Optimization of surgical outcomes with prehabilitation

Comparing Frailty Markers in Predicting Poor Outcomes after Transcatheter Aortic Valve Replacement

INTRODUCTION

Frailty is an important component of risk prognostication in transcatheter aortic valve replacement (TAVR). Objective markers of frailty, including sarcopenia, the modified Frailty Index (mFI), and albumin levels, have emerged, but little is known how such markers compare to each other in predicting outcomes after TAVR. We sought to define and compare these markers in predicting long-term outcomes after TAVR.

METHODS

Patients who underwent TAVR at our institution from 2011 to 2016 were included. Indexed cross-sectional areas of the lumbosacral muscles on preoperative computed tomography scans were used to assess sarcopenia. Optimal cutoffs for sarcopenia were defined using a statistically validated method. mFI was calculated using an 11-point scale of clinical characteristics. The primary outcome was 2-year all-cause mortality. Adjusted survival analysis was used to analyze outcomes.

RESULTS

A total of 381 patients were included in this study. Sarcopenia of the psoas muscles was associated with an increased risk of mortality on univariate (HR: 2.3, P = 0.01) and multivariate (HR: 2.5, P = 0.01) analysis. Sarcopenia of the paravertebral muscles was associated with increased risk of mortality only on univariate analysis (HR: 2.1, P = 0.03). Increased preoperative albumin levels were associated with decreased risk of mortality on univariate (HR: 0.3, P < 0.01) and multivariate analysis (HR: 0.3, P < 0.01). The (mFI) was not associated with mortality on univariate or multivariate analysis.

DISCUSSION

Novel cutoffs for sarcopenia of the psoas muscles were determined and associated with decreased survival after TAVR. Sarcopenia and albumin levels may be better tools for risk prediction than mFI in TAVR.

Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence

INTRODUCTION

Focal cartilage defects are an increasingly relevant clinical problem especially in athletes. Cartilage regenerative surgery (CRS) including microfracture and autologous chondrocyte implantation (ACI) to treat such isolated cartilage defects in the knee joint has been well established in the last two decades. In contradiction to high-level evidence concerning the surgical technique, cell-related issues, and clinical results, the knowledge about the optimal rehabilitation process is still sparse although the importance of optimizing the rehabilitation process has recently led to new research focus in this field. The preoperative time frame may be used to start rehabilitation which may fasten the postoperative recovery and optimize clinical outcome ("Prehabilitation"-PREHAB). The aim of this article, therefore, was to review the available literature on prehabilitation concepts and to present a prehabilitation guideline for CRS patients based on the best evidence available.

METHODS

A systemic literature research was conducted on rehabilitation for cartilage regenerative surgery as well as prehabilitation in knee joint procedures. From the available literature a prehabilitation concept was generated and tested in 10 ACI patients.

RESULTS

As the literature search found no studies addressing prehabilitation in CRS patients, an evidence-based PREHAB program has been compiled based on the available evidence from (a) studies addressing postoperative rehabilitation in CRS patients and (b) PREHAB studies on other knee procedures including TKA. This presented prehabilitation guideline has been tested in > 50 CRS patients and was found to be feasible as all of the patients showed a good compliance and were able to perform the protocol as suggested.

CONCLUSION

The presented PREHAB regimen may serve clinicians as a guideline for early rehabilitation of their CRS patients. Obviously, further research is mandatory to quantify its clinical effect and to demonstrate its cost-effectiveness and benefits in surgically treated patients.

Increasing Advance Care Planning Using a Surgical Optimization Program for Older Adults

OBJECTIVES

To describe an innovative model of care, the Surgery Wellness Program (SWP), that uses a multidisciplinary team to develop and implement preoperative care plans for older adults, and its effect on engagement in advance care planning (ACP).

DESIGN

Retrospective analysis of clinical demonstration project.

SETTING

Preoperative optimization program for older adults undergoing surgery at a 796-bed academic tertiary hospital.

PARTICIPANTS

Older adults (N=131) who participated in the SWP from February 2015 to August 2017.

INTERVENTION

All SWP participants met with a geriatrician who engaged them in a semistructured ACP discussion. Trained medical and nurse practitioner students were used as health coaches who contacted participants regularly to address and document ACP.

MEASUREMENTS

Self-report of ACP engagement before and after participation in the SWP was determined using SWP geriatrician and health coach progress notes. Medical records were examined for scanned documentation. Feasibility data on number of health coach calls were collected.

RESULTS

After completion of the program, the proportion of participants with a designated surrogate increased from 67% to 78% (p<.001), completed advance directive (AD) from 51% to 72% (p<.001), and an AD scanned into the medical record from 14% to 60% (p<.001). Participants who underwent surgery received a median of 4 health coaching calls over a median of 27 days between their clinic visit and surgery. Case examples are presented to highlight how the SWP attends to the many components of the ACP process.

