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McGettigan M, Cardwell CR, Cantwell MM, Tully MA. Physical activity interventions for disease-related physical and mental health during and following treatment in people with non-advanced colorectal cancer. Cochrane Database Syst Rev 2020; 5:CD012864. [PMID: 32361988 PMCID: PMC7196359 DOI: 10.1002/14651858.cd012864.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Colorectal cancer is the third most commonly diagnosed cancer worldwide. A diagnosis of colorectal cancer and subsequent treatment can adversely affect an individuals physical and mental health. Benefits of physical activity interventions in alleviating treatment side effects have been demonstrated in other cancer populations. Given that regular physical activity can decrease the risk of colorectal cancer, and cardiovascular fitness is a strong predictor of all-cause and cancer mortality risk, physical activity interventions may have a role to play in the colorectal cancer control continuum. Evidence of the efficacy of physical activity interventions in this population remains unclear. OBJECTIVES To assess the effectiveness and safety of physical activity interventions on the disease-related physical and mental health of individuals diagnosed with non-advanced colorectal cancer, staged as T1-4 N0-2 M0, treated surgically or with neoadjuvant or adjuvant therapy (i.e. chemotherapy, radiotherapy or chemoradiotherapy), or both. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6), along with OVID MEDLINE, six other databases and four trial registries with no language or date restrictions. We screened reference lists of relevant publications and handsearched meeting abstracts and conference proceedings of relevant organisations for additional relevant studies. All searches were completed between 6 June and 14 June 2019. SELECTION CRITERIA We included randomised control trials (RCTs) and cluster-RCTs comparing physical activity interventions, to usual care or no physical activity intervention in adults with non-advanced colorectal cancer. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, performed the data extraction, assessed the risk of bias and rated the quality of the studies using GRADE criteria. We pooled data for meta-analyses by length of follow-up, reported as mean differences (MDs) or standardised mean differences (SMDs) using random-effects wherever possible, or the fixed-effect model, where appropriate. If a meta-analysis was not possible, we synthesised studies narratively. MAIN RESULTS We identified 16 RCTs, involving 992 participants; 524 were allocated to a physical activity intervention group and 468 to a usual care control group. The mean age of participants ranged between 51 and 69 years. Ten studies included participants who had finished active treatment, two studies included participants who were receiving active treatment, two studies included both those receiving and finished active treatment. It was unclear whether participants were receiving or finished treatment in two studies. Type, setting and duration of physical activity intervention varied between trials. Three studies opted for supervised interventions, five for home-based self-directed interventions and seven studies opted for a combination of supervised and self-directed programmes. One study did not report the intervention setting. The most common intervention duration was 12 weeks (7 studies). Type of physical activity included walking, cycling, resistance exercise, yoga and core stabilisation exercise. Most of the uncertainty in judging study bias came from a lack of clarity around allocation concealment and blinding of outcome assessors. Blinding of participants and personnel was not possible. The quality of the evidence ranged from very low to moderate overall. We did not pool physical function results at immediate-term follow-up due to considerable variation in results and inconsistency of direction of effect. We are uncertain whether physical activity interventions improve physical function compared with usual care. We found no evidence of effect of physical activity interventions compared to usual care on disease-related mental health (anxiety: SMD -0.11, 95% confidence interval (CI) -0.40 to 0.18; 4 studies, 198 participants; I2 = 0%; and depression: SMD -0.21, 95% CI -0.50 to 0.08; 4 studies, 198 participants; I2 = 0%; moderate-quality evidence) at short- or medium-term follow-up. Seven studies reported on adverse events. We did not pool adverse events due to inconsistency in reporting and measurement. We found no evidence of serious adverse events in the intervention or usual care groups. Minor adverse events, such as neck, back and muscle pain were most commonly reported. No studies reported on overall survival or recurrence-free survival and no studies assessed outcomes at long-term follow-up We found evidence of positive effects of physical activity interventions on the aerobic fitness component of physical fitness (SMD 0.82, 95% CI 0.34 to 1.29; 7 studies, 295; I2 = 68%; low-quality evidence), cancer-related fatigue (MD 2.16, 95% CI 0.18 to 4.15; 6 studies, 230 participants; I2 = 18%; low-quality evidence) and health-related quality of life (SMD 0.36, 95% CI 0.10 to 0.62; 6 studies, 230 participants; I2 = 0%; moderate-quality evidence) at immediate-term follow-up. These positive effects were also observed at short-term follow-up but not medium-term follow-up. Only three studies reported medium-term follow-up for cancer-related fatigue and health-related quality of life. AUTHORS' CONCLUSIONS The findings of this review should be interpreted with caution due to the low number of studies included and the quality of the evidence. We are uncertain whether physical activity interventions improve physical function. Physical activity interventions may have no effect on disease-related mental health. Physical activity interventions may be beneficial for aerobic fitness, cancer-related fatigue and health-related quality of life up to six months follow-up. Where reported, adverse events were generally minor. Adequately powered RCTs of high methodological quality with longer-term follow-up are required to assess the effect of physical activity interventions on the disease-related physical and mental health and on survival of people with non-advanced colorectal cancer. Adverse events should be adequately reported.
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Affiliation(s)
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Marie M Cantwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Mark A Tully
- Institute of Mental Health Sciences, School of Health Sciences, Ulster University, Newtownabbey, UK
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Sheill G, Guinan E, O'Neill L, Normand C, Doyle SL, Moore S, Newell J, McDermott G, Ryan R, Reynolds JV, Hussey J. Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PRE-HIIT): protocol for a randomized controlled trial. BMC Cancer 2020; 20:321. [PMID: 32293334 PMCID: PMC7160913 DOI: 10.1186/s12885-020-06795-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/27/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with cancer of the lung or oesophagus, undergoing curative treatment, usually require a thoracotomy and a complex oncological resection. These surgeries carry a risk of major morbidity and mortality, and risk assessment, preoperative optimisation, and enhanced recovery after surgery (ERAS) pathways are modern approaches to optimise outcomes. Pre-operative fitness is an established predictor of postoperative outcome, accordingly, targeting pre-operative fitness through exercise prehabilitation has logical appeal. Exercise prehabilitation is challenging to implement however due to the short opportunity for intervention between diagnosis and surgery. Therefore, individually prescribed, intensive exercise training protocols which convey clinically meaningful improvements in cardiopulmonary fitness over a short period need to be investigated. This project will examine the influence of exercise prehabilitation on physiological outcomes and postoperative recovery and, through evaluation of health economics, the impact of the programme on hospital costs. METHODS The PRE-HIIT Randomised Controlled Trial (RCT) will compare a 2-week high intensity interval training (HIIT) programme to standard preoperative care in a cohort of thoracic and oesophageal patients who are > 2-weeks pre-surgery. A total of 78 participants will be recruited (39 per study arm). The primary outcome is cardiorespiratory fitness. Secondary outcomes include, measures of pulmonary and physical and quality of life. Outcomes will be measured at baseline (T0), and post-intervention (T1). Post-operative morbidity will also be captured. The impact of PRE-HIIT on well-being will be examined qualitatively with focus groups/interviews post-intervention (T1). Participant's experience of preparation for surgery on the PRE-HIIT trial will also be explored. The healthcare costs associated with the PRE-HITT programme, in particular acute hospital costs, will also be examined. DISCUSSION The overall aim of this RCT is to examine the effect of tailored, individually prescribed high intensity interval training aerobic exercise on pre-operative fitness and postoperative recovery for patients undergoing complex surgical resections, and the impact on use of health services. TRIAL REGISTRATION The study is registered with Clinical Trials.Gov (NCT03978325). Registered on 7th June 2019.
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Affiliation(s)
- Gráinne Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland.
| | - Emer Guinan
- School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Linda O'Neill
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College, the University of Dublin, Dublin, Ireland
| | - Suzanne L Doyle
- School of Biological and Health Sciences, Technological University Dublin, Dublin, Ireland
| | - Sarah Moore
- Physiotherapy Department, St James's Hospital, Dublin 8, Ireland
| | - John Newell
- School of Mathematics, Statistics and Applied Mathematics, National University of Ireland, Galway, Ireland
| | - Grainne McDermott
- Department of Anaesthesia and Intensive Care, St. James's Hospital, Dublin, Ireland
| | - Ronan Ryan
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College, The University of Dublin and St. James's Hospital, Dublin, Ireland
| | - John V Reynolds
- Department of Surgery, St. James's Hospital, Dublin, Ireland
| | - Juliette Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
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Agasi-Idenburg CS, Zuilen MKV, Westerman MJ, Punt CJ, Aaronson NK, Stuiver MM. “I am busy surviving” - Views about physical exercise in older adults scheduled for colorectal cancer surgery. J Geriatr Oncol 2020; 11:444-450. [DOI: 10.1016/j.jgo.2019.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/06/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
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High-intensity interval training produces a significant improvement in fitness in less than 31 days before surgery for urological cancer: a randomised control trial. Prostate Cancer Prostatic Dis 2020; 23:696-704. [PMID: 32157250 PMCID: PMC7655502 DOI: 10.1038/s41391-020-0219-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
Objectives To assess the efficacy of high-intensity interval training (HIIT) for improving cardiorespiratory fitness (CRF) in patients awaiting resection for urological malignancy within four weeks. Subjects/patients and methods A randomised control trial of consecutive patients aged (>65 years) scheduled for major urological surgery in a large secondary referral centre in a UK hospital. The primary outcome is change in anaerobic threshold (VO2AT) following HIIT vs. standard care. Results Forty patients were recruited (mean age 72 years, male (39): female (1)) with 34 completing the protocol. Intention to treat analysis showed significant improvements in anaerobic threshold (VO2AT; mean difference (MD) 2.26 ml/kg/min (95% CI 1.25–3.26)) following HIIT. Blood pressure (BP) also significantly reduced in following: HIIT (SBP: −8.2 mmHg (95% CI −16.09 to −0.29) and DBP: −6.47 mmHg (95% CI −12.56 to −0.38)). No reportable adverse safety events occurred during HIIT and all participants achieved >85% predicted maximum heart rate during sessions, with protocol adherence of 84%. Conclusions HIIT can improve CRF and cardiovascular health, representing clinically meaningful and achievable pre-operative improvements. Larger randomised trials are required to investigate the efficacy of prehabilitation HIIT upon different cancer types, post-operative complications, socio-economic impact and long-term survival.
