSC HR 1.76 (95% CI 1.35-2.29, p < 0.001) were independently associated with poor survival. These associations were also observed in patients with TNM stage I and II disease with morbidity HR 7.06 (95% CI 1.89-26.38, p = 0.004) and CDSC HR 2.93 (95% CI 1.89-4.55, p < 0.001) offering independent prognostic value. CONCLUSION Post-operative CDSC was an important independent prognostic factor after potentially curative gastrectomy for carcinoma associated with both DFS and OS. Prehabilitation strategies to minimize complications are warranted.
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Affiliation(s)
- Arfon Powell
- Division of Cancer and Genetics, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, Wales, UK.
| | | | - Neil Patel
- Department of Surgery, Cardiff & Vale University Health Board, Cardiff, Wales, UK
| | - David Chan
- Department of Surgery, Cardiff & Vale University Health Board, Cardiff, Wales, UK
| | - Adam Christian
- Department of Pathology, Cardiff & Vale University Health Board, Cardiff, Wales, UK
| | - Wyn Lewis
- Department of Surgery, Cardiff & Vale University Health Board, Cardiff, Wales, UK
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462
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Gillis C, Buhler K, Bresee L, Carli F, Gramlich L, Culos-Reed N, Sajobi TT, Fenton TR. Effects of Nutritional Prehabilitation, With and Without Exercise, on Outcomes of Patients Who Undergo Colorectal Surgery: A Systematic Review and Meta-analysis. Gastroenterology 2018; 155:391-410.e4. [PMID: 29750973 DOI: 10.1053/j.gastro.2018.05.012] [Citation(s) in RCA: 278] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/10/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Although there have been meta-analyses of the effects of exercise-only prehabilitation on patients undergoing colorectal surgery, little is known about the effects of nutrition-only (oral nutritional supplements with and without counseling) and multimodal (oral nutritional supplements with and without counseling and with exercise) prehabilitation on clinical outcomes and patient function after surgery. We performed a systemic review and meta-analysis to determine the individual and combined effects of nutrition-only and multimodal prehabilitation compared with no prehabilitation (control) on outcomes of patients undergoing colorectal resection. METHODS We searched Medline, EMBASE, CINAHL, CENTRAL, and ProQuest for cohort and randomized controlled studies of adults awaiting colorectal surgery who received at least 7 days of nutrition prehabilitation with or without exercise. We performed a random-effects meta-analysis to estimate the pooled risk ratio for categorical data and the weighted mean difference for continuous variables. The primary outcome was length of hospital stay; the secondary outcome was recovery of functional capacity based on results of a 6-minute walk test. RESULTS We identified 9 studies (5 randomized controlled studies and 4 cohort studies) composed of 914 patients undergoing colorectal surgery (438 received prehabilitation and 476 served as controls). Receipt of any prehabilitation significantly decreased days spent in the hospital compared with controls (weighted mean difference of length of hospital stay = -2.2 days; 95% confidence interval = -3.5 to -0.9). Only 3 studies reported on functional outcomes but could not be pooled owing to methodologic heterogeneity. In the individual studies, multimodal prehabilitation significantly improved results of the 6-minute walk test at 4 and 8 weeks after surgery compared with standard Enhanced Recovery Pathway care and at 8 weeks compared with standard Enhanced Recovery Pathway care with added rehabilitation. The 4 observational studies had a high risk of bias. CONCLUSIONS In a systematic review and meta-analysis, we found that nutritional prehabilitation alone or combined with an exercise program significantly decreased length of hospital stay by 2 days in patients undergoing colorectal surgery. There is some evidence that multimodal prehabilitation accelerated the return to presurgical functional capacity.