CONCLUSION

Preoperative optimization programs provide a unique opportunity to engage older adults in ACP.

Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty

Enhanced recovery after surgery (ERAS) programs for orthopedics involve a multidisciplinary approach to accelerating return to function, reducing pain, improving patient comfort and satisfaction, reducing complications from the surgical procedure, reducing hospital length of stay, and reducing costs. ERAS pathways for patients receiving total knee arthroplasty are different from those having intracavitary surgery; they are less focused on fluid homeostasis and gut motility than they are with optimizing systemic and local analgesics and providing a balance between the highest quality pain control and accelerated return to ambulation.

Feasibility and Preliminary Efficacy of a 10-Week Resistance and Aerobic Exercise Intervention During Neoadjuvant Chemoradiation Treatment in Rectal Cancer Patients

Background: Neoadjuvant chemoradiation treatment (CRT) in rectal cancer patients is associated with a reduction in physical capacity, lean mass and increased fatigue. As a countermeasure to these treatment-related adverse effects, we examined the feasibility and preliminary efficacy of a 10-week exercise program during CRT. Methods: Ten rectal cancer patients (7 men, aged 27-70 years, body mass index = 26.4 ± 3.8 kg/m²) receiving CRT undertook supervised resistance and aerobic exercise twice weekly. Assessments were undertaken pre- and post-intervention for upper and lower body muscle strength by 1-RM, muscle endurance, physical performance tests, body composition by dual X-ray absorptiometry, quality of life, and fatigue. Results: There was a significant loss in appendicular skeletal muscle (−1.1 kg, P = .012), and fat mass (−0.8 kg, P = .029) following CRT. Despite the loss in skeletal muscle, leg press (P = .030) and leg extension (P = .046) strength improved by 27.2% and 22.7%, respectively, and leg press endurance by 76.7% (P = .007). Changes in strength were accompanied by improved performance (P < .05) in 6-m fast walking speed (6.9%) and dynamic balance as determined by the 6-m backwards walk (15.5%). There was minimal change in quality of life and fatigue, and no adverse events related to training. Conclusions: Exercise during neoadjuvant CRT appears to be feasible and well tolerated in rectal cancer patients and may enhance physical function while minimizing adverse changes in body composition and cancer-related fatigue. These initial findings need to be confirmed in randomized controlled trials.

The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects

The combination of an increasing number of new cancer cases and improving survival rates has led to a large and rapidly growing population with unique health-care requirements. Exercise has been proposed as a strategy to help address the issues faced by cancer patients. Supported by a growing body of research, major health organizations commonly identify the importance of incorporating exercise in cancer care and advise patients to be physically active. This systematic review comprehensively summarizes the available epidemiologic and randomized controlled trial evidence investigating the role of exercise in the management of cancer. Literature searches focused on determining the potential impact of exercise on 1) cancer mortality and recurrence and 2) adverse effects of cancer and its treatment. A total of 100 studies were reviewed involving thousands of individual patients whose exercise behavior was assessed following the diagnosis of any type of cancer. Compared with patients who performed no/less exercise, patients who exercised following a diagnosis of cancer were observed to have a lower relative risk of cancer mortality and recurrence and experienced fewer/less severe adverse effects. The findings of this review support the view that exercise is an important adjunct therapy in the management of cancer. Implications on cancer care policy and practice are discussed.

Radiologically Determined Sarcopenia Predicts Morbidity and Mortality Following Abdominal Surgery: A Systematic Review and Meta-Analysis

Background

Individualised risk prediction is crucial if targeted pre-operative risk reduction strategies are to be deployed effectively. Radiologically determined sarcopenia has been shown to predict outcomes across a range of intra-abdominal pathologies. Access to pre-operative cross-sectional imaging has resulted in a number of studies investigating the predictive value of radiologically assessed sarcopenia over recent years. This systematic review and meta-analysis aimed to determine whether radiologically determined sarcopenia predicts post-operative morbidity and mortality following abdominal surgery.

Method

CENTRAL, EMBASE and MEDLINE databases were searched using terms to capture the concept of radiologically assessed sarcopenia used to predict post-operative complications in abdominal surgery. Outcomes included 30 day post-operative morbidity and mortality, 1-, 3- and 5-year overall and disease-free survival and length of stay. Data were extracted and meta-analysed using either random or fixed effects model (Revman^® 5.3).