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Harnessing cancer immunotherapy during the unexploited immediate perioperative period. Nat Rev Clin Oncol 2020; 17:313-326. [PMID: 32066936 DOI: 10.1038/s41571-019-0319-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
The immediate perioperative period (days before and after surgery) is hypothesized to be crucial in determining long-term cancer outcomes: during this short period, numerous factors, including excess stress and inflammatory responses, tumour-cell shedding and pro-angiogenic and/or growth factors, might facilitate the progression of pre-existing micrometastases and the initiation of new metastases, while simultaneously jeopardizing immune control over residual malignant cells. Thus, application of anticancer immunotherapy during this critical time frame could potentially improve patient outcomes. Nevertheless, this strategy has rarely been implemented to date. In this Perspective, we discuss apparent contraindications for the perioperative use of cancer immunotherapy, suggest safe immunotherapeutic and other anti-metastatic approaches during this important time frame and specify desired characteristics of such interventions. These characteristics include a rapid onset of immune activation, avoidance of tumour-promoting effects, no or minimal increase in surgical risk, resilience to stress-related factors and minimal induction of stress responses. Pharmacological control of excess perioperative stress-inflammatory responses has been shown to be clinically feasible and could potentially be combined with immune stimulation to overcome the direct pro-metastatic effects of surgery, prevent immune suppression and enhance immunostimulatory responses. Accordingly, we believe that certain types of immunotherapy, together with interventions to abrogate stress-inflammatory responses, should be evaluated in conjunction with surgery and, for maximal effectiveness, could be initiated before administration of adjuvant therapies. Such strategies might improve the overall success of cancer treatment.
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Stubbs DJ, Grimes LA, Ercole A. Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review. PLoS One 2020; 15:e0226480. [PMID: 32012165 PMCID: PMC6996804 DOI: 10.1371/journal.pone.0226480] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.
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Affiliation(s)
- Daniel J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Lisa A. Grimes
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Ari Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
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Otto JM, Levett DZH, Grocott MPW. Cardiopulmonary Exercise Testing for Preoperative Evaluation: What Does the Future Hold? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00373-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Purpose of Review
Cardiopulmonary exercise testing (CPET) informs the preoperative evaluation process by providing individualised risk profiles; guiding shared decision-making, comorbidity optimisation and preoperative exercise training; and informing perioperative patient management. This review summarises evidence on the role of CPET in preoperative evaluation and explores the role of novel and emerging CPET variables and alternative testing protocols that may improve the precision of preoperative evaluation in the future.
Recent Findings
CPET provides a wealth of physiological data, and to date, much of this is underutilised clinically. For example, impaired chronotropic responses during and after CPET are simple to measure and in recent studies are predictive of both cardiac and noncardiac morbidity following surgery but are rarely reported. Exercise interventions are increasingly being used preoperatively, and endurance time derived from a high intensity constant work rate test should be considered as the most sensitive method of evaluating the response to training. Further research is required to identify the clinically meaningful difference in endurance time. Measuring efficiency may have utility, but this requires exploration in prospective studies.
Summary
Further work is needed to define contemporaneous risk thresholds, to explore the role of other CPET variables in risk prediction, to better characterise CPET’s role in combination with other tools in multifactorial risk stratification and increasingly to evaluate CPET’s utility for preoperative exercise prescription in prehabilitation.
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Does prehabilitation modify muscle mass in patients with rectal cancer undergoing neoadjuvant therapy? A subanalysis from the REx randomised controlled trial. Tech Coloproctol 2020; 24:959-964. [PMID: 32564236 PMCID: PMC7429543 DOI: 10.1007/s10151-020-02262-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with rectal cancer who present with sarcopenia (low muscle mass) are at significantly greater risk of postoperative complications and reduction in disease-free survival. We performed a subanalysis of a randomised controlled study [the REx trial; www.isrctn.com ; 62859294] to assess the potential of prehabilitation to modify muscle mass in patients having neoadjuvant chemoradiotherapy (NACRT). METHODS Patients scheduled for NACRT, then potentially curative surgery (August 2014-March 2016) had baseline physical assessment and psoas muscle mass measurement (total psoas index using computed tomography-based measurements). Participants were randomised to either the intervention (13-17-week telephone-guided graduated walking programme) or control group (standard care). Follow-up testing was performed 1-2 weeks before surgery. RESULTS The 44 patients had a mean age of 66.8 years (SD 9.6) and were male (64%); white (98%); American Society of Anesthesiologists class 2 (66%); co-morbid (58%); overweight (72%) (body mass index ≥ 25 kg/m2). At baseline, 14% were sarcopenic. At follow-up, 13 (65%) of patients in the prehabilitation group had increased muscle mass versus 7 (35%) that experienced a decrease. Conversely, 16 (67%) controls experienced a decrease in muscle mass and 8 (33%) showed an increase. An adjusted linear regression model estimated a mean treatment difference in Total Psoas Index of 40.2mm2/m2 (95% CI - 3.4 to 83.7) between groups in change from baseline (p = 0.07). CONCLUSIONS Prehabilitation improved muscle mass in patients with rectal cancer who had NACRT. These results need to be explored in a larger trial to determine if the poorer short- and long-term patient outcomes associated with low muscle mass can be minimised by prehabilitation.
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Ndjavera W, Orange ST, O'Doherty AF, Leicht AS, Rochester M, Mills R, Saxton JM. Exercise-induced attenuation of treatment side-effects in patients with newly diagnosed prostate cancer beginning androgen-deprivation therapy: a randomised controlled trial. BJU Int 2019; 125:28-37. [PMID: 31605663 DOI: 10.1111/bju.14922] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES (i) To assess whether exercise training attenuates the adverse effects of treatment in patients with newly diagnosed prostate cancer beginning androgen-deprivation therapy (ADT), and (ii) to examine whether exercise-induced improvements are sustained after the withdrawal of supervised exercise. PATIENTS AND METHODS In all, 50 patients with prostate cancer scheduled for ADT were randomised to an exercise group (n = 24) or a control group (n = 26). The exercise group completed 3 months of supervised aerobic and resistance exercise training (twice a week for 60 min), followed by 3 months of self-directed exercise. Outcomes were assessed at baseline, 3- and 6-months. The primary outcome was difference in fat mass at 3-months. Secondary outcomes included: fat-free mass, cardiopulmonary exercise testing variables, QRISK® 2 (ClinRisk Ltd, Leeds, UK) score, anthropometry, blood-borne biomarkers, fatigue, and quality of life (QoL). RESULTS At 3-months, exercise training prevented adverse changes in peak O2 uptake (1.9 mL/kg/min, P = 0.038), ventilatory threshold (1.7 mL/kg/min, P = 0.013), O2 uptake efficiency slope (0.21, P = 0.005), and fatigue (between-group difference in Functional Assessment of Chronic Illness Therapy-Fatigue score of 4.5 points, P = 0.024) compared with controls. After the supervised exercise was withdrawn, the differences in cardiopulmonary fitness and fatigue were not sustained, but the exercise group showed significantly better QoL (Functional Assessment of Cancer Therapy-Prostate difference of 8.5 points, P = 0.034) and a reduced QRISK2 score (-2.9%, P = 0.041) compared to controls. CONCLUSION A short-term programme of supervised exercise in patients with prostate cancer beginning ADT results in sustained improvements in QoL and cardiovascular events risk profile.
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Affiliation(s)
- Wilphard Ndjavera
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Samuel T Orange
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Alasdair F O'Doherty
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Anthony S Leicht
- Sport and Exercise Science, College of Healthcare Sciences, James Cook University, Townsville, QLD, Australia
| | - Mark Rochester
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Robert Mills
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
| | - John M Saxton
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK.,Norwich Medical School, Faculty of Medicine and Health Sciences, Norwich Research Park, University of East Anglia, Norwich, UK
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Ackland GL, Abbott TEF, Minto G, Clark M, Owen T, Prabhu P, May SM, Reynolds JA, Cuthbertson BH, Wijesundera D, Pearse RM. Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies. PLoS One 2019; 14:e0221277. [PMID: 31433825 PMCID: PMC6703687 DOI: 10.1371/journal.pone.0221277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 08/02/2019] [Indexed: 12/02/2022] Open
Abstract
Background Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery. Methods In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals). Results 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14–1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05–1.62);p = 0.02)), infective (OR:1.38 (1.10–1.72); p = 0.006), renal (OR:1.91 (1.30–2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15–1.69); p<0.001)), neurological (OR:1.73 (1.11–2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14–1.68); p = 0.001) within 5 days of surgery. Conclusions Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing. Clinical trial registry ISRCTN88456378.
