Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial

STRIVE pilot trial: a protocol for a multicentre pragmatic internal pilot randomised controlled trial of Structured TRaining to Improve fitness in a Virtual Environment (STRIVE) before surgery

INTRODUCTION

Home-based, virtually-supported care models may represent the most efficient and scalable approach to delivering prehabilitation services. However, virtual approaches to prehabilitation are understudied. This manuscript describes the protocol for an internal pilot randomised controlled trial of a virtually-delivered, multimodal prehabilitation intervention.

METHODS AND ANALYSIS

We will conduct a pragmatic, individual patient, internal pilot randomised controlled trial of home-based, virtually supported, multimodal prehabilitation compared with standard perioperative care in adults undergoing elective, inpatient thoracic, abdominal, pelvic and vascular surgery at five Canadian hospitals. Participants will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of 3-12 weeks of a home-based, multimodal (exercise, nutrition and psychosocial support) prehabilitation programme supported through an online platform. The primary feasibility outcomes and their progression targets are (1) monthly recruitment of>6 participants at each centre, (2) intervention adherence of>75%, (3) retention of>90% of participants at the patient-reported primary outcome point of 30-days after surgery and (4) elicitation of patient, clinician and researcher-identified barriers to our pragmatic trial. A sample size of 144 participants will be adequate to estimate recruitment, adherence and retention rates with acceptable precision. All participants will be followed to either death or up to 1 year. As an internal pilot, if no substantive changes to the trial or intervention design are required, pilot participant outcome data will migrate, unanalysed by allocation, to the future full-scale trial.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Clinical Trials Ontario (Project ID: 4479) and our ethics review board (Protocol Approval #20230399-01T). Results will be disseminated through presentations at scientific conferences, peer-reviewed publications, partner organisations and engagement of social and traditional media.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT06042491. Protocol, V.1.2, dated 6 June 2024.

Clinical significance of the CALLY index in patients with gastric cancer undergoing gastrectomy

BACKGROUND

The aim of this study was to elucidate the clinical impact of the CALLY index in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

Between January 2014 and December 2020, 617 patients who underwent gastrectomy for GC at the Osaka City General Hospital were enrolled in this study. The CALLY index was calculated using the following formula: [albumin (g/dL) × lymphocytes (/μl)]/[CRP (mg/dL) × 104]. We compared the predictive value of four biomarkers [CALLY index, modified Glasgow prognostic score (mGPS), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR)] for short- and long-term outcomes and focused on the CALLY index to elucidate its clinical value.

RESULTS

Receiver operating characteristic analysis showed that the area under the curve for the CALLY index was the highest among the four biomarkers. The 5-year overall survival (OS) and cancer-specific survival (CSS) rates in the low and the high CALLY groups were statistically significant. Multivariate analysis identified the CALLY index as an independent factor for OS and CSS but not NLR or PLR. The mGPS was an independent factor for OS but not for CSS in multivariate analysis. Regarding complications, only the CALLY index was an independent predictor of major complications (≧ Clavien-Dindo grade 3) in multivariate analysis but not others.

CONCLUSIONS

The CALLY index may have a clinical value in predicting OS, CSS, and major complications in GC patients undergoing gastrectomy.

Improved functional oral intake and exercise training attenuate decline in aerobic capacity following chemoradiotherapy in patients with esophageal cancer

PURPOSE

To investigate the impact of chemoradiotherapy on the physical fitness of patients with oesophageal cancer, and the clinical factors influencing it.

METHOD

A total of 67 participants successfully completed the study, with 18 of them engaging in supervised, in-hospital aerobic training at moderate intensity for a minimum of 20 sessions. Cardiopulmonary exercise testing, hand grip strength, body composition assessed via bioelectrical impedance analysis, patient-generated subjective global assessment, albumin, and the Functional Oral Intake Scale (FOIS) were evaluated before chemoradiotherapy and 6-8 weeks after its completion.

RESULT

Among the participants, cardiopulmonary fitness, hand grip strength, and phase angle of BC-BIA declined during chemoradiotherapy. Before and after chemoradiotherapy, V̇O2peak was 19.6 ± 4.4 and 17.4 ± 3.9 mL/min/kg respectively. The improvement in FOIS during chemoradiotherapy showed a positive correlation with changes in aerobic capacity. Additionally, exercise training was associated with attenuating the decline in aerobic capacity.

CONCLUSION

Physical fitness deteriorated in patients with oesophageal cancer following chemoradiotherapy. Improvement in dysphagia helps maintain aerobic capacity. Additionally, exercise training has the potential to mitigate the decline. This discovery can serve as a reference for enhancing holistic care for patients with oesophageal cancer.

A cross-sectional survey of prehabilitation among surgeons and anesthesiologists

BACKGROUND

Prehabilitation, which includes nutritional and exercise therapies, is recommended for patients before surgery to improve physical and cognitive functions. This study aimed to identify the awareness, understanding, and issues among surgeons and anesthesiologists regarding the implementation of prehabilitation.

METHODS

We conducted a survey on prehabilitation targeting surgeons and anesthesiologists working at a university hospital and two private hospitals. The survey collection period was set for 1 month, commencing on February 5, 2024. Descriptive statistics were employed to summarize the characteristics of the participants.

RESULTS

A total of 254 surgeons and 49 anesthesiologists from three hospitals participated, with a response rate of 61.7%. Regarding the understanding of prehabilitation, 16.7% of anesthesiologists and only 2% of surgeons had a good grasp of its content. When enquired about the necessity of prehabilitation, 100% of anesthesiologists indicated it as necessary or somewhat necessary, whereas 98.7% of surgeons responded similarly. Several barriers to the implementation of prehabilitation were identified, with the most common reason being the busy schedule of outpatient services.

CONCLUSION

This study highlights that while both surgeons and anesthesiologists recognize the importance of prehabilitation, significant challenges exist in its practical implementation. This underscores the need for simple explanatory tools for patients, the introduction of remote care options, and simple orders to relevant departments, which are essential and require multidisciplinary collaboration.