Results

A total of 24 studies involving 5267 patients were included in the review. The presence of sarcopenia was associated with a significant increase in major post-operative complications (RR 1.61 95% CI 1.24–4.15 p = <0.00001) and 30-day mortality (RR 2.06 95% CI 1.02–4.17 p = 0.04). In addition, sarcopenia predicted 1-, 3- and 5-year survival (RR 1.61 95% CI 1.36–1.91 p = <0.0001, RR 1.45 95% CI 1.33–1.58 p = <0.0001, RR 1.25 95% CI 1.11–1.42 p = 0.0003, respectively) and 1- and 3-year disease-free survival (RR 1.30 95% CI 1.12–1.52 p = 0.0008).

Conclusion

Peri-operative cross-sectional imaging may be utilised in order to predict those at risk of complications following abdominal surgery. These findings should be interpreted in the context of retrospectively collected data and no universal sarcopenic threshold. Targeted prehabilitation strategies aiming to reverse sarcopenia may benefit patients undergoing abdominal surgery.

Electronic supplementary material

The online version of this article (doi:10.1007/s00268-017-3999-2) contains supplementary material, which is available to authorized users.

Enhanced recovery after surgery-ERAS-principles, practice and feasibility in the elderly

This is a short overview of the principles of a novel development in surgery called enhanced recovery after surgery (ERAS) programs. This is an evidence-based approach to perioperative care that has shown to reduce complications and recovery time by 30–50%. The main mechanism is reduction of the stress reactions to the operation. These principles have been shown to be particularly well suited for the compromised patient and hence very good for the elderly people who often have co-morbidities and run a higher risk of complications.

Assessing the Effect of Preoperative Nutrition on Upper Body Function in Elderly Patients Undergoing Elective Abdominal Surgery

BACKGROUND

Malnutrition among elderly surgical patients has been associated with poor postoperative outcomes and reduced functional status. Although previous studies have shown that nutrition contributes to patient outcomes, its long-term impact on functional status requires better characterization. This study examines the effect of nutrition on postoperative upper body function over time in elderly patients undergoing elective surgery.

METHODS

This is a 2-year prospective study of elderly patients (≥70 years) undergoing elective abdominal surgery. Preoperative nutrition status was determined with the Subjective Global Assessment (SGA). The primary outcome was handgrip strength (HGS) at 1, 4, 12, and 24 weeks postsurgery. Repeated measures analysis was used to determine whether SGA status affects the trajectory of postoperative HGS.

RESULTS

The cohort included 144 patients with a mean age of 77.8 ± 5.0 years and a mean body mass index of 27.7 ± 5.1 kg/m² . The median (interquartile range) Charlson Comorbidity Index was 3 (2-6). Participants were categorized as well-nourished (86%) and mildly to moderately malnourished (14%), with mean preoperative HGS of 25.8 ± 9.2 kg and 19.6 ± 7.0 kg, respectively. At 24 weeks, 64% of well-nourished patients had recovered to baseline HGS, compared with 44% of mildly to moderately malnourished patients. Controlling for relevant covariates, SGA did not significantly affect the trajectory of postoperative HGS.

CONCLUSION

While HGS values over the 24 weeks were consistently higher in the well-nourished SGA group than the mildly to moderately malnourished SGA group, no difference in the trajectories of HGS was detected between the groups.

Association of the Modified Frailty Index With 30-Day Surgical Readmission

Importance

Frail patients are known to have poor perioperative outcomes. There is a paucity of literature investigating how the Modified Frailty Index (mFI), a validated measure of frailty, is associated with unplanned readmission among military veterans following surgery.

Objective

To understand the association between frailty and 30-day postoperative unplanned readmission.

Design, Setting, and Participants

A retrospective cohort study was conducted among adult patients who underwent surgery and were discharged alive from Veterans Affairs hospitals for orthopedic, general, and vascular conditions between October 1, 2007, and September 30, 2014, with a postoperative length of stay between 2 and 30 days.

Exposure

Frailty, as calculated by the 11 variables on the mFI.

Main Outcomes and Measures

The primary outcome of interest is 30-day unplanned readmission. Secondary outcomes included any 30-day predischarge or postdischarge complication, 30-day postdischarge mortality, and 30-day emergency department visit.

Results

The study sample included 236 957 surgical procedures (among 223 877 men and 13 080 women; mean [SD] age, 64.0 [11.3] years) from high-volume surgical specialties: 101 348 procedures (42.8%) in orthopedic surgery, 92 808 procedures (39.2%) in general surgery, and 42 801 procedures (18.1%) in vascular surgery. The mFI was associated with readmission (odds ratio [OR], 1.11; 95% CI, 1.10-1.12; R2 = 10.3%; C statistic, 0.71). Unadjusted rates of overall 30-day readmission (26 262 [11.1%]), postdischarge emergency department visit (34 204 [14.4%]), any predischarge (13 855 [5.9%]) or postdischarge (14 836 [6.3%]) complication, and postdischarge mortality (1985 [0.8%]) varied by frailty in a dose-dependent fashion. In analysis by individual mFI components using Harrell ranking, impaired functional status, identified as nonindependent functional status (OR, 1.16; 95% CI, 1.11-1.21; P < .01) or having a residual deficit from a prior cerebrovascular accident (OR, 1.17; 95% CI, 1.11-1.22; P < .01), contributed most to the ability of the mFI to anticipate readmission compared with the other components. Acutely impaired sensorium (OR, 1.12; 95% CI, 0.99-1.27; P = .08) and history of a myocardial infarction within 6 months (OR, 0.93; 95% CI, 0.81-1.06; P = .28) were not significantly associated with readmission.