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Affiliation(s)
- Gareth L. Ackland
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- * E-mail:
| | - Tom E. F. Abbott
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gary Minto
- Department of Anaesthesia, Derriford Hospital, Plymouth Hospitals NHS Trust; Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, United Kingdom
| | - Martin Clark
- Department of Anaesthesia, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Thomas Owen
- Department of Anaesthesia, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Pradeep Prabhu
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Shaun M. May
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joseph A. Reynolds
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Brian H. Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Duminda Wijesundera
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rupert M. Pearse
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Perioperative exercise capacity in chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy. PLoS One 2019; 14:e0221079. [PMID: 31412075 PMCID: PMC6693770 DOI: 10.1371/journal.pone.0221079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/30/2019] [Indexed: 01/06/2023] Open
Abstract
Dynamic assessment of preoperative exercise capacity may be a useful predictor of postoperative prognosis. We aimed to clarify whether perioperative exercise capacity was related to long-term survival in hepatocellular carcinoma patients with chronic liver injury undergoing hepatectomy. One hundred-six patients with hepatocellular carcinoma underwent pre- and postoperative cardiopulmonary exercise testing to determine their anaerobic threshold, defined as the point between carbon dioxide production and oxygen consumption per unit of time. Testing involved 35 items including blood biochemistry analysis, in-vivo component analysis, dual-energy X-ray absorptiometry, and cardiopulmonary exercise testing preoperatively and 6 months postoperatively. We classified patients with anaerobic threshold ≥ 90% 6 months postoperatively compared with the preoperative level as the maintenance group (n = 78) and patients with anaerobic threshold < 90% as the decrease group (n = 28). Five-year recurrence-free survival rates were 39.9% vs. 9.9% (maintenance vs. decrease group) (hazard ratio: 1.87 [95% confidence interval: 1.12–3.13]; P = 0.018). Five-year overall survival rates were maintenance: 81.9%, and decrease: 61.7% (hazard ratio: 2.95 [95% confidence interval: 1.37–6.33]; P = 0.006). Multivariable Cox proportional hazards models showed that perioperative maintenance of anaerobic threshold was an independent prognostic indicator for both recurrence-free- and overall survival. Although the mean anaerobic threshold from preoperative to postoperative month 6 decreased in the exercise-not-implemented group, the exercise-implemented group experienced increased anaerobic threshold, on average, at postoperative month 6. The significant prognostic factor affecting postoperative survival for chronic liver injury patients with HCC undergoing hepatectomy was maintenance of anaerobic threshold up to 6 months postoperatively.
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West MA, van Dijk DP, Gleadowe F, Reeves T, Primrose JN, Abu Hilal M, Edwards MR, Jack S, Rensen SS, Grocott MP, Levett DZ, Olde Damink SW. Myosteatosis is associated with poor physical fitness in patients undergoing hepatopancreatobiliary surgery. J Cachexia Sarcopenia Muscle 2019; 10:860-871. [PMID: 31115169 PMCID: PMC6711456 DOI: 10.1002/jcsm.12433] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Body composition assessment, measured using single-slice computed tomography (CT) image at L3 level, and aerobic physical fitness, objectively measured using cardiopulmonary exercise testing (CPET), are each independently used for perioperative risk assessment. Sarcopenia (i.e. low skeletal muscle mass), myosteatosis [i.e. low skeletal muscle radiation attenuation (SM-RA)], and impaired objectively measured aerobic fitness (reduced oxygen uptake) have been associated with poor post-operative outcomes and survival in various cancer types. However, the association between CT body composition and physical fitness has not been explored. In this study, we assessed the association of CT body composition with selected CPET variables in patients undergoing hepatobiliary and pancreatic surgery. METHODS A pragmatic prospective cohort of 123 patients undergoing hepatobiliary and pancreatic surgery were recruited. All patients underwent preoperative CPET. Preoperative CT scans were analysed using a single-slice CT image at L3 level to assess skeletal muscle mass, adipose tissue mass, and muscle radiation attenuation. Multivariate linear regression was used to test the association between CPET variables and body composition. Main outcomes were oxygen uptake at anaerobic threshold ( V̇ O2 at AT), oxygen uptake at peak exercise ( V̇ O2 peak), skeletal muscle mass, and SM-RA. RESULTS Of 123 patients recruited [77 men (63%), median age 66.9 ± 11.7, median body mass index 27.3 ± 5.2], 113 patients had good-quality abdominal CT scans available and were included. Of the CT body composition variables, SM-RA had the strongest correlation with V̇ O2 peak (r = 0.57, P < 0.001) and V̇ O2 at AT (r = 0.45, P < 0.001) while skeletal muscle mass was only weakly associated with V̇ O2 peak (r = 0.24, P < 0.010). In the multivariate analysis, only SM-RA was associated with V̇ O2 peak (B = 0.25, 95% CI 0.15-0.34, P < 0.001, R2 = 0.42) and V̇ O2 at AT (B = 0.13, 95% CI 0.06-0.18, P < 0.001, R2 = 0.26). CONCLUSIONS There is a positive association between preoperative CT SM-RA and preoperative physical fitness ( V̇ O2 at AT and at peak). This study demonstrates that myosteatosis, and not sarcopenia, is associated with reduced aerobic physical fitness. Combining both myosteatosis and physical fitness variables may provide additive risk stratification accuracy and guide interventions during the perioperative period.
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Affiliation(s)
- Malcolm A. West
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - David P.J. van Dijk
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Fredrick Gleadowe
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Thomas Reeves
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - John N. Primrose
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Mohammed Abu Hilal
- Academic Unit of Cancer Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Mark R. Edwards
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Sander S.S. Rensen
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Michael P.W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Denny Z.H. Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust, Anaesthesia and Critical CareSouthamptonUK
| | - Steven W.M. Olde Damink
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
- Departments of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
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Kalesan B, Nicewarner H, Intwala S, Leung C, Balady GJ. Pre-operative stress testing in the evaluation of patients undergoing non-cardiac surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0219145. [PMID: 31295274 PMCID: PMC6622497 DOI: 10.1371/journal.pone.0219145] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022] Open
Abstract
Background Pre-operative stress testing is widely used to evaluate patients for non-cardiac surgeries. However, its value in predicting peri-operative mortality is uncertain. The objective of this study is to assess the type and quality of available evidence in a comprehensive and statistically rigorous evaluation regarding the effectiveness of pre-operative stress testing in reducing 30-day post -operative mortality following non -cardiac surgery. Methods The databases of MEDLINE, EMBASE, and CENTRAL databases (from inception to January 27, 2016) were searched for all studies in English. We included studies with pre-operative stress testing prior to 10 different non-cardiac surgery among adults and excluded studies with sample size<15. The data on study characteristics, methodology and outcomes were extracted independently by two observers and checked by two other observers. The primary outcome was 30-day mortality. We performed random effects meta-analysis to estimate relative risk (RR) and 95% confidence intervals (95% CI) in two-group comparison and pooled the rates for stress test alone. Heterogeneity was assessed using I2 and methodological quality of studies using Newcastle-Ottawa Quality Assessment Scale. The predefined protocol was registered in PROSPERO #CRD42016049212. Results From 1807 abstracts, 79 studies were eligible (297,534 patients): 40 had information on 30-day mortality, of which 6 studies compared stress test versus no stress test. The risk of 30-day mortality was not significant in the comparison of stress testing versus none (RR: 0.79, 95% CI = 0.35–1.80) along with weak evidence for heterogeneity. For the studies that evaluated stress testing without a comparison group, the pooled rates are 1.98% (95% CI = 1.25–2.85) with a high heterogeneity. There was evidence of potential publication bias and small study effects. Conclusions Despite substantial interest and research over the past 40 years to predict 30-day mortality risk among patients undergoing non-cardiac surgery, the current body of evidence is insufficient to derive a definitive conclusion as to whether stress testing leads to reduced peri-operative mortality.
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Affiliation(s)
- Bindu Kalesan
- Department of Medicine and Community Health Sciences, Boston University School of Medicine and Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Heidi Nicewarner
- Department of Medicine, Boston Medical Center, Boston University Medical Campus, Boston, Massachusetts, United States of America
| | - Sunny Intwala
- Department of Medicine, Boston Medical Center, Boston University Medical Campus, Boston, Massachusetts, United States of America
| | - Christopher Leung
- Department of Medicine, Boston Medical Center, Boston University Medical Campus, Boston, Massachusetts, United States of America
| | - Gary J. Balady
- Department of Medicine, Boston Medical Center, Boston University Medical Campus, Boston, Massachusetts, United States of America
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Patel N, Powell AG, Wheat JR, Brown C, Appadurai IR, Davies RG, Bailey DM, Lewis WG. Cardiopulmonary fitness predicts postoperative major morbidity after esophagectomy for patients with cancer. Physiol Rep 2019; 7:e14174. [PMID: 31342676 PMCID: PMC6656866 DOI: 10.14814/phy2.14174] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 06/21/2019] [Indexed: 12/16/2022] Open
Abstract
Surgery for radical treatment of esophageal cancer (EC) carries significant inherent risk. The objective identification of patients who are at high risk of complications is of importance. In this study the prognostic value of cardiopulmonary fitness variables (CPF) derived from cardiopulmonary exercise testing (CPET) was assessed in patients undergoing potentially curative surgery for EC within an enhanced recovery program. OC patients underwent preoperative CPET using automated breath-by-breath respiratory gas analysis, with measurements taken during a ramped exercise test on a bicycle. The prognostic value of V ˙ O 2 Peak , Anaerobic Threshold (AT) and VE/VCO2 derived from CPET were studied in relation to post-operative morbidity, which was collected prospectively, and overall survival. Consecutive 120 patients were included for analysis (median age 65 years, 100 male, 75 neoadjuvant therapy). Median AT in the cohort developing major morbidity (Clavien-Dindo classification >2) was 10.4 mL/kg/min compared with 11.3 mL/kg/min with no major morbidity (P = 0.048). Median V ˙ O 2 Peak in the cohort developing major morbidity was 17.0 mL/kg/min compared with 18.7 mL/kg/min in the cohort (P = 0.009). V ˙ O 2 Peak optimum cut-off was 17.0 mL/kg/min (sensitivity 70%, specificity 53%) and for AT was 10.5 mL/kg/min (sensitivity 60%, specificity 44%). Multivariable analysis revealed V ˙ O 2 Peak to be the only independent factor to predict major morbidity (OR 0.85, 95% CI 0.75-0.97, P = 0.018). Cumulative survival was associated with operative morbidity severity (χ2 = 4.892, df = 1, P = 0.027). These results indicate that V ˙ O 2 Peak as derived from CPET is a significant predictor of major morbidity after oesophagectomy highlighting the physiological importance of cardiopulmonary fitness.