Multimodal prehabilitation to enhance functional capacity of patients with esophageal cancer during concurrent neoadjuvant chemotherapies-a randomized feasibility trial

Esophageal adenocarcinoma continues to bear high morbidity and mortality. Prehabilitation, using exercise, nutrition, and psychosocial strategies to optimize patients prior to surgical resection, is largely underexplored in this malignancy, especially in patients undergoing neoadjuvant chemotherapy. Objectives of this study were (i) to determine feasibility of prehabilitation during treatment in patients with esophageal cancer and (ii) to establish differences between hospital and home-based exercise. Patients were recruited from August 2019 - February 2023 and blindly randomized to either supervised or homebased exercise, receiving identical nutritional and psychosocial support. The main outcome measures were recruitment, retention, and dropout rates. The secondary outcomes included cardiorespiratory fitness, functional capacity, and quality of life. Forty-four subjects were blindly randomized: 23 to supervised exercise and 21 to home-based exercise (72% recruitment rate). Overall compliance for the supervised group was 72%; home-based group was 77%. Baseline to pre-operative, both groups experienced significant increases in sit-to-stand, arm curls, and amount of weekly moderate-vigorous physical activity. The home-based group experienced an additional considerable decrease in up-and-go test times. Both groups maintained cardiorespiratory fitness and saw substantial increases in some quality-of-life scores. Multimodal prehabilitation is feasible for patients with esophageal cancer undergoing neoadjuvant chemotherapy. In both groups, patient fitness, which is relevant for this patient population given the anticipated decline in functional status during this period, was maintained. This study provides a foundation for future prehabilitation interventions in this patient population.

Nutritional literacy of patients who underwent surgery for esophageal cancer based on Nutbeam's health literacy model: a qualitative study

PURPOSE

The level of nutritional literacy reflects the self-management ability of individuals for a healthy diet and serves as a foundation for effective nutritional interventions. This qualitative study aimed to gain a comprehensive insight into the nutritional literacy levels of patients with esophageal cancer who underwent surgery, obtaining information from both patients and medical staff through interviews.

METHODS

Based on Nutbeam's health literacy model, 27 participants were selected from December 2023 to February 2024. We used semi-structured interviews and directed content analysis.

RESULTS

Sixteen patients who underwent surgery for esophageal cancer and 11 medical staff from the Department of Esophageal Cancer completed the interviews. There were five themes, including attitude and cognition, functional nutrition literacy, interactive nutrition literacy, critical nutrition literacy, and ways to improve patients' nutritional literacy.

CONCLUSION

This study investigated the nutritional literacy levels of patients after esophageal cancer surgery from the perspectives of both patients and medical staff, offering comprehensive insights into the assessment of patients' nutritional literacy and the corresponding strategies for improvement. It emphasizes the hierarchical nature of nutritional literacy among patients after surgery and systematically outlines the different levels of nutritional literacy in this population. The results indicated that the level of nutrient literacy was low and exhibited marked differences. This finding suggests that future studies should be individualized, continuous, and comprehensive, following the Nutbeam's health literacy model, to improve patients' nutritional literacy levels.

Current perioperative care in patients undergoing a beyond total mesorectal excision procedure for rectal cancer: What are the differences with the colorectal enhanced recovery after surgery protocol?

AIM

Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS-related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol.

METHOD

This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS-related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients.

RESULTS

Seven studies reported on ERAS-related outcomes in patients undergoing bTME. Median length of hospital stay was 9-19 days, median stay in the intensive care unit was 2-4 days and 30-day postoperative major complication rates were 22.6%-61.3%. Seventy-five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization.

CONCLUSION

Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS-related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC.

Preoperative physiotherapy for improving the reserve capacity in a patient with esophageal cancer and frailty: A case report

INTRODUCTION

Frailty is significantly correlated with a higher incidence of medical complications during hospitalization after esophagectomy. As frailty is thought to be a reversible condition, improving the reserve capacity through preoperative physical therapy is expected to reduce the risk of postoperative pulmonary complications (PPCs). Herein, we report our experience with preoperative physical therapy in a patient with esophageal cancer who was considered to have inadequate fitness for surgery owing to poor physical performance.

CASE PRESENTATION

A 72-year-old man (height: 169.5 cm, weight: 54.7 kg, body mass index: 18.9 kg/m2) with esophagogastric junction tumors (cStage IIIA) was hospitalized and scheduled to undergo surgery based on preoperative screening. He was categorized as frail according to the revised Japanese version of the Cardiovascular Health Study criteria and the Mini Nutritional Assessment Short-Form indicated severe malnutrition. We focused on physical therapy to improve exercise tolerance and prevent PPCs and devised a short-term intensive physical therapy program comprising minimal exercises that the patient could perform efficiently. The program consisted of only inspiratory muscle training and aerobic exercises. His maximal inspiratory pressure (MIP) and 6-min walking distance improved by 30 cm H2O and 145 m, respectively, on the day before surgery compared with those on day 8. The percentage predicted value of the MIP improved from 56.6% at the start of physical therapy to 102.9% on the day before surgery. On day 43, the patient underwent subtotal esophagectomy and was able to ambulate on postoperative day 5 without respiratory complications.

CONCLUSION

We conducted a short-term, intensive, and minimal preoperative physical therapy program for a patient with esophageal cancer who had physical frailty. Preoperative physical therapy to increase the reserve capacity may result in a favorable postoperative course even in patients with physical frailty.

Effect of Combined Exercise and Nutrition Interventions During Inpatient Chemotherapy in Acute Leukemia and Malignant Lymphoma Patients: A Randomized Controlled Trial

The aim of the present study was to determine the effectiveness of combined exercise and nutrition interventions on physical function and quality of life (QOL) in patients with acute leukemia or malignant lymphoma (ML) during inpatient chemotherapy. The study was a randomized controlled trial where patients with acute leukemia or ML who were receiving inpatient chemotherapy and exercise therapy were divided into an intervention group (IG) and a control group (CG). Both groups underwent resistance training and aerobic exercise. The patients in the IG were instructed to take nutritional supplements twice a day. Assessment items were muscle strength (handgrip strength and knee extension strength), 6-min walking test, skeletal muscle mass, QOL, nutritional status, and fatigue. Two-way analysis of variance showed a significant interaction for bilateral handgrip strength and knee extension strength. No significant interactions were found for the other items. The results of the present study showed improved muscle strength in the IG compared to the CG, indicating the effectiveness of combined exercise and nutrition interventions during inpatient chemotherapy in patients with acute leukemia or ML.

Effect of prehabilitation programmes on functional capacity in patients awaiting oncological resections: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

To investigate the effects of prehabilitation on the perioperative functional capacity of patients awaiting oncological resections.