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Affiliation(s)
- Chelsia Gillis
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Katherine Buhler
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lauren Bresee
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal, Quebec, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole Culos-Reed
- Faculty of Kinesiology and Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Tolulope T Sajobi
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Tanis R Fenton
- Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada; Nutrition Services, Alberta Health Services, Calgary, Canada
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463
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Martin L, Gillis C, Atkins M, Gillam M, Sheppard C, Buhler S, Hammond CB, Nelson G, Gramlich L. Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery. JPEN J Parenter Enteral Nutr 2018; 43:206-219. [DOI: 10.1002/jpen.1417] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/04/2018] [Indexed: 01/30/2023]
Affiliation(s)
- Lisa Martin
- AgriculturalFood and Nutritional SciencesUniversity of Alberta Edmonton Alberta Canada
| | - Chelsia Gillis
- Department of Community Health SciencesCumming School of MedicineUniversity of Calgary Calgary Alberta Canada
| | - Marlis Atkins
- Nutrition ServicesAlberta Health Services Edmonton Alberta Canada
| | - Melani Gillam
- Nutrition ServicesAlberta Health Services Calgary Alberta Canada
| | - Caroline Sheppard
- Surgery Strategic Clinical NetworkAlberta Health Services Edmonton Alberta Canada
| | - Sue Buhler
- Nutrition ServicesAlberta Health Services Edmonton Alberta Canada
| | | | - Gregg Nelson
- Department of OncologyUniversity of Calgary Calgary Alberta Canada
| | - Leah Gramlich
- AgriculturalFood and Nutritional SciencesUniversity of Alberta Edmonton Alberta Canada
- Division of GastroenterologyDepartment of MedicineUniversity of Alberta Edmonton Alberta Canada
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464
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Protocol for regional implementation of collaborative self-management services to promote physical activity. BMC Health Serv Res 2018; 18:560. [PMID: 30016944 PMCID: PMC6050723 DOI: 10.1186/s12913-018-3363-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability. METHODS The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017-2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment. DISCUSSION The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites. TRIAL REGISTRATION This study protocol has been registered at ClinicalTrials.org ( NCT02976064 ). Registered November 24th, 2016.
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465
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Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass: A pooled analysis of randomized controlled trials. Clin Nutr 2018; 38:1053-1060. [PMID: 30025745 DOI: 10.1016/j.clnu.2018.06.982] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Preservation of lean body mass is an important cancer care objective. The capacity for prehabilitation interventions to modulate the lean body mass (LBM) of colorectal cancer patients before and after surgery is unknown. METHODS A pooled analysis of two randomized controlled trials of trimodal prehabilitation vs. trimodal rehabilitation at a single university-affiliated tertiary center employing Enhanced Recovery After Surgery (ERAS) care was conducted. The prehabilitation interventions included exercise, nutrition, and anxiety-reduction elements that began approximately four weeks before surgery and continued for eight weeks after surgery. The rehabilitation interventions were identical to the prehabilitation interventions but were initiated only after surgery. Body composition, measured using multifrequency bioelectrical impedance analysis, was recorded at baseline, pre-surgery, 4 and 8 weeks after surgery. The primary outcome was change in LBM before and after colorectal surgery for cancer. A mixed effects regression model was used to estimate changes in body mass and body composition over time controlling for age, sex, baseline body mass index (BMI), baseline six-minute walk test (6MWT), and postoperative compliance to the interventions. NCT02586701 &NCT01356264. RESULTS Pooled data included 76 patients who followed prehabilitation and 63 patients who followed rehabilitation (n = 139). Neither group experienced changes in preoperative LBM. Compared to rehabilitated patients, prehabilitated patients had significantly more absolute and relative LBM at four and eight-weeks post-surgery in models controlling for age, sex, baseline BMI, baseline 6MWT, and compliance to the postoperative intervention. CONCLUSION Trimodal prehabilitation attenuated the post-surgical LBM loss compared to the loss observed in patients who received the rehabilitation intervention. Patients who receive neither intervention (i.e., standard of care) would be likely to lose more LBM. Offering a prehabilitation program to colorectal cancer patients awaiting resection is a useful strategy to mitigate the impact of the surgical stress response on lean tissue in an ERAS setting, and, in turn, might have a positive impact on the cancer care course. CLINICAL TRIAL REGISTRATION NCT02586701 &NCT01356264 (clinicaltrials.gov).