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Affiliation(s)
- Neil Patel
- Department of General SurgeryUniversity Hospital of WalesCardiffUnited Kingdom
| | - Arfon G. Powell
- Division of Cancer and GeneticsCardiff University School of MedicineHeath ParkCardiffUnited Kingdom
| | - Jenni R. Wheat
- Department of General SurgeryUniversity Hospital of WalesCardiffUnited Kingdom
| | - Christopher Brown
- Department of General SurgeryUniversity Hospital of WalesCardiffUnited Kingdom
| | - Ian R. Appadurai
- Department of AnaestheticsUniversity Hospital of WalesCardiffUnited Kingdom
| | - Richard G. Davies
- Department of AnaestheticsUniversity Hospital of WalesCardiffUnited Kingdom
| | - Damian M. Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUnited Kingdom
| | - Wyn G. Lewis
- Department of General SurgeryUniversity Hospital of WalesCardiffUnited Kingdom
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65
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Boereboom CL, Blackwell JEM, Williams JP, Phillips BE, Lund JN. Short-term pre-operative high-intensity interval training does not improve fitness of colorectal cancer patients. Scand J Med Sci Sports 2019; 29:1383-1391. [PMID: 31116453 PMCID: PMC6771883 DOI: 10.1111/sms.13460] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/01/2019] [Accepted: 04/25/2019] [Indexed: 12/16/2022]
Abstract
Background Pre‐operative cardiorespiratory fitness (CRF) in colorectal cancer (CRC) patients has been shown to affect post‐operative outcomes. The aim of this study was to test the feasibility of high‐intensity interval training (HIIT) for improving fitness in pre‐operative CRC patients within the 31‐day cancer waiting‐time targets imposed in the UK. Methods Eighteen CRC patients (13 males, mean age: 67 years (range: 52‐77 years) participated in supervised HIIT on cycle ergometers 3 or 4 times each week prior to surgery. Exercise intensity during 5 × 1‐minute HIIT intervals (interspersed with 90‐second recovery) was 100%‐120% maximum wattage achieved at a baseline cardiopulmonary exercise test (CPET). CPET before and after HIIT was used to assess CRF. Results Patients completed a mean of eight HIIT sessions (range 6‐14) over 19 days (SD 7). There was no significant increase in VO2 peak (23.9 ± 7.0 vs 24.2 ± 7.8 mL/kg/min (mean ± SD), P = 0.58) or anaerobic threshold (AT: 14.0 ± 3.4 vs 14.5 ± 4.5 mL/kg/min, P = 0.50) after HIIT. There was a significant reduction in resting systolic blood pressure (152 ± 19 vs 142 ± 19 mm Hg, P = 0.0005) and heart rate at submaximal exercise intensities after HIIT. Conclusions Our pragmatic HIIT exercise protocol did not improve the pre‐operative fitness of CRC patients within the 31‐day window available in the UK to meet cancer surgical waiting‐time targets.
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Affiliation(s)
- Catherine L Boereboom
- MRC-ARUK Centre for Musculoskeletal Ageing Research, Royal Derby Hospital Centre, University of Nottingham, Derby, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queens Medical Centre, Nottingham, UK.,Surgical Department, Royal Derby Hospital, Derby, UK
| | - James E M Blackwell
- MRC-ARUK Centre for Musculoskeletal Ageing Research, Royal Derby Hospital Centre, University of Nottingham, Derby, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queens Medical Centre, Nottingham, UK.,Surgical Department, Royal Derby Hospital, Derby, UK
| | - John P Williams
- MRC-ARUK Centre for Musculoskeletal Ageing Research, Royal Derby Hospital Centre, University of Nottingham, Derby, UK.,Anaesthetic Department, Royal Derby Hospital, Derby, UK
| | - Bethan E Phillips
- MRC-ARUK Centre for Musculoskeletal Ageing Research, Royal Derby Hospital Centre, University of Nottingham, Derby, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queens Medical Centre, Nottingham, UK
| | - Jonathan N Lund
- MRC-ARUK Centre for Musculoskeletal Ageing Research, Royal Derby Hospital Centre, University of Nottingham, Derby, UK.,Surgical Department, Royal Derby Hospital, Derby, UK
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Minnella EM, Liberman AS, Charlebois P, Stein B, Scheede-Bergdahl C, Awasthi R, Gillis C, Bousquet-Dion G, Ramanakuma AV, Pecorelli N, Feldman LS, Carli F. The impact of improved functional capacity before surgery on postoperative complications: a study in colorectal cancer. Acta Oncol 2019; 58:573-578. [PMID: 30724678 DOI: 10.1080/0284186x.2018.1557343] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Poor functional capacity (FC) is an independent predictor of postoperative morbidity. However, there is still a lack of evidence as to whether enhancing FC before surgery has a protective effect on postoperative complications. The purpose of this study was to determine whether an improvement in preoperative FC impacted positively on surgical morbidity. Methods: This was a secondary analysis of a cohort of patients who underwent colorectal resection for cancer under Enhanced Recovery After Surgery care. FC was assessed with the 6-min walk test, which measures the distance walked in 6 min (6MWD), at 4 weeks before surgery and again the day before. The study population was classified into two groups depending on whether participants achieved a significant improvement in FC preoperatively (defined as a preoperative 6MWD change ≥19 meters) or not (6MWD change <19 meters). The primary outcome measure was 30-d postoperative complications, assessed with the Comprehensive Complication Index (CCI). The association between improved preoperative FC and severe postoperative complication was evaluated using multivariable logistic regression. Results: A total of 179 eligible adults were studied: 80 (44.7%) improved in 6MWD by ≥19 m preoperatively, and 99 (55.3%) did not. Subjects whose FC increased had lower CCI (0 [0-8.7] versus 8.7 [0-22.6], p = .022). Furthermore, they were less likely to have a severe complication (adjusted OR 0.28 (95% CI 0.11-0.74), p = .010), and to have an ED visit. Conclusion: Improved preoperative FC was independently associated with a lower risk of severe postoperative complications. Further investigation is required to establish a causative relationship conclusively.
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Affiliation(s)
- Enrico Maria Minnella
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Alexander Sender Liberman
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Patrick Charlebois
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Barry Stein
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Celena Scheede-Bergdahl
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Rashami Awasthi
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Chelsia Gillis
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Guillaume Bousquet-Dion
- Department of Anesthesia, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Agnihotram V. Ramanakuma
- Research Institute, McGill University Health Center, Glen Site, Boulevard Décarie, Montréal, QC, Canada
| | - Nicoló Pecorelli
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Liane S. Feldman
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
| | - Francesco Carli
- Department of Surgery, McGill University Health Center, Montreal General Hospital, Montréal, QC, Canada
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Moug SJ, Mutrie N, Barry SJE, Mackay G, Steele RJC, Boachie C, Buchan C, Anderson AS. Prehabilitation is feasible in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy and may minimize physical deterioration: results from the REx trial. Colorectal Dis 2019; 21:548-562. [PMID: 30657249 DOI: 10.1111/codi.14560] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/07/2018] [Indexed: 12/11/2022]
Abstract
AIM Rectal cancer patients undergoing neoadjuvant chemoradiotherapy (NACRT) experience physical deterioration and reductions in their quality of life. This feasibility study assessed prehabilitation (a walking intervention) before, during and after NACRT to inform a definitive multi-centred randomized clinical trial (REx trial). METHODS Patients planned for NACRT followed by potentially curative surgery were approached (August 2014-March 2016) (www.isrctn.com; 62859294). Prior to NACRT, baseline physical and psycho-social data were recorded using validated tools. Participants were randomized to either the intervention group (exercise counselling session followed by a 13-17 week telephone-guided walking programme) or a control group (standard care). Follow-up testing was undertaken 1-2 weeks before surgery. RESULTS Of the 296 screened patients, 78 (26%) were eligible and 48 (61%) were recruited. N = 31 (65%) were men with a mean age of 65.9 years (range 33.7-82.6). Mean intervention duration was 14 weeks with 75% adherence. n = 40 (83%) completed follow-up testing. Both groups recorded reductions in daily walking but the reduction was less in the intervention group although not statistically significant. Participants reported high satisfaction and fidelity to trial procedures. CONCLUSION This study demonstrates that prehabilitation is feasible in rectal cancer patients undergoing NACRT. Good recruitment, adherence, retention and patient satisfaction rates support the development of a fully powered trial. The effects of the intervention on physical outcomes were promising.