METHODS

A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist and within the databases Cochrane Library, EBSCOhost, Google Scholar, MEDLINE PubMed, and Web of Science. The eligibility criteria were set to include peer-reviewed randomised control trials including only adult (≥ 18 years old) patients undergoing any type of prehabilitation (PREHAB) prior to any type of oncological resection. The studies had to feature at least one control group undergoing standard care (SC) and had to assess functional capacity by means of a 6-min walk distance (6MWD) or peak oxygen uptake (VO2Peak) at different stages pre- and post- operatively.

RESULTS

Twenty-seven randomised controlled trials involving 1994 patients were included. After processing the data, the number of patients was 1889. Studies featured different cancer specialties: lung (11), colorectal (5), urological (4), abdominal (3), esophagogastric (2), liver (1), and gastrointestinal (1). Overall, PREHAB enhanced both 6MWD (g = 0.273, 95% CI 0.174 to 0.371, Z = 5.406, p < 0.001) and VO2Peak (g = 0.615, 95% CI 0.243 to 0.987, Z = 3.240, p = 0.001) compared with SC. The 6MWD subgroup analysis revealed a small mean effect size favouring both unimodal and multimodal PREHAB interventions.

CONCLUSION

These findings support that prehabilitation, whether implemented as unimodal or multimodal format, elicits small preoperative improvements in functional capacity in patients awaiting oncological resections. PROSPERO registration number CRD42023428676.

Ethical Considerations and Equipoise in Cancer Surgery

The changing landscape of cancer surgery requires ongoing consideration of ethical issues to ensure patient-centered care and fair access to treatments. With technological advancements and the global expansion of surgical interventions, healthcare professionals must navigate complex ethical dilemmas related to patient autonomy, informed consent, and the impact of new technologies on the physician-patient relationship. Additionally, ethical principles and decision-making in oncology, especially in the context of genetic predisposition to breast cancer, highlight the importance of integrating patient knowledge, preferences, and alignment between goals and treatments. As global surgery continues to grow, addressing ethical considerations becomes crucial to reduce disparities in access to surgical interventions and uphold ethical duties in patient care. Furthermore, the rise of digital applications in healthcare, such as digital surgery, requires heightened awareness of the unique ethical issues in this domain. The ethical implications of using artificial intelligence (AI) in robotic surgical training have drawn attention to the challenges of protecting patient and surgeon data, as well as the ethical boundaries that innovation may encounter. These discussions collectively emphasize the complex ethical issues associated with surgical innovation and underscore the importance of upholding ethical standards in the pursuit of progress in the field. In this study, we thoroughly analyzed previous scholarly works on ethical considerations and equipoise in the field of oncological surgery. Our main focus was on the use of AI in this specific context.

Research Progress on Patients of Esophageal Cancer Complicated with Sarcopenia

Aims/Background The application of immunochemotherapy has significantly enhanced the quality of life and overall survival of patients with esophageal cancer. Sarcopenia, which is increasingly prevalent in these patients, markedly affects prognosis, but can be reversed by appropriate and effective treatment. Methods The narrative review was conducted on PubMed using the keywords ("esophageal" or "esophagus" and "sarcopenia"). Results This article reviews the measurement, timing, and intervention strategies for sarcopenia in patients with esophageal cancer. It summarizes the evaluation indicators of skeletal muscle loss in these patients, analyzes the barriers to intervention for frailty among esophageal cancer patients, and proposes corresponding countermeasures. Conclusion Patients with esophageal cancer often suffer from severe sarcopenia. Clinical intervention is crucial in addressing this issue.

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Role of Outpatient Physical Medicine and Rehabilitation in a Multidisciplinary Prehabilitation Program for Older Adults Before Allogeneic Hematopoietic Stem Cell Transplant

INTRODUCTION

Physical rehabilitation is increasingly incorporated throughout the allogeneic hematopoietic stem cell transplant journey for older adults.

OBJECTIVE

This study aimed to describe physical medicine and rehabilitation-related diagnoses, exercise barriers, and management recommendations for older adults before allogeneic hematopoietic stem cell transplant.

DESIGN

Fifty physical medicine and rehabilitation consults as part of the Enhanced Recovery-Stem Cell Transplant multidisciplinary prehabilitation program at a comprehensive cancer center were retrospectively reviewed.

RESULTS

Many physical medicine and rehabilitation-related diagnoses (173), exercise barriers (55), and management recommendations (112) were found. Common diagnoses were musculoskeletal dysfunction (more commonly back, shoulder, then knee) ( n = 39, 23%) and fatigue ( n = 36, 21%). Common exercise barriers were also musculoskeletal dysfunction (more commonly back, knee, then shoulder) (total n = 20, 36%) and fatigue ( n = 20, 36%). Most patients ( n = 32, 64%) had one or more exercise barriers. Common physical medicine and rehabilitation management recommendations were personalized exercise counseling ( n = 37, 33%), personalized nutrition management ( n = 19, 17%), body composition recommendations ( n = 17, 15%), medications ( n = 15, 13%), and orthotics and durable medical equipment ( n = 8, 7%).

CONCLUSIONS

Routine physical medicine and rehabilitation referral of older allogeneic hematopoietic stem cell transplant patients for prehabilitation resulted in the identification of many rehabilitative needs and substantial additional management recommendations. Increased early, collaborative prehabilitation efforts between physical medicine and rehabilitation and allogeneic hematopoietic stem cell transplant teams to optimize care for these patients is recommended.

Loss of Independence in Older Adults With Operable Oral Cavity Cancer: A Retrospective Cohort Study

OBJECTIVE

To ascertain the effect of curative-intent surgery on loss of independence (LOI) in patients with oral cavity squamous cell carcinoma (OCSCC).

STUDY DESIGN

Retrospective observational study of patients diagnosed from 2014 to 2021.

SETTING

Single tertiary care academic center. Patients having undergone curative-intent surgical treatment for OCSCC from 2014 to 2021 in the cancer registry.

METHODS

LOI as the primary outcome was measured based on a combination of decrease in activities of daily living (ADLs) and/or decline in mobility during treatment. Descriptive statistics were used to compare baseline demographics and multivariable logistic regression was used to assess the association between LOI and perioperative variables of interest.

RESULTS

Of the 180 patients included in this study, 139 (79%) were fully independent in ADLs/instrumental ADLs prior to surgery. The average age of the cohort was 74 with 49% males. Thirty-seven (21%) experienced a decline in mobility or increased care needs following surgery, and 18 (10%) experienced an independent decline in functional status. Increasing age, osseous flap reconstruction, high Charlson Comorbidity Index, and major postoperative adverse events were associated with LOI. Fifty-five percent of patients with LOI had recovered to baseline within 7 months from surgery. LOI was associated with poor treatment tolerance (odds ratio: 4.77, 95% confidence interval: 1.87-12.2) while adjusting for multiple confounders.