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466
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Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018; 44:919-926. [DOI: 10.1016/j.ejso.2018.04.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 01/24/2023] Open
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467
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Boden I. Critically appraised paper: Preoperative physiotherapy education halved postoperative pulmonary complications in patients after upper abdominal surgery [commentary]. J Physiother 2018; 64:195-196. [PMID: 29895419 DOI: 10.1016/j.jphys.2018.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ianthe Boden
- Physiotherapy Department, Allied Health Services, Tasmanian Health Services, North Launceston General Hospital, Australia
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- Physiotherapy Department, Allied Health Services, Tasmanian Health Services, North Launceston General Hospital, Australia
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468
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Stethen TW, Ghazi YA, Heidel RE, Daley BJ, Barnes L, McLoughlin JM. Factors Influencing Length of Stay after Elective Bowel Resection within an Enhanced Recovery Protocol. Am Surg 2018. [DOI: 10.1177/000313481808400746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.
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Affiliation(s)
- Trent W. Stethen
- University of Tennessee Health Sciences Center, Memphis, Tennessee
| | | | - R. Eric Heidel
- University of Tennessee Medical Center, Knoxville, Tennessee
| | - Brian J. Daley
- University of Tennessee Medical Center, Knoxville, Tennessee
| | - Linda Barnes
- University of Tennessee Medical Center, Knoxville, Tennessee
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Narayanan S, Martin AN, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Mortality after pancreaticoduodenectomy: assessing early and late causes of patient death. J Surg Res 2018; 231:304-308. [PMID: 30278945 DOI: 10.1016/j.jss.2018.05.075] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/06/2018] [Accepted: 05/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. METHODS All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. RESULTS A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). CONCLUSIONS Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.
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Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgery Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia
| | - Reid B Adams
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgery Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia.
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470
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The effect of time from diagnosis to surgery on oncological outcomes in patients undergoing surgery for colon cancer: A systematic review. Eur J Surg Oncol 2018; 44:1479-1485. [PMID: 30251641 DOI: 10.1016/j.ejso.2018.06.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/08/2018] [Accepted: 06/18/2018] [Indexed: 01/05/2023] Open
Abstract
Many countries have implemented cancer pathways with strict time limits dictating the pace of diagnostic testing and treatment. There are concerns that prehabilitation may worsen long-term oncological outcomes if surgery is delayed. We aimed to systematically review the literature investigating the association between increased time between diagnosis of colon cancer and surgical treatment, with special focus on survival outcomes. METHODS Through a systematic search and analysis of the databases PubMed (1966-2017), EMBASE (1974-2017), CINHAL (1981-2017), and The Cochrane Library performed on June 7th, 2017, the effect of treatment delays on overall survival in colon cancer patients was reviewed. Treatment delay was defined as time from diagnosis to initiation of surgical treatment. All patients included were diagnosed with colon cancer and treated with elective curative surgery without neoadjuvant chemotherapy. This review was prospectively registered on the PROSPERO database of systematic review protocols with registration number CRD42017059774. RESULTS Five observational studies including 13,514 patients were included. The treatment delay intervals ranged from 1 to ≥56 days. Four of the five studies found no association between time elapsed from diagnosis to surgery and reduced overall survival. One study found a clinically insignificant association between longer treatment delays and overall survival. Three studies investigated the effect on disease specific survival and found no negative associations. CONCLUSION The available data showed no association between treatment delay and reduced overall survival in colon cancer patients.