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Affiliation(s)
- S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - N Mutrie
- Institute of Sport, Physical Education and Health Sciences, Moray House School of Education, Edinburgh, UK
| | - S J E Barry
- Department of Mathematics and Statistics, Strathclyde University, Glasgow, UK
| | - G Mackay
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - R J C Steele
- Head of Cancer Research Division, Ninewells Hospital and Medical School, Dundee, UK
| | - C Boachie
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - C Buchan
- Department of Surgery (Patient Representative), Royal Alexandra Hospital, Paisley, UK
| | - A S Anderson
- Public Health Nutrition, Division of Cancer Research, Ninewells Medical School, Dundee, UK
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68
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Allen S, Brown V, Prabhu P, Scott M, Rockall T, Preston S, Sultan J. A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol. BMJ Open 2018; 8:e023190. [PMID: 30580268 PMCID: PMC6318540 DOI: 10.1136/bmjopen-2018-023190] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients' functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery. METHODS AND ANALYSIS This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal 'prehabilitation' intervention with 'standard care' in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality. ETHICS AND DISSEMINATION This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02950324; Pre-results.
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Affiliation(s)
- Sophie Allen
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Vanessa Brown
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Pradeep Prabhu
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Michael Scott
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Timothy Rockall
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Shaun Preston
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Javed Sultan
- The Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Schonborn JL, Anderson H. Perioperative medicine: a changing model of care. BJA Educ 2018; 19:27-33. [PMID: 33456851 DOI: 10.1016/j.bjae.2018.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - H Anderson
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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Exercise and Nutrition Prehabilitation for the Evaluation of Risk and Therapeutic Potential in Cancer Patients: A Review. Int Anesthesiol Clin 2018; 54:e47-61. [PMID: 27648892 DOI: 10.1097/aia.0000000000000122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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71
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Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
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Birkey T, Dixon J, Jacobsen R, Ginde S, Nugent M, Yan K, Simpson P, Kovach J. Cardiopulmonary Exercise Testing for Surgical Risk Stratification in Adults with Congenital Heart Disease. Pediatr Cardiol 2018; 39:1468-1475. [PMID: 29882186 DOI: 10.1007/s00246-018-1918-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 06/01/2018] [Indexed: 11/28/2022]
Abstract
Adult congenital heart disease (ACHD) patients often require repeat cardiothoracic surgery, which may result in significant morbidity and mortality. Currently, there are few pre-operative risk assessment tools available. In the general adult population, pre-operative cardiopulmonary exercise testing (CPET) has a predictive value for post-operative morbidity and mortality following major non-cardiac surgery. The utility of CPET for risk assessment in ACHD patients requiring cardiothoracic surgery has not been evaluated. Retrospective chart review was conducted on 75 ACHD patients who underwent CPET less than 12 months prior to major cardiothoracic surgery at Children's Hospital of Wisconsin. Minimally invasive procedures, cardiomyopathy, acquired heart disease, single ventricle physiology, and heart transplant patients were excluded. Demographic information, CPET results, and peri-operative surgical data were collected. The study population was 56% male with a median age of 25 years (17-58). Prolonged post-operative length of stay correlated with increased ventilatory efficiency slope (VE/[Formula: see text] slope) (P = 0.007). Prolonged intubation time correlated with decreased peak HR (P = 0.008), decreased exercise time (P = 0.002), decreased heart rate response (P = 0.008) and decreased relative peak oxygen consumption (P = 0.034). Post-operative complications were documented in 59% of patients. While trends were noted between post-operative complications and some measurements of exercise capacity, none met statistical significance. Future studies may further define the relationship between exercise capacity and post-operative morbidity in ACHD patients.
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Affiliation(s)
| | - Jennifer Dixon
- Department of Cardiology, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Roni Jacobsen
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Salil Ginde
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Ke Yan
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Joshua Kovach
- Medical College of Wisconsin, Milwaukee, WI, USA. .,, Milwaukee, USA.
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Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation. Surg Clin North Am 2018; 98:1149-1169. [PMID: 30390849 DOI: 10.1016/j.suc.2018.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.
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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: 11] [Impact Index Per Article: 1.8] [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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McSorley ST, Roxburgh CSD, Horgan PG, McMillan DC. The relationship between cardiopulmonary exercise test variables, the systemic inflammatory response, and complications following surgery for colorectal cancer. Perioper Med (Lond) 2018; 7:11. [PMID: 29983927 PMCID: PMC6003031 DOI: 10.1186/s13741-018-0093-8] [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: 04/06/2018] [Accepted: 05/27/2018] [Indexed: 01/29/2023] Open
Abstract
Background Both preoperative cardiopulmonary exercise test (CPET)-derived measures of fitness and postoperative C-reactive protein (CRP) concentrations are associated with complications following surgery for colorectal cancer. The aim of the present pilot study was to examine the relationship between CPET and postoperative CRP concentrations in this patient group. Methods Patients who had undergone CPET prior to elective surgery for histologically confirmed colorectal cancer in a single centre between September 2008 and April 2017 were included. Preoperative VO2 at the anaerobic threshold (AT) and peak exercise were recorded, along with preoperative modified Glasgow Prognostic Score (mGPS) and CRP on each postoperative day. Results Thirty-eight patients were included. The majority were male (30, 79%), over 65 years old (30, 79%), with colonic cancer (23, 61%) and node-negative disease (24, 63%). Fourteen patients (37%) had open surgery and 24 (63%) had a laparoscopic resection. A progressive reduction in VO2 at peak exercise was significantly associated with both increasing American Society of Anesthesiology (ASA) grade (median, ml/kg/min: ASA 1 = 22, ASA 2 = 19, ASA 3 = 15, ASA 4 = 12, p = 0.014) and increasing mGPS (median, ml/kg/min: mGPS 0 = 18, mGPS 1 = 16, mGPS 2 = 14, p = 0.039) There was no significant association between either VO2 at the AT or peak exercise and postoperative CRP. Conclusions The present pilot study reports a possible association between preoperative CPET-derived measures of exercise tolerance, and the preoperative systemic inflammatory response, but not postoperative CRP in patients undergoing surgery for colorectal cancer.
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Affiliation(s)
- Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, R2.06, Level 2, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G31 2ER UK
| | - Campbell S D Roxburgh
- Academic Unit of Surgery, School of Medicine, University of Glasgow, R2.06, Level 2, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G31 2ER UK
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, R2.06, Level 2, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G31 2ER UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, R2.06, Level 2, New Lister Building, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G31 2ER UK
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76
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Scott JM, Zabor EC, Schwitzer E, Koelwyn GJ, Adams SC, Nilsen TS, Moskowitz CS, Matsoukas K, Iyengar NM, Dang CT, Jones LW. Efficacy of Exercise Therapy on Cardiorespiratory Fitness in Patients With Cancer: A Systematic Review and Meta-Analysis. J Clin Oncol 2018; 36:2297-2305. [PMID: 29894274 DOI: 10.1200/jco.2017.77.5809] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose To evaluate the effects of exercise therapy on cardiorespiratory fitness (CRF) in randomized controlled trials (RCTs) among patients with adult-onset cancer. Secondary objectives were to evaluate treatment effect modifiers, safety, and fidelity. Methods A systematic search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library was conducted to identify RCTs that compared exercise therapy to a nonexercise control group. The primary end point was change in CRF as evaluated by peak oxygen consumption (VO2peak; in mL O2 × kg-1 × min-1) from baseline to postintervention. Subgroup analyses evaluated whether treatment effects differed as a function of exercise prescription (ie, modality, schedule, length, supervision), study characteristics (ie, intervention timing, primary cancer site), and publication year. Safety was defined as report of any adverse event (AE); fidelity was evaluated by rates of attendance, adherence, and loss to follow-up. Results Forty-eight unique RCTs that represented 3,632 patients (mean standard deviation age, 55 ± 7.5 years; 68% women); 1,990 (55%) and 1,642 (45%) allocated to exercise therapy and control/usual care groups, respectively, were evaluated. Exercise therapy was associated with a significant increase in CRF (+2.80 mL O2 × kg-1 × min-1) compared with no change (+0.02 mL O2 × kg-1 × min-1) in the control group (weighted mean differences, +2.13 mL O2 × kg-1 × min-1; 95% CI, 1.58 to 2.67; I2, 20.6; P < .001). No statistical significant differences were observed on the basis of any treatment effect modifiers. Thirty trials (63%) monitored AEs; a total of 44 AEs were reported. The mean standard deviation loss to follow-up, attendance, and adherence rates were 11% ± 13%, 84% ± 12%, and 88% ± 32%, respectively. Conclusion Exercise therapy is an effective adjunctive therapy to improve CRF in patients with cancer. Our findings support the recommendation of exercise therapy for patients with adult-onset cancer.
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Affiliation(s)
- Jessica M Scott
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Emily C Zabor
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Emily Schwitzer
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Graeme J Koelwyn
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Scott C Adams
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Tormod S Nilsen
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Chaya S Moskowitz
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Konstantina Matsoukas
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Neil M Iyengar
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Chau T Dang
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Lee W Jones
- Jessica M. Scott, Emily C. Zabor, Scott C. Adams, Chaya S. Moskowitz, Konstantina Matsoukas, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Memorial Sloan Kettering Cancer Center; Graeme J. Koelwyn, New York University Langone Medical Center; and Chaya S. Moskowitz, Neil M. Iyengar, Chau T. Dang, Lee W. Jones, Weill Cornell Medical College, New York, NY; Emily Schwitzer, Duke University Medical Center, Durham, NC; and Tormod S. Nilsen, The Norwegian School of Sport Sciences, Oslo, Norway
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Abstract
The surgical patient population is increasingly elderly and comorbid and poses challenges to perioperative physicians. Accurate preoperative risk stratification is important to direct perioperative care. Reduced aerobic fitness is associated with increased postoperative morbidity and mortality. Cardiopulmonary exercise testing is an integrated and dynamic test that gives an objective measure of aerobic fitness or functional capacity and identifies the cause of exercise intolerance. Cardiopulmonary exercise testing provides an individualized estimate of patient risk that can be used to predict postoperative morbidity and mortality. This technology can therefore be used to inform collaborative decision-making and patient consent, to triage the patient to an appropriate perioperative care environment, to diagnose unexpected comorbidity, to optimize medical comorbidities preoperatively, and to direct individualized preoperative exercise programs. Functional capacity, evaluated as the anaerobic threshold and peak oxygen uptake ([Formula: see text]o2peak) predicts postoperative morbidity and mortality in the majority of surgical cohort studies. The ventilatory equivalents for carbon dioxide (an index of gas exchange efficiency), is predictive of surgical outcome in some cohorts. Prospective cohort studies are needed to improve the precision of risk estimates for different patient groups and to clarify the best combination of variables to predict outcome. Early data suggest that preoperative exercise training improves fitness, reduces the debilitating effects of neoadjuvant chemotherapy, and may improve clinical outcomes. Further research is required to identify the most effective type of training and the minimum duration required for a positive effect.