CONCLUSION

LOI is common in older adults undergoing curative-intent surgery for OCSCC and associated with poor treatment tolerance.

Integrated impact of multiple body composition parameters on overall survival in gastrointestinal or genitourinary cancers: A descriptive cohort study

BACKGROUND

This study aimed to evaluate if combining low muscle mass with additional body composition abnormalities, such as myosteatosis or adiposity, could improve survival prediction accuracy in a large cohort of gastrointestinal and genitourinary malignancies.

METHODS

In total, 2015 patients with surgically-treated gastrointestinal or genitourinary cancer were retrospectively analyzed. Skeletal muscle index, skeletal muscle radiodensity, and visceral/subcutaneous adipose tissue index were determined. The primary outcome was overall survival determined by hospital records. Multivariate Cox hazard models were used to identify independent predictors for poor survival. C-statistics were assessed to quantify the prognostic capability of the models with or without incorporating body composition parameters.

RESULTS

Survival curves were significantly demarcated by all 4 measures. Skeletal muscle radiodensity was associated with non-cancer-related deaths but not with cancer-specific survival. The survival outcome of patients with low skeletal muscle index was poor (5-year OS; 65.2%), especially when present in combination with low skeletal muscle radiodensity (5-year overall survival; 50.2%). All examined body composition parameters were independent predictors of lower overall survival. The model for predicting overall survival without incorporating body composition parameters had a c-index of 0.68 but increased to 0.71 with the inclusion of low skeletal muscle index and 0.72 when incorporating both low skeletal muscle index and low skeletal muscle radiodensity/visceral adipose tissue index/subcutaneous adipose tissue index.

CONCLUSION

Patients exhibiting both low skeletal muscle index and other body composition abnormalities, particularly low skeletal muscle radiodensity, had poorer overall survival. Models incorporating multiple body composition prove valuable for mortality prediction in oncology settings.

LUNA EMG as a Marker of Adherence to Prehabilitation Programs and Its Effect on Postoperative Outcomes among Patients Undergoing Cytoreductive Surgery for Ovarian Cancer and Suspected Ovarian Tumors

BACKGROUND

Prehabilitation is a novel strategy in preoperative management. The aim of this study was to investigate the effect of prehabilitation programs on peri- and postoperative outcomes and to verify if LUNA EMG has the capacity to monitor compliance with prehabilitation programs.

METHODS

A total of seventy patients with suspected ovarian cancer were recruited between April 2021 and September 2022 and were divided into a prehabilitation group (36 patients) or a control group (34 patients). A LUNA EMG device was utilized to monitor muscle strength and tension.

RESULTS

Within the prehabilitation group, we observed a significant increase in the 6-Minute Walk Test distance by 17 m (median, IQR: 0-42.5, p < 0.001) and a significant increase in muscle strength measured with LUNA EMG. In comparison to the control group, the prehabilitation group showed fewer complications according to the Clavien-Dindo classification (47.2% vs. 20.6%, p = 0.02) and shorter postoperative hospital stays (median 5.0 days [IQR: 4.0-6.2] vs. 7.0 days [IQR: 6.0-10.0], p < 0.001).

CONCLUSION

Prehabilitation has a positive effect on physical capacity and muscle strength and is associated with a reduction in the number of complications after surgery. LUNA EMG can be a useful tool for monitoring patients' adherence to prehabilitation programs.

Association of magnetic resonance imaging-derived sarcopenia with outcomes of patients with hepatocellular carcinoma after hepatectomy

PURPOSE

To evaluate whether sarcopenia, diagnosed by magnetic resonance imaging (MRI) protocol, constitutes a prognosis-associated risk factor in patients with hepatocellular carcinoma (HCC) after hepatectomy.

METHODS

One hundred and ninety-three patients who underwent hepatectomy for HCC were retrospectively enrolled. The areas of the total skeletal muscle (SM) and psoas muscle (PM) were evaluated at the third lumbar vertebra in the preoperative MR images, and divided by the square of height in order to obtain the skeletal muscle index (SMI) and psoas muscle mass index (PMI). Sarcopenia was diagnosed respectively on the definitions based on the SMI or PMI. The potential of muscle-defined sarcopenia as a prognostic factor for overall survival (OS) and recurrence-free survival (RFS) was investigated in these patients.

RESULTS

The areas of SM and PM, and SMI and PMI were significantly higher in the men than in the women (all p < 0.05). Notably, SMI-defined sarcopenia displayed a significant sex difference (p = 0.003), while PMI-defined sarcopenia did not (p = 0.370). Through univariate and multivariate analyses, PMI-defined sarcopenia remained an independent predictor for OS and RFS (HR = 3.486, 95% CI: 1.700-7.145, p = 0.001 and HR = 1.993, 95% CI: 1.246-3.186, p = 0.004), even after adjusting for other clinical variables. Moreover, Kaplan-Meier analysis demonstrated significantly poorer OS and RFS for patients with sarcopenia defined by using PMI, but not SMI, compared to those without sarcopenia (p < 0.001 and p = 0.006, respectively).

CONCLUSION

MRI-derived, sarcopenia defined by using PMI, not SMI, may serve as a significant risk factor for RFS and OS in patients with HCC after hepatectomy.

Effect of nutrition-based prehabilitation on the postoperative outcomes of patients with esophagogastric cancer undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Meta-analyses have primarily focused on the effects of exercise-based prehabilitation on postoperative outcomes and ignored the role of nutritional intervention. In this study, we filled this gap by investigating the effect of nutrition-based prehabilitation on the postoperative outcomes of patients who underwent esophagectomy and gastrectomy.

METHODS

Five electronic databases, namely, PubMed, the Web of Science, Embase, Cochrane Library, and CINAHL, were searched. Adults diagnosed with esophagogastric cancer who were scheduled to undergo surgery and had undergone uni- or multimodal prehabilitation, with at least a week of mandatory nutritional intervention, were included. Forest plots were used to extract and visualize the data from the included studies. The occurrence of any postoperative complication was considered the primary endpoint.