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471
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Woodfield J, Zacharias M, Wilson G, Munro F, Thomas K, Gray A, Baldi J. Protocol, and practical challenges, for a randomised controlled trial comparing the impact of high intensity interval training against standard care before major abdominal surgery: study protocol for a randomised controlled trial. Trials 2018; 19:331. [PMID: 29941028 PMCID: PMC6019731 DOI: 10.1186/s13063-018-2701-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 05/21/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk factors, such as the number of pre-existing co-morbidities, the extent of the underlying pathology and the magnitude of the required operation, cannot be changed before surgery. It may, however, be possible to improve the cardiopulmonary fitness of the patient with an individualised exercise program. We are performing a randomised controlled trial (RCT) assessing the impact of High Intensity Interval Training (HIIT) on preoperative cardiopulmonary fitness and postoperative outcomes in patients undergoing major abdominal surgery. METHODS Consecutive eligible patients undergoing elective abdominal surgery are being randomised to HIIT or standard care in a 1:1 ratio. Participants allocated to HIIT will perform 14 exercise sessions on a stationary cycle ergometer, over a period of 4-6 weeks before surgery. The sessions, which are individualised, aim to start with ten repeated 1-min blocks of intense exercise with a target of reaching a heart rate exceeding 90% of the age predicted maximum, followed by 1 min of lower intensity cycling. As endurance improves, the duration of exercise is increased to achieve five 2-min intervals of high intensity exercise followed by 2 min of lower intensity cycling. Each training session lasts approximately 30 min. The primary endpoint, change in peak oxygen consumption (Peak VO2) measured during cardiopulmonary exercise testing, is assessed at baseline and before surgery. Secondary endpoints include postoperative complications, length of hospital stay and three clinically validated scores: the surgical recovery scale; the postoperative morbidity survey; and the SF-36 quality of life score. The standard deviation for changes in Peak VO2 will be assessed after the first 30 patients and will be used to calculate the required sample size. DISCUSSION We want to assess if 14 sessions of HIIT is sufficient to improve Peak VO2 by 2 mL/kg/min in patients undergoing major abdominal surgery and to explore the best clinical endpoint for a subsequent RCT designed to assess if improving Peak VO2 will translate into improving clinical outcomes after surgery. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12617000587303 . Registered on 26 April 2017.
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Affiliation(s)
- John Woodfield
- Department of Surgery, University of Otago, Dunedin, New Zealand
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Matthew Zacharias
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
- Department of Anaesthesia, University of Otago, Dunedin, New Zealand
| | - Genevieve Wilson
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Fran Munro
- Department of Surgery, University of Otago, Dunedin, New Zealand
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Kate Thomas
- Department of Surgery, University of Otago, Dunedin, New Zealand
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Andrew Gray
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - James Baldi
- Department of Medicine, University of Otago, Dunedin, New Zealand
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472
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McIsaac DI, Saunders C, Hladkowicz E, Bryson GL, Forster AJ, Gagne S, Huang A, Lalu M, Lavallee LT, Moloo H, Nantel J, Power B, Scheede-Bergdahl C, Taljaard M, van Walraven C, McCartney CJL. PREHAB study: a protocol for a prospective randomised clinical trial of exercise therapy for people living with frailty having cancer surgery. BMJ Open 2018; 8:e022057. [PMID: 29934394 PMCID: PMC6020976 DOI: 10.1136/bmjopen-2018-022057] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/10/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Exercise prehabilitation may improve outcomes after surgery. Frailty is a key predictor of adverse postoperative outcomes in older people; the multidimensional nature of frailty makes this a population who may derive substantial benefit from exercise prehabilitation. The objective of this trial is to test the efficacy of exercise prehabilitation to improve postoperative functional outcomes for people living with frailty having cancer surgery with curative intent. METHODS AND ANALYSIS We will conduct a single-centre, parallel-arm randomised controlled trial of home-based exercise prehabilitation versus standard care among consenting patients >60 years having elective cancer surgery (intra-abdominal and intrathoracic) and who are frail (Clinical Frailty Scale >4). The intervention consists of > 3 weeks of exercise prehabilitation (strength, aerobic and stretching). The primary outcome is the 6 min walk test at the first postoperative clinic visit. Secondary outcomes include the short physical performance battery, health-related quality of life, disability-free survival, complications and health resource utilisation. The primary outcome will be analysed by intention to treat using analysis of covariance. Outcomes up to 1 year after surgery will be ascertained through linkage to administrative data. ETHICS AND DISSEMINATION Ethical approval has been granted by our ethics review board (Protocol Approval #2016009-01H). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media. TRIAL REGISTRATION NUMBER NCT02934230; Pre-results.