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78
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Durrand JW, Wagstaff K, Kasim A, Cawthorn L, Danjoux GR, Kothmann E. Reliability of repeated arm-crank cardiopulmonary exercise tests in patients with small abdominal aortic aneurysm. Anaesthesia 2018; 73:967-971. [PMID: 29727012 DOI: 10.1111/anae.14312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 11/28/2022]
Abstract
Arm-crank ergometry may be useful in patients unable to pedal, for instance due to peripheral arterial disease. Twenty participants with small abdominal aortic aneurysm undertook two serial arm-crank tests and then a pedal test, four of whom had indeterminate anaerobic thresholds, precluding analysis. The mean (SD) peak arm and leg oxygen consumptions in 16 participants were 13.71 (2.62) ml.kg-1 .min-1 and 16.82 (4.44) ml.kg-1 .min-1 , with mean (SD) individual differences of 3.11 (2.48) ml.kg-1 .min-1 , p = 0.0001. The respective values at the anaerobic thresholds were 7.83 (1.58) ml O2 .kg-1 .min-1 and 10.09 (3.15) ml O2 .kg-1 .min-1 , with mean (SD) individual differences of 2.26 (2.34) ml O2 .kg-1 .min-1 , p = 0.0001. The correlation coefficients (95%CI) for peak oxygen consumption and anaerobic threshold were 0.88 (0.62-1.0) and 0.70 (0.32-1.0). There were no significant differences in serial arm-crank tests, with intracluster correlations (95%CI) of 0.87 (0.86-0.88) and 0.65 (0.61-0.69) for peak oxygen consumption and anaerobic threshold, respectively.
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Affiliation(s)
- J W Durrand
- Northern School of Anaesthesia and Intensive Care Medicine, Health Education North East, Newcastle-upon-Tyne, UK
| | - K Wagstaff
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A Kasim
- Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK
| | - L Cawthorn
- Department of Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - G R Danjoux
- Department of Anaesthesia, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK.,Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - E Kothmann
- Department of Anaesthesia, North Tees and Hartlepool NHS Foundation Trust, Middlesbrough, UK
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Vallance AE, Fearnhead NS, Kuryba A, Hill J, Maxwell-Armstrong C, Braun M, van der Meulen J, Walker K. Effect of public reporting of surgeons' outcomes on patient selection, "gaming," and mortality in colorectal cancer surgery in England: population based cohort study. BMJ 2018; 361:k1581. [PMID: 29720371 PMCID: PMC5930269 DOI: 10.1136/bmj.k1581] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine the effect of surgeon specific outcome reporting in colorectal cancer surgery on risk averse clinical practice, "gaming" of clinical data, and 90 day postoperative mortality. DESIGN National cohort study. SETTING English National Health Service hospital trusts. POPULATION 111 431 patients diagnosed as having colorectal cancer from 1 April 2011 to 31 March 2015 included in the National Bowel Cancer Audit. INTERVENTION Public reporting of surgeon specific 90 day mortality in elective colorectal cancer surgery in England introduced in June 2013. MAIN OUTCOME MEASURES Proportion of patients with colorectal cancer who had an elective major resection, predicted 90 day mortality based on characteristics of patients and tumours, and observed 90 day mortality adjusted for differences in characteristics of patients and tumours, comparing patients who had surgery between April 2011 and June 2013 and between July 2013 and March 2015. RESULTS The proportion of patients with colorectal cancer undergoing major resection did not change after the introduction of surgeon specific public outcome reporting (39 792/62 854 (63.3%) before versus 30 706/48 577 (63.2%) after; P=0.8). The proportion of these major resections categorised as elective or scheduled also did not change (33 638/39 792 (84.5%) before versus 25 905/30 706 (84.4%) after; P=0.5). The predicted 90 day mortality remained the same (2.7% v 2.7%; P=0.3), but the observed 90 day mortality fell (952/33 638 (2.8%) v 552/25 905 (2.1%)). Change point analysis showed that this reduction was over and above the existing downward trend in mortality before the introduction of public outcome reporting (P=0.03). CONCLUSIONS This study did not find evidence that the introduction of public reporting of surgeon specific 90 day postoperative mortality in elective colorectal cancer surgery has led to risk averse clinical practice behaviour or "gaming" of data. However, its introduction coincided with a significant reduction in 90 day mortality.
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Affiliation(s)
- Abigail E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - Nicola S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
| | - James Hill
- Manchester Royal Infirmary, Manchester M13 9WL, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Charles Maxwell-Armstrong
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
| | - Michael Braun
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Kate Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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80
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Abstract
Cardio-oncology is an emerging discipline focused predominantly on the detection and management of cancer treatment-induced cardiac dysfunction (cardiotoxicity), which predisposes to development of overt heart failure or coronary artery disease. The direct adverse consequences, as well as those secondary to anticancer therapeutics, extend beyond the heart, however, to affect the entire cardiovascular-skeletal muscle axis (ie, whole-organism cardiovascular toxicity). The global nature of impairment creates a strong rationale for treatment strategies that augment or preserve global cardiovascular reserve capacity. In noncancer clinical populations, exercise training is an established therapy to improve cardiovascular reserve capacity, leading to concomitant reductions in cardiovascular morbidity and its attendant symptoms. Here, we overview the tolerability and efficacy of exercise on cardiovascular toxicity in adult patients with cancer. We also propose a conceptual research framework to facilitate personalized risk assessment and the development of targeted exercise prescriptions to optimally prevent or manage cardiovascular toxicity after a cancer diagnosis.
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Affiliation(s)
- Jessica M Scott
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., D.G., L.W.H.).
| | - Tormod S Nilsen
- Department of Physical Performance, Norwegian School of Sports Sciences, Oslo, Norway (T.S.N.)
| | - Dipti Gupta
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., D.G., L.W.H.)
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., D.G., L.W.H.)
- Weill Cornell Medical College, New York, NY (J.L.W.J.)
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81
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Systematic Review and Meta-analysis of Objective Assessment of Physical Fitness in Patients Undergoing Colorectal Cancer Surgery. Dis Colon Rectum 2018; 61:400-409. [PMID: 29377872 DOI: 10.1097/dcr.0000000000001017] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gas exchange-derived variables obtained from cardiopulmonary exercise testing allow objective assessment of functional capacity and hence physiological reserve to withstand the stressors of major surgery. Field walk tests provide an alternate means for objective assessment of functional capacity that may be cheaper and have greater acceptability, in particular, in elderly patients. OBJECTIVE This systematic review evaluated the predictive value of cardiopulmonary exercise testing and field walk tests in surgical outcomes after colorectal surgery. DATA SOURCE A systematic search was undertaken using Medline, PubMed, Embase, CINAHL, and PEDro. STUDY SELECTION Adult patients who had cardiopulmonary exercise testing and/or field walk test before colorectal surgery were included. MAIN OUTCOME MEASURE The primary outcomes measured were hospital length of stay and postoperative morbidity and mortality. RESULTS A total of 7 studies with a cohort of 1418 patients who underwent colorectal surgery were identified for inclusion in a qualitative analysis. Both pooled oxygen consumption at anaerobic threshold (range, 10.1-11.1 mL·kg·min) and peak oxygen consumption (range, 16.7-18.6 mL·kg·min) were predictive of complications (OR for anaerobic threshold, 0.76; 95% CI, 0.66-0.85, p<0.0001; OR for peak oxygen consumption, 0.76; 95% CI, 0.67-0.85, p<0.0001). Patients had significant increased risk of developing postoperative complications if their anaerobic threshold was below this cut point (p<0.001). However, it was not predictive of anastomotic leak (p = 0.644). Shorter distance (<250 m) walked in incremental shuttle walk test, lower anaerobic threshold, and lower peak oxygen consumption were associated with prolonged hospital length of stay, which was closely related to the development of complications. CONCLUSIONS Variables derived from cardiopulmonary exercise testing are predictive of postoperative complications and hospital length of stay. Currently, there are insufficient data to support the predictive role of the field walk test in colorectal surgery.