RESULTS

Eight studies met the eligibility criteria, with five randomized controlled trials (RCTs) and three cohort studies. In total, 661 patients were included. Any prehabilitation, that is, unimodal (only nutrition) and multimodal prehabilitation, collectively decreased the risk of any postoperative complication by 23% (95% confidence interval [CI] = 0.66-0.90). A similar effect was exclusively observed for multimodal prehabilitation (risk ratio [RR] = 0.78, 95% CI = 0.66-0.93); however, it was not significant for unimodal prehabilitation. Any prehabilitation significantly decreased the length of hospital stay (LOS) (weighted mean difference = -0.77, 95% CI = -1.46 to -0.09).

CONCLUSIONS

Nutrition-based prehabilitation, particularly multimodal prehabilitation, confers protective effects against postoperative complications after esophagectomy and gastrectomy. Our findings suggest that prehabilitation slightly decreases LOS; however, the finding is not clinically significant. Therefore, additional rigorous RCTs are warranted for further substantiation.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Start Strong, Finish Strong: A Review of Prehabilitation in Cardiac Surgery

Cardiac surgery constitutes a significant surgical insult in a patient population that is often marred by significant comorbidities, including frailty and reduced physiological reserve. Prehabilitation programs seek to improve patient outcomes and recovery from surgery by implementing a number of preoperative optimization initiatives. Since the initial trial of cardiac prehabilitation twenty-four years ago, new data have emerged on how to best utilize this tool for the perioperative care of patients undergoing cardiac surgery. This review will explore recent cardiac prehabilitation investigations, provide clinical considerations for an effective cardiac prehabilitation program, and create a framework for future research studies.

The effect of a pre- and post- operative exercise program versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): a randomized controlled trial

INTRODUCTION

Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window.

METHODS

A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery.

RESULTS

Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures.

CONCLUSIONS

This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT.

Feasibility of an exercise-nutrition-psychology integrated rehabilitation model based on mobile health and virtual reality for cancer patients: a single-center, single-arm, prospective phase II study

OBJECTIVE

Explore the feasibility of a mobile health(mHealth) and virtual reality (VR) based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients.

METHODS

We recruited cancer patients in the Oncology department of the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University from October 2022 to April 2023. The rehabilitation program was provided by a team of medical oncologists, dietitians, psychotherapists, and oncology specialist nurses. Participants received standard anti-cancer therapy and integrated intervention including hospitalized group-based exercise classes, at-home physical activity prescription, behavior change education, oral nutrition supplements, and psychological counseling. An effective intervention course includes two consecutive hospitalization and two periods of home-based rehabilitation (8 weeks). Access the feasibility as well as changes in aspects of physical, nutritional, and psychological status.

RESULTS

At the cutoff date of April 2023, the recruitment rate was 75% (123/165). 11.4%patients were lost to follow-up, and 3.25% withdrew halfway. Respectively, the completion rate of nutrition, exercise, and psychology were 85%,55%, and 63%. Nutrition interventions show the highest compliance. The parameters in nutrition, psychology, muscle mass, and quality of life after the rehabilitation showed significant improvements (P < .05). There was no significant statistical difference (P > .05) in handgrip strength and 6-minute walking speed.

CONCLUSION

It is feasible to conduct mHealth and VR-based nutrition-exercise-psychology integrated rehabilitation model in Chinese cancer patients. A larger multi-center trial is warranted in the future.

TRIAL REGISTRATION

ChiCTR2200065748 Registered 14 November 2022.

What is the role of physical exercise in the era of cancer prehabilitation? A systematic review

PURPOSE

Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding.

METHODS

A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included.

RESULTS

A total of 96 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported.

CONCLUSION

Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies.

Sarcopenia predicts short-term treatment-related toxicity in patients undergoing curative-intent therapy for head and neck cancer: A systematic review and meta-analysis

Sarcopenia is an increasingly recognized biomarker associated with poorer outcomes. The objective of this study was to ascertain the effect of sarcopenia on treatment tolerance and short-term toxicity in head and neck cancer (HNC). A systematic review was performed using multiple databases. An inverse-variation, random-effects model was used to perform the meta-analysis to evaluate the effect of sarcopenia on severe treatment toxicity and poor treatment tolerance. Sixteen observational studies, including 3187 patients with HNC, were analyzed. The combined odds ratio (OR) for severe treatment toxicity and tolerance was 2.22 (95%CI 1.50-3.29) and 1.40 (95%CI 0.84-2.32), respectively. The effect of sarcopenia on short-term severe treatment toxicity was similar with upfront surgery (OR 2.03, 95%CI 1.22-3.37) and definitive radiotherapy (OR 2.24, 95%CI 1.18-4.27) Patients with sarcopenia are more than twice as likely to suffer a short-term treatment-related toxicity when undergoing curative-intent HNC treatment.

Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study

Background

Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.

Methods

Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.

Results

Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien-Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.

Conclusions

VO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.

Clinical trial registration

NCT03637647.

Prehabilitation of surgical patients: a bibliometric analysis from 2005 to 2023

BACKGROUND

Good preoperative conditions help patients to counteract surgical injury. Prehabilitation is a multimodal preoperative management strategy, including physical, nutritional, psychological, and other interventions, which can improve the functional reserve of patients and enhance postoperative recovery. The purpose of this study is to show the evolution trend and future directions of research related to the prehabilitation of surgical patients.

METHODS

The global literature regarding prehabilitation was identified from The Web of Science Core Collection database. Bibliometric methods of the Bibliometrix package of R (version 4.2.1) and VOSviewer were used to analyze publication trends, cooperative networks, study themes, and co-citation relationships in the field.

RESULTS

A total of 638 publications were included and the number of publications increased rapidly since 2016, with an average annual growth rate of 41.0%. "Annals of Surgery", "British Journal of Surgery" and "British Journal of Anesthesia" were the most cited journals. Experts from the USA, Canada, the UK, and the Netherlands contributed the most in this field, and an initial cooperative network among different countries and clinical teams was formed. Malnutrition, older patients, frailty, and high-risk patients were the hotspots of recent studies. However, among the top 10 cited articles, the clinical effects of prehabilitation were conflicting.

CONCLUSION

This bibliometric review summarized the most influential publications as well as the publication trends and clarified the progress and future directions of prehabilitation, which could serve as a guide for developing evidence-based practices.