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Affiliation(s)
- Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chelsey Saunders
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emily Hladkowicz
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregory L Bryson
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sylvain Gagne
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Allen Huang
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Geriatric Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Manoj Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Luke T Lavallee
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Urology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Nantel
- School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Barbara Power
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Geriatric Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Population Health and Preventative Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Carl van Walraven
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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473
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Fit for surgery? Evidence supporting prehabilitation programs. Br J Anaesth 2018; 120:1429. [DOI: 10.1016/j.bja.2018.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/14/2018] [Indexed: 11/20/2022] Open
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Abstract
To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.
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Affiliation(s)
- Neil N Shah
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Health Discovery Building, 1701 Trinity Street, Austin, TX 78712-1875, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA; Department of Population Health, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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475
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Takeda Y, Akiyoshi T, Matsueda K, Fukuoka H, Ogura A, Miki H, Hiyoshi Y, Nagasaki T, Konishi T, Fujimoto Y, Fukunaga Y, Ueno M. Skeletal muscle loss is an independent negative prognostic factor in patients with advanced lower rectal cancer treated with neoadjuvant chemoradiotherapy. PLoS One 2018; 13:e0195406. [PMID: 29630652 PMCID: PMC5890989 DOI: 10.1371/journal.pone.0195406] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/21/2018] [Indexed: 12/11/2022] Open
Abstract
Background The impact of body composition on the short- or long-term outcomes of patients with surgically treated advanced rectal cancer after neoadjuvant chemoradiotherapy remains unclear. This study examined the correlation between low skeletal muscle mass and morbidity and survival in patients with advanced lower rectal cancer. Methods We enrolled 144 clinical stage II/III patients with advanced lower rectal cancer who underwent neoadjuvant chemoradiotherapy followed by curative resection between 2004 and 2011. The cross-sectional skeletal muscle area at the third lumbar vertebra (L3) level was evaluated by computed tomography before chemoradiotherapy, and this was normalized by the square of the height to obtain the skeletal muscle index. Low skeletal muscle mass was defined as the sex-specific lowest quartile of the L3 skeletal muscle index. The association between low skeletal muscle mass and morbidity, relapse-free survival, or overall survival was assessed. Results Low skeletal muscle mass was identified in 37 (25.7%) patients. Age and body mass index were associated with low skeletal muscle mass. By multivariate analysis, we found that low skeletal muscle mass was independently associated with poor overall survival (hazard ratio = 2.93; 95%CI: 1.11–7.71; p = 0.031) and relapse-free survival (hazard ratio = 2.15; 95%CI: 1.06–4.21; p = 0.035), but was not associated with the rate of postoperative complications. Conclusions Low skeletal muscle mass is an independent negative prognostic factor for relapse-free and overall survival in patients with advanced lower rectal cancer treated with neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Yasuhiro Takeda
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- * E-mail:
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hironori Fukuoka
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Ogura
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hisanori Miki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yukiharu Hiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Konishi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiya Fujimoto
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masashi Ueno
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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476
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Scientific surgery. Br J Surg 2018. [DOI: 10.1002/bjs.10854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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477