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82
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Levett D, Jack S, Swart M, Carlisle J, Wilson J, Snowden C, Riley M, Danjoux G, Ward S, Older P, Grocott M. Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth 2018; 120:484-500. [DOI: 10.1016/j.bja.2017.10.020] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/20/2017] [Accepted: 10/22/2017] [Indexed: 01/09/2023] Open
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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84
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McGettigan M, Cardwell CR, Cantwell MM, Tully MA. Physical activity and exercise interventions for disease-related physical and mental health during and following treatment in people with non-advanced colorectal cancer. Cochrane Database Syst Rev 2017. [DOI: 10.1002/14651858.cd012864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Maresa McGettigan
- Cancer Focus Northern Ireland; Cancer Prevention; 40-44 Eglantine Avenue Belfast County Antrim UK BT9 6DX
| | - Chris R Cardwell
- Queen's University Belfast; Centre for Public Health; School of Medicine Dentistry and Biomedical Sciences Belfast Northern Ireland UK BT12 6BJ
| | - Marie M Cantwell
- Queen's University Belfast; Centre for Public Health; School of Medicine Dentistry and Biomedical Sciences Belfast Northern Ireland UK BT12 6BJ
| | - Mark A Tully
- Queen's University Belfast; UKCRC Centre of Excellence for Public Health (Northern Ireland), Centre for Public Health; Grosvenor Road Belfast Northern Ireland UK BT12 6BJ
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85
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Heldens AFJM, Bongers BC, Lenssen AF, Stassen LPS, Buhre WF, van Meeteren NLU. The association between performance parameters of physical fitness and postoperative outcomes in patients undergoing colorectal surgery: An evaluation of care data. Eur J Surg Oncol 2017; 43:2084-2092. [PMID: 28943177 DOI: 10.1016/j.ejso.2017.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/11/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Preoperative cardiorespiratory fitness, as measured by cardiopulmonary testing or estimated using the less sophisticated incremental shuttle walk test, timed up-and-go test or stair climb test is known to be associated with postoperative outcome. This study aimed to evaluate whether parameters of physical fitness are associated with postoperative outcome in patients with colorectal cancer scheduled for elective resection. PATIENTS AND METHODS Perioperative data of patients who underwent colorectal resection at Maastricht University Medical Center were retrospectively analyzed. Preoperative variables (e.g., age, body mass index, comorbidities, physical fitness, tumour characteristics, neoadjuvant treatment, American Society of Anesthesiologists score, level of perceived fatigue and nutritional status) were compared with postoperative outcomes. RESULTS Out of 80 consecutive cases, 75 (93.8%) were available for analysis (57.3% male, median ± interquartile range age 69.2 ± 11.7 years). A higher Charlson comorbidity index (odds ratio (OR) of 1.604, 95% confidence interval (CI) 1.120-2.296), worse functional exercise capacity (in meters, OR of 0.995, 95% CI 0.991-1.000), a lower physical activity level (in min/day, OR of 0.994, 95% CI 0.988-1.000), and a higher level of perceived fatigue (OR of 1.047, 95% CI 1.016-1.078), were associated with a slower time to recovery of physical functioning. A better functional exercise capacity was associated with a lower OR (OR of 0.995, 95% CI 0.991-1.000) for non-surgical complications. CONCLUSION There is an association between preoperative parameters and postoperative outcomes in patients with colorectal cancer scheduled for resection. Patients benefit from an optimal preoperative physical fitness level. Specific interventions can target this physical fitness level.
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Affiliation(s)
- A F J M Heldens
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Physical Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - B C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - A F Lenssen
- Department of Physical Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - W F Buhre
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - N L U van Meeteren
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Top Sector Life Sciences and Health (Health∼Holland), The Hague, The Netherlands.
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86
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Bongers BC, Berkel AE, Klaase JM, van Meeteren NL. An evaluation of the validity of the pre-operative oxygen uptake efficiency slope as an indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery. Anaesthesia 2017; 72:1206-1216. [PMID: 28741667 DOI: 10.1111/anae.14003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 12/28/2022]
Abstract
This study aimed to investigate the validity of the oxygen uptake efficiency slope as an objective and submaximal indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery. Patients ≥ 60 years of age, with a metabolic equivalent score using the Veterans Activity Questionnaire ≤ 7 and scheduled for major colorectal surgery participated in a pre-operative cardiopulmonary exercise test. The oxygen uptake efficiency slope was calculated up to different exercise intensities, using 100%, 90% and 80% of the exercise data. Data from 71 patients (47 men, mean (SD) age 75.2 (6.7) years) were analysed. The efficiency slope obtained from all the data was statistically significantly different from the values when 90% (p = 0.027) and 80% (p = 0.023) of the data were used. The 90% and 80% values did not differ significantly from each other (p = 0.152). Correlations between the oxygen uptake efficiency slope and the peak oxygen uptake ranged from 0.816 to 0.825 (all p < 0.001), and correlations between oxygen uptake efficiency slope and the ventilatory anaerobic threshold ranged from 0.793 to 0.805 (all p < 0.001). Receiver operating characteristic curves showed that the oxygen uptake efficiency slope is a sensitive and specific predictor of a peak oxygen uptake ≤ 18.2 ml.kg-1 .min-1 , with an area under the curve (95%CI) of 0.876 (0.780-0.972, p < 0.001) and a ventilatory anaerobic threshold ≤ 11.1 ml.kg-1 .min-1 , with an area under the curve (95%CI) of 0.828 (0.726-0.929, p < 0.001). These correlations suggest that the oxygen uptake efficiency slope provides a valid (sub)maximal measure of cardiorespiratory fitness in these patients, and the predictive ability described indicates that it might help discriminate patients at higher risk of postoperative morbidity. However, future research should investigate the prognostic value of the oxygen uptake efficiency slope for postoperative outcomes.
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Affiliation(s)
- B C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - A E Berkel
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - J M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - N L van Meeteren
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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87
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Sothisrihari SR, Wright C, Hammond T. Should preoperative optimization of colorectal cancer patients supersede the demands of the 62-day pathway? Colorectal Dis 2017; 19:617-620. [PMID: 28493352 DOI: 10.1111/codi.13713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/24/2017] [Indexed: 02/08/2023]
Affiliation(s)
| | - C Wright
- Department of Anaesthetics, Broomfield Hospital, Chelmsford, UK
| | - T Hammond
- Department of Colorectal Surgery, Broomfield Hospital, Chelmsford, UK
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88
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Moug SJ, Bryce A, Mutrie N, Anderson AS. Lifestyle interventions are feasible in patients with colorectal cancer with potential short-term health benefits: a systematic review. Int J Colorectal Dis 2017; 32:765-775. [PMID: 28374148 PMCID: PMC5432596 DOI: 10.1007/s00384-017-2797-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Lifestyle interventions have been proposed to improve cancer survivorship in patients with colorectal cancer (CRC), but with treatment pathways becoming increasingly multi-modal and prolonged, opportunities for interventions may be limited. This systematic review assessed the evidence for the feasibility of performing lifestyle interventions in CRC patients and evaluated any short- and long-term health benefits. METHODS Using PRISMA Guidelines, selected keywords identified randomised controlled studies (RCTs) of lifestyle interventions [smoking, alcohol, physical activity (PA) and diet/excess body weight] in CRC patients. These electronic databases were searched in June 2015: Dynamed, Cochrane Database, OVID MEDLINE, OVID EMBASE, and PEDro. RESULTS Fourteen RCTs were identified: PA RCTs (n = 10) consisted mainly of telephone-prompted walking or cycling interventions of varied durations, predominately in adjuvant setting; dietary/excess weight interventions RCTs (n = 4) focused on low-fat and/or high-fibre diets within a multi-modal lifestyle intervention. There were no reported RCTs in smoking or alcohol cessation/reduction. PA and/or dietary/excess weight interventions reported variable recruitment rates, but good adherence and retention/follow-up rates, leading to short-term improvements in dietary quality, physical, psychological and quality-of-life parameters. Only one study assessed long-term follow-up, finding significantly improved cancer-specific survival after dietary intervention. CONCLUSIONS This is the first systematic review on lifestyle interventions in patients with CRC finding these interventions to be feasible with improvements in short-term health. Future work should focus on defining the optimal type of intervention (type, duration, timing and intensity) that not only leads to improved short-term outcomes but also assesses long-term survival.
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Affiliation(s)
- Susan J Moug
- The University of Glasgow, Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN, UK.
| | - Adam Bryce
- The University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
| | - Nanette Mutrie
- Physical Activity for Health Research Centre, Moray House School of Education, The University of Edinburgh, St. Leonard's Land, Holyrood Road, Edinburgh, EH8 8AQ, UK
| | - Annie S Anderson
- Centre for Public Health Nutrition Research, Division of Cancer Research, Ninewells Medical School, Level 7, Mailbox 7, Dundee, DD1 9SY, UK
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90
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Cascella M. Preoperative cardiac evaluation and anesthetic considerations for cancer patients who underwent chemotherapy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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91
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A comparison of methods for determining the ventilatory threshold: implications for surgical risk stratification. Can J Anaesth 2017; 64:634-642. [DOI: 10.1007/s12630-017-0862-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/16/2017] [Accepted: 03/13/2017] [Indexed: 12/22/2022] Open
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92
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Brunet J, Burke S, Grocott MPW, West MA, Jack S. The effects of exercise on pain, fatigue, insomnia, and health perceptions in patients with operable advanced stage rectal cancer prior to surgery: a pilot trial. BMC Cancer 2017; 17:153. [PMID: 28228123 PMCID: PMC5322650 DOI: 10.1186/s12885-017-3130-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/09/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Promoting quality of life (QoL) is a key priority in cancer care. We investigated the hypothesis that, in comparison to usual care, exercise post-neoadjuvant chemoradiation therapy/prior to surgical resection will reduce pain, fatigue, and insomnia, and will improve physical and mental health perceptions in patients with locally advanced stage rectal cancer. METHODS In this non-randomized controlled pilot trial, patients in the supervised exercise group (EG; M age = 64 years; 64% male) and in the control group (CG; M age = 72 years; 69% male) completed the European Organization for Research and Treatment of Cancer core Quality of Life questionnaire and the RAND 36-Item Health Survey three times: pre-neoadjuvant chemoradiation therapy (Time 1; n EC = 24; n CG = 11), post-neoadjuvant chemoradiation therapy/pre-exercise intervention (Time 2; n EC = 23; n CG = 10), and post-exercise intervention (Time 3; n EC = 22; n CG = 10). The 6-week exercise intervention was delivered in hospital and comprised of interval aerobic training. Patients trained in pairs three times per week for 30 to 40 min. Data were analyzed by Mann-Whitney tests and by Wilcoxon matched-pairs signed-rank tests. RESULTS No significant between-group differences in changes were found for any of the outcomes. In both groups, fatigue levels decreased and physical health perceptions increased from pre- to post-exercise intervention. Pain levels also decreased from pre- to post-exercise intervention, albeit not significantly. CONCLUSIONS The findings from this study can be used to guide a more definitive trial as they provide preliminary evidence regarding the potential effects of pre-operative exercise on self-reported pain, fatigue, insomnia, and health perceptions in patients with locally advanced rectal cancer. TRIAL REGISTRATION This study has been registered with clinicaltrials.gov (NCT01325909; March 29, 2011).