Nutrition Risk Screening 2002 for Adult Cancer Patients: A Systematic Review and Meta-Analysis

It is critical to screen and assess malnutrition in cancer patients early. However, there is no uniform standard for nutritional risk screening and malnutrition assessment. We aimed to analyze the effects of the Nutrition Risk Screening 2002 (NRS2002) in screening for nutritional risk among adult cancer patients, using the Patient-Generated Subjective Global Assessment (PG-SGA) as the reference standard. A systematic search was performed using PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, and China Science and Technology Journal Database (VIP). Studies comparing NRS2002 with PG-SGA in adult cancer patients were included. To assess the quality of the included studies, the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used. The combined sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the receiver-operating characteristic curve (AUC) were calculated. In addition, sensitivity, subgroup, and publication bias analyses were performed. Thirteen articles involving 3,373 participants were included. The combined sensitivity, specificity, DOR, and AUC were 0.62 (95% CI, 0.60-0.64), 0.86 (95% CI, 0.84-0.88), 11.23 (95% CI, 8.26-15.27), and 0.85 (95% CI, 0.82-0.88), respectively. For adult cancer patients, NRS2002 has moderate sensitivity, high specificity, and high AUC in screening for nutritional risk.

Preoperative walking exercise to improve prognosis in patients with supratentorial brain tumours after craniotomy: protocol for a randomised controlled trial

INTRODUCTION

Cardiopulmonary complications and cognitive impairment following craniotomy have a significantly impact on the general health of individuals with brain tumours. Observational research indicates that engaging in walking is linked to better prognosis in patient after surgery. This trial aims to explore whether walking exercise prior to craniotomy in brain tumour patients can reduce the incidence of cardiopulmonary complications and preserve patients' cognitive function.

METHODS AND ANALYSIS

In this randomised controlled trial, 160 participants with supratentorial brain tumours aged 18-65 years, with a preoperative waiting time of more than 3-4 weeks and without conditions that would interfere with the trial such as cognitive impairment, will be randomly assigned in a ratio of 1:1 to either receive traditional treatment or additional combined with a period of 3-4 weeks of walking exercise of 10 000-15 000 steps per day. Wearable pedometer devices will be used to record step counts. The researchers will evaluate participants at enrolment, baseline, 14 days preoperatively, 3 days prior to surgery and 1 week after surgery or discharge (select which occurs first). The primary outcomes include the incidence of postoperative cardiopulmonary complications and changes in cognitive function (gauged by the Montreal Cognitive Assessment test). Secondary outcomes include the average length of hospital stay, postoperative pain, participant contentment, healthcare-associated costs and incidence of other postoperative surgery-related complications. We anticipate that short-term preoperative walking exercises will reduce the incidence of surgery-related complications in the short term after craniotomy, protect patients' cognitive function, aid patients' postoperative recovery and reduce the financial cost of treatment.

ETHICS AND DISSEMINATION

The study protocol has been approved by Ethics Committee of Xiangya Hospital of Central South University (approval number: 202305117). The findings of the research will be shared via publications that have been reviewed by experts in the field and through presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT05930288.

Malnutrition in cancer patients: Causes, consequences and treatment options

Cancer patients are at a high risk of malnutrition and disease-associated catabolic derangements. It is important to differentiate between 'simple' - voluntary or involuntary - caloric restriction with protein-sparing ketogenic metabolic adaptation and cachexia, characterized by the combination of weight loss and dysmetabolism, most prominently systemic inflammation. While both conditions result in the sacrifice of fat and protein stores and thus impact on treatment tolerance, complication rates and survival, the presence of metabolic derangements is especially dangerous by straining multiple organ functions. To avoid underdiagnosing and undertreating malnutrition, all cancer patients should be routinely screened for nutritional risk. At-risk patients require comprehensive assessment for contributing and treatable causes and, if available, multi-professional efforts to improve food intake, support anabolism, alleviate distress and antagonize pro-inflammatory processes. In curative settings, anabolic support should accompany or even precede anticancer treatments. Prehabilitation before major surgery, has been studied extensively, including muscle training as well as nutritional and/or psychological support. Recent meta-analyses report a consistent benefit on functional capacity and possible improvement in postoperative complications and length of hospital stay. In palliative settings, prevailing catabolic derangements require careful assessment of the individual constellation of disturbed functions and an empathic evaluation of benefits and risks of nutritional interventions. This is of special relevance in patients with an expected survival of less than a few months. Due to the complex interactions of mechanical, metabolic and psychological factors, multi-professional teams should be involved.

Six-minute walking distance and desaturation-distance ratio in allogeneic stem cell transplantation

BACKGROUND

Most patients with haematological malignancies who undergo allogeneic haematopoietic stem cell transplant (HSCT) receive chemotherapy before the transplant to control the disease. Certain chemotherapy drugs can cause lung toxicity. Conversely, in patients with chronic respiratory conditions, the 6-min walking test (6MWT) and the desaturation-distance ratio (DDR) have demonstrated prognostic significance. Our objective was to determine whether the 6MWD and DDR, assessed prior to HSCT, have a prognostic impact on survival at 24 months post-HSCT.

METHODS

A prospective experimental study was conducted in consecutive patients referred for allogeneic HSCT at Hospital Clinic, Barcelona, Spain. A complete functional respiratory study, including the 6MWT and DDR, was conducted prior to admission. The area under the curve (AUC) and cut-off points were calculated. Data on patients' characteristics, HSCT details, main events, with a focus on lung complications, and survival at 24 months were analysed.

RESULTS

One hundred and seventy-five patients (39% women) with mean age of 48 ± 13 years old were included. Before HSCT, forced vital capacity and forced expiratory volume in the first second were 96% ± 13% predicted and 92% ± 14% predicted, respectively; corrected diffusing capacity for carbon monoxide 79% ± 15% predicted; 6MWD was 568 ± 83 m and DDR of .27 (.20-.41). The cut-off points for 6MWD and DDR were 566 m, [.58 95% CI (.51-.64)], p = .024 and .306, [.63 95% CI (.55-.70)], p = .0005, respectively. The survival rate at 24 months was 55%.

CONCLUSION

Our results showed that individuals who exhibit a 6MWD shorter than 566 ms or a decline in DDR beyond .306 experienced reduced survival rates at 24 months after HSCT.

Standard Nutritional Assessment Tools Are Unable to Predict Loss of Muscle Mass in Patients Due to Undergo Pancreatico-Duodenectomy: Highlighting the Need for Detailed Nutritional Assessment

BACKGROUND AND METHODS

Pancreatico-duodenectomy (PD) carries significant morbidity and mortality, with very few modifiable risk factors. Radiological evidence of sarcopenia is associated with poor outcomes. This retrospective study aimed to analyse the relationship between easy-to-use bedside nutritional assessment techniques and radiological markers of muscle loss to identify those patients most likely to benefit from prehabilitation.