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Higgins RM, Helm M, Gould JC, Kindel TL. Preoperative immobility significantly impacts the risk of postoperative complications in bariatric surgery patients. Surg Obes Relat Dis 2018; 14:842-848. [PMID: 29599072 DOI: 10.1016/j.soard.2018.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Preoperative immobility in general surgery patients has been associated with an increased risk of postoperative complications. It is unknown if immobility affects bariatric surgery outcomes. OBJECTIVES The aim of this study was to determine the impact of immobility on 30-day postoperative bariatric surgery outcomes. SETTING This study took place at a university hospital in the United States. METHODS The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. Preoperative immobility was defined as limited ambulation most or all the time. Logistic regression analysis was performed to determine if immobile patients are at increased risk (odds ratio [OR]) for 30-day complications. RESULTS There were 148,710 primary minimally invasive bariatric procedures in 2015. Immobile patients had an increased risk of mortality (OR 4.59, P<.001) and greater operative times, length of stay, reoperation rates, and readmissions. Immobile patients had a greater risk of multiple complications, including acute renal failure (OR 6.42, P<.001), pulmonary embolism (OR 2.44, P = .01), cardiac arrest (OR 2.81, P = .05), and septic shock (OR 2.78, P = .02). Regardless of procedure type, immobile patients had a higher incidence of perioperative morbidity compared with ambulatory patients. CONCLUSIONS This study is the first to specifically assess the impact of immobility on 30-day bariatric surgery outcomes. Immobile patients have a significantly increased risk of morbidity and mortality. This study provides an opportunity for the development of multiple quality initiatives to improve the safety and perioperative complication profile for immobile patients undergoing bariatric surgery.
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Affiliation(s)
- Rana M Higgins
- Department of Surgery, Division of General Surgery Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Melissa Helm
- Department of Surgery, Division of General Surgery Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jon C Gould
- Department of Surgery, Division of General Surgery Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tammy L Kindel
- Department of Surgery, Division of General Surgery Medical College of Wisconsin, Milwaukee, Wisconsin
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478
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Berkel AEM, Bongers BC, van Kamp MJS, Kotte H, Weltevreden P, de Jongh FHC, Eijsvogel MMM, Wymenga ANM, Bigirwamungu-Bargeman M, van der Palen J, van Det MJ, van Meeteren NLU, Klaase JM. The effects of prehabilitation versus usual care to reduce postoperative complications in high-risk patients with colorectal cancer or dysplasia scheduled for elective colorectal resection: study protocol of a randomized controlled trial. BMC Gastroenterol 2018; 18:29. [PMID: 29466955 PMCID: PMC5822670 DOI: 10.1186/s12876-018-0754-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 01/28/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands.
| | - Bart C Bongers
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands
| | - Marie-Janne S van Kamp
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - Hayke Kotte
- Physical therapy practice, Fysio Twente, J.J. van Deinselaan 34a, 7541, PE, Enschede, The Netherlands
| | - Paul Weltevreden
- Physical therapy practice, FITclinic, Roomweg 180, 7523, BT, Enschede, The Netherlands
| | - Frans H C de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - Michiel M M Eijsvogel
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - A N Machteld Wymenga
- Department of Internal medicine, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - Marloes Bigirwamungu-Bargeman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - Job van der Palen
- Epidemiology, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, 7600, SZ, Almelo, The Netherlands
| | - Nico L U van Meeteren
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands.,Top Sector Life Sciences and Health (Health~Holland), Laan van Nieuw Oost-Indië 334, 2593, CE, The Hague, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, PO Box 50 000, 7500, KA, Enschede, The Netherlands
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479
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Reeves T, Bates S, Sharp T, Richardson K, Bali S, Plumb J, Anderson H, Prentis J, Swart M, Levett DZH. Cardiopulmonary exercise testing (CPET) in the United Kingdom-a national survey of the structure, conduct, interpretation and funding. Perioper Med (Lond) 2018; 7:2. [PMID: 29423173 PMCID: PMC5787286 DOI: 10.1186/s13741-017-0082-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/26/2017] [Indexed: 12/13/2022] Open
Abstract
Background Cardiopulmonary exercise testing (CPET) is an exercise stress test with concomitant expired gas analysis that provides an objective, non-invasive measure of functional capacity under stress. CPET-derived variables predict postoperative morbidity and mortality after major abdominal and thoracic surgery. Two previous surveys have reported increasing utilisation of CPET preoperatively in England. We aimed to evaluate current CPET practice in the UK, to identify who performs CPET, how it is performed, how the data generated are used and the funding models. Methods All anaesthetic departments in trusts with adult elective surgery in the UK were contacted by telephone to obtain contacts for their pre-assessment and CPET service leads. An online survey was sent to all leads between November 2016 and March 2017. Results The response rate to the online survey was 73.1% (144/197) with 68.1% (98/144) reporting an established clinical service and 3.5% (5/144) setting up a service. Approximately 30,000 tests are performed a year with 93.0% (80/86) using cycle ergometry. Colorectal surgical patients are the most frequently tested (89.5%, 77/86). The majority of tests are performed and interpreted by anaesthetists. There is variability in the methods of interpretation and reporting of CPET and limited external validation of results. Conclusions This survey has identified the continued expansion of perioperative CPET services in the UK which have doubled since 2011. The vast majority of CPET tests are performed and reported by anaesthetists. It has highlighted variation in practice and a lack of standardised reporting implying a need for practice guidelines and standardised training to ensure high-quality data to inform perioperative decision making.