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Affiliation(s)
- Jennifer Brunet
- Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, 125 University Private, Montpetit Hall Room 339, Ottawa, ON, K1N 6N5, Canada. .,Institut de Recherche de l'Hôpital Montfort (IRHM), Hôpital Montfort, Ottawa, ON, Canada. .,Cancer Therapeutic Program, Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
| | - Shaunna Burke
- Centre for Sport and Exercise Sciences, School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Malcolm A West
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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93
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West MA, Loughney L, Ambler G, Dimitrov BD, Kelly JJ, Mythen MG, Sturgess R, Calverley PMA, Kendrick A, Grocott MPW, Jack S. The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study. BMC Cancer 2016; 16:710. [PMID: 27589870 PMCID: PMC5010720 DOI: 10.1186/s12885-016-2682-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/05/2016] [Indexed: 11/13/2022] Open
Abstract
Background In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery. Methods This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L). Discussion The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival. Trial registration ClinicalTrials.gov NCT01325883 - 29th March 2011.
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Affiliation(s)
- M A West
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.,Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - L Loughney
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - B D Dimitrov
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
| | - J J Kelly
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - M G Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - R Sturgess
- Department of Gastroenterology, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - P M A Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Longmoor Road, Liverpool, UK
| | - A Kendrick
- Department of Physiological Sciences, University of Bristol, Bristol, UK
| | - M P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK. .,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK.
| | - S Jack
- Anaesthesia and Critical Care Research Area, NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, CE93 MP24, Tremona Road, Southampton, SO16 6YD, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Tremona Road, Southampton, UK
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94
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Sinclair R, Navidi M, Griffin SM, Sumpter K. The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma. Ann R Coll Surg Engl 2016; 98:396-400. [PMID: 27138851 PMCID: PMC5209965 DOI: 10.1308/rcsann.2016.0135] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2015] [Indexed: 01/09/2023] Open
Abstract
Introduction Operable oesophagogastric adenocarcinoma management in the UK includes three cycles of neoadjuvant chemotherapy (NAC) followed by resection. Determination of oxygen uptake at the anaerobic threshold (AT) with cardiopulmonary exercise testing (CPET) is used to objectively measure cardiorespiratory reserve. Oxygen uptake at AT predicts perioperative risk, with low values associated with increased morbidity. Previous studies indicate NAC may have a detrimental impact on cardiorespiratory reserve. Methods CPET was completed by 30 patients before and after a standardised NAC protocol. The ventilatory AT was determined using the V-slope method, and the peak oxygen uptake and ventilatory equivalents for carbon dioxide measured. Median AT before and after chemotherapy was compared using a paired Student's t-test. Results Median oxygen uptake at AT pre- and post-NAC was 13.9±3.1 ml/kg/min and 11.5±2.0 ml/kg/min, respectively. The mean decrease was 2.4 ml/kg/min (95% confidence interval [CI] 1.3-3.85; p<0.001). Median peak oxygen delivery also decreased by 2.17 ml/kg/min (95% CI 1.02-3.84; p=0.001) after NAC. Ventilatory equivalents were unchanged. Conclusions This reduction in AT objectively quantifies a decrease in cardiorespiratory reserve after NAC. Patients with lower cardiorespiratory reserve have increased postoperative morbidity and mortality. Preventing this decrease in cardiorespiratory reserve during chemotherapy, or optimising the timing of surgical resection after recovery of AT, may allow perioperative risk-reduction.
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Affiliation(s)
- Rcf Sinclair
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - M Navidi
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - S M Griffin
- Royal Victoria Infirmary , Newcastle-upon-Tyne , UK
| | - K Sumpter
- Freeman Hospital , Newcastle-upon-Tyne , UK
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95
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Levett DZ, Edwards M, Grocott M, Mythen M. Preparing the patient for surgery to improve outcomes. Best Pract Res Clin Anaesthesiol 2016; 30:145-57. [DOI: 10.1016/j.bpa.2016.04.002] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/01/2016] [Accepted: 04/20/2016] [Indexed: 12/01/2022]
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96
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Chan KE, Pathak S, Smart NJ, Batchelor N, Daniels IR. The impact of cardiopulmonary exercise testing on patients over the age of 80 undergoing elective colorectal cancer surgery. Colorectal Dis 2016; 18:578-85. [PMID: 26417705 DOI: 10.1111/codi.13139] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 07/20/2015] [Indexed: 12/07/2022]
Abstract
AIM Advanced age and occult cardiorespiratory disease are associated with increased morbidity and mortality following surgery. Cardiopulmonary exercise testing (CPET) may allow the identification of high-risk patients and facilitate planned postoperative critical care support. The aim of this study was to determine whether preoperative CPET in patients aged over 80 undergoing elective colorectal cancer resection was associated with improved outcome. METHOD All patients aged 80 years and above undergoing elective colorectal cancer resection between 1 March 2011 and 1 September 2013 were retrospectively analysed. Referral for CPET testing was at the discretion of the operating surgeon. Postoperative critical care unit (CCU) admission was based upon the CPET results. RESULTS Ninety-four patients were identified, of whom 48 underwent CPET testing. The CPET group were significantly older than the non-CPET group (85 vs 83 years, P = 0.04) and were more likely to have a planned admission to CCU postoperatively (P < 0.0001). Despite the increased use of CCU resources, the overall CCU length of stay (LOS) in the CPET group did not differ from the non-CPET group, but the non-CPET group had a higher proportion of Level-3 care. There were no differences in the incidence of unplanned CCU admission between the CPET and the non-CPET group (P = 0.23). There were no differences in overall LOS between the two groups (P = 0.42). There was no difference in mortality (P = 0.11), overall complications (P = 0.53) or severe complications (P = 0.3). CONCLUSION Preoperative CPET testing in patients aged over 80 undergoing elective colorectal cancer resection allows identification of higher-risk patients and mitigation of risk by preemptive admission to a CCU. This stratification allows equivalent results to be achieved in high- and low-risk elderly patients undergoing colorectal surgery.
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Affiliation(s)
- K E Chan
- Exeter Surgical Health Services Research Unit (HESRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - S Pathak
- Exeter Surgical Health Services Research Unit (HESRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - N J Smart
- Exeter Surgical Health Services Research Unit (HESRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - N Batchelor
- Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter, UK
| | - I R Daniels
- Exeter Surgical Health Services Research Unit (HESRU), Royal Devon and Exeter Hospital, Exeter, UK
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97
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 2016; 39:1144-1161. [DOI: 10.1093/eurheartj/ehw180] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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98
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Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations. Circulation 2016; 133:e694-711. [PMID: 27143685 DOI: 10.1161/cir.0000000000000406] [Citation(s) in RCA: 245] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.
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99
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Feasibility and preliminary effectiveness of a physical exercise training program during neoadjuvant chemoradiotherapy in individual patients with rectal cancer prior to major elective surgery. Eur J Surg Oncol 2016; 42:1322-30. [PMID: 27156145 DOI: 10.1016/j.ejso.2016.03.021] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/10/2016] [Accepted: 03/21/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Diverse fractions of patients with locally advanced resectable rectal cancer receive neoadjuvant chemoradiotherapy (NACRT). NACRT is known to decrease physical fitness, an undesirable side effect. This pilot aimed to determine the feasibility and preliminary effectiveness of a supervised outpatient physical exercise training program during NACRT in these patients. METHODS We included 13 out of 20 eligible patients (11 males, mean ± SD age: 59.1 ± 19.7 years) with rectal cancer who participated in the exercise training program during NACRT. Feasibility was determined by adherence and number of adverse events. Physical fitness was compared at baseline (B), after five (T1) and ten weeks (T2) of training, and eight weeks postoperatively (T3) using repeated-measures analysis of variance. RESULTS Nine patients (69.2%) completed the program without adverse events. Four patients dropped out. The program was feasible and safe, with a total attendance rate of 95.7%. Leg muscle strength (mean ± SD: 104.0 ± 32.3 versus 144.8 ± 45.6 kg; P < 0.001) and arm muscle strength (mean ± SD: 48.7 ± 13.8 kg versus 36.1 ± 11.0 kg, P = 0.002) increased significantly between B and T2, respectively. A slight, non-significant, increase in functional exercise capacity was found. CONCLUSION This pilot demonstrated that a supervised outpatient physical exercise training program for individual patients with locally advanced resectable rectal cancer during NACRT is feasible for a large part of the patients, safe and seems able to prevent an often seen decline in physical fitness during NACRT. A larger study into the cost-effectiveness of this approach is warranted.
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100
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