RESULTS

Data were available in 184 consecutive patients undergoing PD. Malnutrition was present in 33-71%, and 48% had a high visceral fat-to-skeletal muscle ratio, suggestive of sarcopenic obesity (SO). Surgical risk was higher in patients with obesity (OR 1.07, 95%CI 1.01-1.14, p = 0.031), and length of stay was 5 days longer in those with SO (p = 0.006). There was no correlation between skeletal muscle and malnutrition using percentage weight loss or the malnutrition universal screening tool (MUST), but a weak correlation between the highest hand grip strength (HGS; 0.468, p < 0.001) and the Global Leadership in Malnutrition (GLIM) criteria (-0.379, p < 0.001).

CONCLUSIONS

Nutritional assessment tools give widely variable results. Further research is needed to identify patients at significant nutritional risk prior to PD. In the meantime, those with malnutrition (according to the GLIM criteria), obesity or low HGS should be referred to prehabilitation.

Frailty Screening is Associated with Hospitalization and Decline in Quality of Life and Functional Status in Older Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Our goals were to study frailty screening in association with hospitalization and decline in quality of life [QoL] and functional status in older patients with inflammatory bowel diseases [IBD].

METHODS

This was a prospective multicentre cohort study in IBD patients ≥65 years old using frailty screening [G8 Questionnaire]. Outcomes were all-cause, acute, and IBD-related hospitalization, any infection, any malignancy, QoL [EQ5D-3L], and functional decline (Instrumental Activities of Daily Living [IADL]) during 18 months of follow-up. Confounders were age, IBD type, biochemical disease activity [C-reactive protein ≥10 mg/L and/or faecal calprotectin ≥250 µg/g], and comorbidity [Charlson Comorbidity Index].

RESULTS

Of 405 patients, with a median age of 70 years, 196 [48%] were screened as being at risk for frailty. All-cause hospitalizations occurred 136 times in 96 patients [23.7%], and acute hospitalizations 103 times in 74 patients [18.3%]. Risk of frailty was not associated with all-cause (adjusted hazard ratio [aHR] 1.5, 95% confidence interval [CI] 0.9-2.4), but was associated with acute hospitalizations [aHR 2.2, 95% CI 1.3-3.8]. Infections occurred in 86 patients [21.2%] and these were not associated with frailty. A decline in QoL was experienced by 108 [30.6%] patients, and a decline in functional status by 46 patients [13.3%]. Frailty screening was associated with a decline in QoL (adjusted odds ratio [aOR] 2.1, 95% CI 1.3-3.6) and functional status [aOR 3.7, 95% CI 1.7-8.1].

CONCLUSIONS

Frailty screening is associated with worse health outcomes in older patients with IBD. Further studies are needed to assess the feasibility and effectiveness of its implementation in routine care.

Protocol of a pilot randomized clinical trial to evaluate nutritional support and rehabilitation on prevention of skeletal muscle mass loss during neoadjuvant chemotherapy in patients with esophageal cancer

BACKGROUND

Subtotal esophagectomy with lymph node dissection followed by neoadjuvant chemotherapy (NAC) is the standard treatment for stage II-III esophageal cancer. Esophagectomy is still associated with high morbidity rates, and reducing these rates remains challenging. Among several complications, postoperative pneumonia (PP) is sometimes fatal, which has been reportedly caused by sarcopenia. Thus, nutritional support and rehabilitation may be promising for preventing skeletal muscle mass loss and reduce the incidence of PP.

METHODS

This single-center, randomized, open-label, pilot trial will randomize a total of 40 patients with esophageal cancer in a 1:1 ratio either to ISOCAL Clear + rehabilitation arm or only rehabilitation arm. Although all patients will be educated about rehabilitation by a specialized physician and will be asked to undergo the prespecified rehabilitation program, patients treated with ISOCAL Clear + rehabilitation arm will be supplemented by 400 mL of ISOCAL Clear (Nestlé Japan Ltd, Tokyo, Japan) per day during two courses of NAC with docetaxel, cisplatin, and fluorouracil. Body composition will be assessed using Inbody (Inbody Co., Ltd., Tokyo, Japan) just before starting NAC and surgery. The primary endpoint is the change of skeletal muscle index (SMI) during NAC. Secondary endpoints include (i) body weight, total skeletal muscle mass, appendicular skeletal muscle mass, and lean body mass index changes; (ii) the percentage of ISOCAL Clear continuation; (iii) appetite evaluation; (iv) the percentage of targeted calorie achievement; (v) adverse events of NAC; (vi) postoperative complication rates; and (vii) postoperative hospital stay.

DISCUSSION

This prospective trial assesses the efficacy of nutritional support in addition to rehabilitation during NAC for patients with esophageal cancer. The results will be utilized in assessing whether the effects of nutritional support by ISOCAL Clear are promising or not and in planning future larger clinical trials.

Perioperative Immunotherapy for Node-Negative Non-Small Cell Lung Cancer-Current Evidence and Future Directions

Neoadjuvant immunotherapy has gone from an idea to an indication in locally advanced lung cancer. Several phase III trials have demonstrated the superiority of neoadjuvant chemoimmunotherapy compared with chemotherapy in this setting. Although such progress has revolutionized the treatment of locally advanced disease, the unmet needs of stage I and stage II patients without lymph node disease have largely been underrepresented in existing trials. Up-front resection with few patients going on to complete adjuvant therapy remains the norm for most stage I and II patients. Emerging evidence now supports the exploration of supplemental checkpoint blockade in well-selected early-stage, node-negative patients with large tumors and no actionable driver mutations. Although concerns surrounding safety and risk exist, patient selection could be substantially improved using novel biomarker approaches that leverage our understanding of the tumor immune microenvironment of lung cancer. This review provides a comprehensive overview of the opportunities and controversies of perioperative immunotherapy in node-negative lung cancer.

Comparison of Four Nutritional Screening Tools for Predicting Postoperative Adverse Events Following Degenerative Spinal Deformity Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

To compare the mini nutritional assessment-short form (MNA-SF), geriatric nutritional risk index, prognostic nutritional index (PNI), and preoperative serum albumin level as predictors of postoperative adverse events (AEs) in degenerative spine deformity (DSD) patients.

SUMMARY OF BACKGROUND DATA

Although various nutritional screening tools have been well evaluated in patients undergoing spinal fusion surgery, the most suitable tool for the DSD population remains uncertain at present.