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Affiliation(s)
- T Reeves
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - S Bates
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - T Sharp
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - K Richardson
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - S Bali
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - J Plumb
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - H Anderson
- 4Department of Anaesthesia and Critical Care Medicine, Plymouth Hospitals NHS trust Hospital, Plymouth, UK
| | - J Prentis
- 5Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,6Departments of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Swart
- 7Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - D Z H Levett
- 1Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,2Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,3Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Tew GA, Ayyash R, Durrand J, Danjoux GR. Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. Anaesthesia 2018; 73:750-768. [PMID: 29330843 DOI: 10.1111/anae.14177] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2017] [Indexed: 01/17/2023]
Abstract
Despite calls for the routine implementation of pre-operative exercise programmes to optimise patient fitness before elective major surgery, there is no practical guidance for providing safe and effective exercise in this specific context. The following clinical guideline was developed following a review of the evidence on the effects of pre-operative exercise interventions. We developed a series of best-practice and, where possible, evidence-based statements to advise on patient care with respect to exercise training in the peri-operative period. These statements cover: patient selection for exercise training in surgical patients; integration of exercise training into multi-modal prehabilitation programmes; and advice on exercise prescription factors and follow-up. Although we acknowledge that further research is needed to identify the optimal exercise prescription in different clinical scenarios, we urge peri-operative teams to make use of these recommendations.
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Affiliation(s)
- G A Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle-upon-Tyne, UK
| | - R Ayyash
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - J Durrand
- Northern School of Anaesthesia and Intensive Care Medicine, Newcastle University, Newcastle, UK
| | - G R Danjoux
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK.,School of Health and Social Care, Teesside University, Middlesbrough, UK
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481
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Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition). Eur J Surg Oncol 2018; 44:509-514. [PMID: 29398322 DOI: 10.1016/j.ejso.2017.12.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 12/15/2022] Open
Abstract
Malnutrition in cancer patients - in both prevalence and degree - depends primarily on tumor stage and site. Preoperative malnutrition in surgical patients is a frequent problem and is associated with prolonged hospital stay, a higher rate of postoperative complications, higher re-admission rates, and a higher incidence of postoperative death. Given the focus on the cancer and its cure, nutrition is often neglected or under-evaluated, and this despite the availability of international guidelines for nutritional care in cancer patients and the evidence that nutritional deterioration negatively affects survival. Inadequate nutritional support for cancer patients should be considered ethically unacceptable; prompt nutritional support must be guaranteed to all cancer patients, as it can have many clinical and economic advantages. Patients undergoing multimodal oncological care are at particular risk of progressive nutritional decline, and it is essential to minimize the nutritional/metabolic impact of oncological treatments and to manage each surgical episode within the context of an enhanced recovery pathway. In Europe, enhanced recovery after surgery (ERAS) and routine nutritional assessment are only partially implemented because of insufficient awareness among health professionals of nutritional problems, a lack of structured collaboration between surgeons and clinical nutrition specialists, old dogmas, and the absence of dedicated resources. Collaboration between opinion leaders dedicated to ERAS from both the European Society of Surgical Oncology (ESSO) and the ERAS Society was born with the aim of promoting nutritional assessment and perioperative nutrition with and without an enhanced recovery program. The goal will be to improve awareness in the surgical oncology community and at institutional level to modify current clinical practice and identify optimal treatment options.