Conclusions and Relevance

The mFI is associated with poor surgical outcomes, including readmission, primarily due to impaired functional status. Targeting potentially modifiable aspects of frailty preoperatively, such as improving functional status, may improve perioperative outcomes and decrease readmissions.

Feasibility of Presurgical Exercise in Men With Prostate Cancer Undergoing Prostatectomy

BACKGROUND

Prostatectomy is associated with short- and long-term morbidity, which includes attenuation of muscle function and deterioration of lean body mass. Physical function is a known predictor of morbidity and mortality, with initial evidence indicating that presurgical exercise is associated with fewer postsurgical complications and shorter hospitalization. The aim was to determine the feasibility of a supervised presurgical exercise program for prostate cancer (PCa) patients scheduled for prostatectomy.

METHODS

Ten men (68+6.4 years old) with localized PCa undertook a 6-week resistance and aerobic exercise program prior surgery. Training was undertaken twice weekly and patients were assessed at baseline, presurgery, and 6 weeks postsurgery. Outcome measures included muscle and physical performance, body composition, urinary incontinence and questionnaire.

RESULTS

Muscle strength increased by 7.5% to 24.3% ( P < .05) from baseline to presurgery but decreased to pretraining levels postsurgery, except for knee extensor strength ( P = .247). There were significant improvements ( P < .05) in the 6-m fast walk (9.3%), 400-m walk (7.4%), and chair rise (12.3%) at presurgery. Following surgery, improvements in physical performance were maintained. There was no change in lean or fat mass prior to surgery, but lean mass declined by 2.7 kg ( P = .014) following surgery. There were no adverse effects from the exercise program.

CONCLUSIONS

Exercise undertaken prior to prostatectomy improved muscle and physical performance, with functional benefits maintained 6 weeks postsurgery. Presurgical exercise for PCa patients has the potential to facilitate recovery by improving physical reserve capacity, especially in men with poor muscle nd physical performance.

Reversibility of Frailty After Bridge-to-Transplant Ventricular Assist Device Implantation or Heart Transplantation

Background

We recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures.

Methods

Between August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried’s Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx—including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention.

Results

Frail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention.

Conclusions

Frail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity.

Physical activity before radical prostatectomy reduces sick leave after surgery - results from a prospective, non-randomized controlled clinical trial (LAPPRO)

BACKGROUND

Studies have reported that early physical rehabilitation after surgical procedures is associated with improved outcome measured as shorter hospital stay and enhanced recovery. The aim of this study was to explore the relationship between the preoperative physical activity level and subsequent postoperative complications, sick-leave and hospital stay after radical prostatectomy for prostate cancer in the setting of the LAPPRO trial (LAParoscopic Prostatectomy Robot Open).

METHODS

LAPPRO is a prospective controlled trial, comparing robot-assisted laparoscopic and open surgery for localized prostate cancer between 2008 and 2011. 1569 patients aged 64 or less with an occupation were included in this sub-study. The Gleason score was <7 in 52 % of the patients. Demographics and the level of self-assessed preoperative physical activity, length of hospital stay, complications, quality of life, recovery and sick-leave were extracted from clinical record forms and questionnaires. Multivariable logistic regression, with log-link and logit-link functions, was used to adjust for potential confounding variables.

RESULTS

The patients were divided into four groups based on their level of activity. As the group with lowest engagement of physical activity was found to be significantly different in base line characteristics from the other groups they were excluded from further analysis. Among patients that were physically active preoperativelly (n = 1467) there was no significant difference between the physical activity-groups regarding hospital stay, recovery or complications. However, in the group with the highest self-assessed level of physical activity, 5-7 times per week, 13 % required no sick leave, compared to 6.3 % in the group with a physical activity level of 1-2 times per week only (p < 0.0001).

CONCLUSIONS

In our study of med operated with radical prostatectomy, a high level of physical activity preoperatively was associated with reduced need for sick leave after radical prostatectomy compared to men with lower physical activity.

TRIAL REGISTRATION

The trial is registered at the ISCRTN register. ISRCTN06393679 .

Making the elderly fit for surgery

Prehabilitation promotes rehabilitation