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482
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Weimann A. Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome. Innov Surg Sci 2017; 3:55-64. [PMID: 31579766 PMCID: PMC6754043 DOI: 10.1515/iss-2017-0039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022] Open
Abstract
Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncologic Surgery including Division of Clinical Nutrition, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129 Leipzig, Germany
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483
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Pecorelli N, Capretti G, Sandini M, Damascelli A, Cristel G, De Cobelli F, Gianotti L, Zerbi A, Braga M. Impact of Sarcopenic Obesity on Failure to Rescue from Major Complications Following Pancreaticoduodenectomy for Cancer: Results from a Multicenter Study. Ann Surg Oncol 2017; 25:308-317. [PMID: 29116490 DOI: 10.1245/s10434-017-6216-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Failure to rescue (FTR) is a quality-of-care indicator in pancreatic surgery, but may also identify patients who may not tolerate major postoperative complications despite being treated with best available care. Previous studies found that high visceral adipose tissue-to-skeletal muscle ratio is associated with poor outcomes following pancreaticoduodenectomy (PD). The aim of the study is to assess the impact of sarcopenic obesity on occurrence of FTR from major complications in cancer patients undergoing PD. METHODS Prospectively collected data from three high-volume hospitals were reviewed. Total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed at preoperative staging computed tomography scan. Sarcopenic obesity was defined as high VFA/TAMA ratio. FTR was defined as postoperative mortality following major complication. RESULTS 120 patients with major complications were included. FTR occurred in 23 (19.2%) patients. The "seminal" complications leading to FTR were pancreatic or biliary fistula-related sepsis (n = 14), postoperative pancreatic fistula (POPF)-related hemorrhage (n = 5), and duodenojejunal anastomosis leak-related sepsis (n = 1). On univariate analysis, older age [odds ratio (OR) 3.5, p = 0.034], American Society of Anesthesiologists (ASA) score 3+ (OR 4.2, p = 0.005), cardiovascular disease (OR 3.3, p = 0.013), low serum albumin (OR 2.6, p = 0.042), sarcopenic obesity (OR 4.2, p = 0.009), POPF (OR 3.1, p = 0.027), and cardiorespiratory complications (OR 3.7, p = 0.011) were significantly associated with FTR. On multivariate analysis, sarcopenic obesity [OR 5.7, 95% confidence interval (CI) 1.6-20.7, p = 0.008], ASA score 3+ (OR 4.1, 95% CI 1.2-14.3, p = 0.025), and pancreatic fistula (OR 3.2, 95% CI 1.0-10.2, p = 0.045) were independently associated with FTR. CONCLUSION Sarcopenic obesity, low preoperative physical status, and occurrence of pancreatic fistula are associated with significantly higher risk of FTR from major complications after PD.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Rozzano, Italy
| | - Marta Sandini
- Unit of Hepato-biliary-pancreatic Surgery, School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Anna Damascelli
- Department of Radiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Giulia Cristel
- Department of Radiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Luca Gianotti
- Unit of Hepato-biliary-pancreatic Surgery, School of Medicine and Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Rozzano, Italy
| | - Marco Braga
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
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