PATIENTS AND METHODS

The authors reviewed consecutive patients who underwent thoracolumbar fusion surgery for DSD between August 2016 and May 2023. Four screening tools were used to assess preoperative nutritional status. Patients were divided into two categories according to each screening tool, and the four screening tools were compared regarding their predictive power for postoperative AEs, including the rates of extended length of hospital stays (LOS), complications, and readmission within three months. Physical functional indicators such as time to first ambulation, nonhome discharge, and postoperative LOS were assessed as secondary outcome measures. A multivariable logistic regression analysis was used to identify factors associated with postoperative AEs.

RESULTS

A total of 228 patients were included. The demographic characteristics, underlying disease, and magnitude of correction were not significantly different between well-nourished and malnourished groups. The nutritional risks shown by MNA-SF and albumin level were significantly associated with infectious complications ( P <0.05). The nutritional risk shown by MNA-SF was significantly associated with nonhome discharge, prolonged postoperative LOS (12.5±8.2 vs. 10.3±6.1, P =0.039), and delayed ambulation (3.7±2.1 vs. 2.2±1.8, P =0.001). Multivariable logistic regression revealed that PNI <50 was significantly associated with total AEs and minor AEs after DSD surgery.

CONCLUSIONS

PNI was significantly associated with the incidence of total AEs and minor AEs, while preoperative albumin level and MNA-SF were more effective in predicting postoperative infectious complications and delayed recovery of physical function, respectively.

LEVEL OF EVIDENCE

Level III.

Identification of subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation

PURPOSE

To identify subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation, and to investigate whether training outcomes varied between subgroups.

MATERIALS AND METHODS

Data from a multicentre cohort study were used, involving participants following prehabilitation before oesophagectomy. Hierarchical cluster analysis was performed using four cluster variables (intensity of aerobic exercise, the Borg score during resistance exercise, intensity of physical activity, and degree of fatigue). Aerobic capacity and muscle strength were estimated before and after prehabilitation.

RESULTS

In 64 participants, three clusters were identified based on exercise intensity. Cluster 1 (n = 23) was characterised by fatigue and physical inactivity, cluster 2 (n = 9) by a low training capacity, despite high physical activity levels, and cluster 3 (n = 32) by a high training capacity. Cluster 1 showed the greatest improvement in aerobic capacity (p = 0.37) and hand grip strength (p = 0.03) during prehabilitation compared with other clusters.

CONCLUSIONS

This cluster analysis identified three subgroups with distinct patterns in exercise intensity during prehabilitation. Participants who were physically fit were able to train at high intensity. Fatigued participants trained at lower intensity but showed the greatest improvement. A small group of participants, despite being physically active, had a low training capacity and could be considered frail.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

"Prehabilitation" for Pediatric Patients With Cancer Before Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is associated with significant physical debility. Studies have suggested that physical activity can improve endurance and strength. However, studies have not yet investigated "prehabilitation," exercise before HSCT, to improve functional outcomes. We describe the impact of exercise therapy on physical debility in children undergoing HSCT to inform the implementation of prehabilitation. This review was conducted through a search of the electronic database PubMed. Articles included were those with original research, including randomized control trials, prospective studies, case controls, and retrospective studies. Eleven of the 191 resulting studies met our review criteria. None focused on prehabilitation, but instead on interventions during HSCT. Ten studies showed improvement or maintenance of strength, endurance, stretching, or aerobic fitness. This review shows that exercise therapy can positively affect outcomes in patients undergoing HSCT. Further investigations are needed to determine whether prehabilitation has better results than concurrent exercise.

Preoperative low skeletal muscle volume can result in insufficient administration of S-1 adjuvant chemotherapy in older patients with stage II/III gastric cancer

BACKGROUND AND PURPOSE

Older patients are more likely to encounter difficulties receiving chemotherapy, but the factors involved in the continuation of chemotherapy in these patients remain unclear. We investigated the importance of muscle mass as a factor involved in delivering a sufficient dose of postoperative S-1 adjuvant chemotherapy (ACT) to older patients with gastric cancer.

METHODS

The subjects of this study were 79 patients aged ≥ 65 years with stage II/III gastric adenocarcinoma, who underwent curative gastrectomy and received S-1 ACT.

RESULTS

The overall median relative dose intensity (RDI) was 75.0% (18.8-93.5%). Patients were divided into two groups for receiver operating characteristic analysis according to the cutoff value. Significantly more patients in the high skeletal muscle index (SMI) group achieved > 62% RDI of S-1 ACT (p = 0.03). Conversely, more patients in the low SMI group suffered from S-1-induced nausea (p = 0.03) and discontinued chemotherapy because of adverse events (p = 0.02). Multivariate analysis identified low SMI as an independent factor for insufficient S-1 dose delivery (p = 0.03, hazard ratio = 2.87).

CONCLUSION

Preoperative SMI is an indicator of the low-dose intensity of S-1 ACT in older patients following curative gastrectomy.

Malnutrition and vitamin deficiencies after surgery for esophageal and gastric cancer: A metanalysis

BACKGROUND & AIMS

Patients receiving oncological esophagectomy or gastrectomy are known to be at high risk for vitamin and micronutrient deficiency before, during and after surgery. However, there are no clear guidelines for these cancer patients regarding postoperative vitamin supplementation.

METHODS

We conducted a metanalysis consisting of 10 studies regarding vitamin and micronutrient deficiencies after oncological gastric or esophageal resection. 5 databases were searched.

RESULTS

Data was sufficient regarding Vitamins B12 and 25-OH D3 as well as calcium. We were able to show deficiencies in 25-OH Vitamin D3 levels (p < 0.001) and lower levels of Vitamin B12 and calcium (bit p < 0.001) when compared to the healthy population.

CONCLUSIONS

Patients from these groups are at risk for vitamin deficiencies. A guideline on postoperative supplementation is needed.

Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges?

INTRODUCTION

Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery.

METHODS

A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality).

RESULTS

A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]).

CONCLUSIONS

Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.

Impact of exercise training and diet therapy on the physical fitness, quality of life, and immune response of people living with HIV/AIDS: a randomized controlled trial

BACKGROUND

Exercise and dietary nutrition are considered crucial in human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) treatment protocols and people living with HIV/AIDS (PLWHA) rehabilitation care. However, there is no well-studied research evaluating the effects of combined interventions on the fitness and immune systems of PLWHA. Therefore, this study aimed to analyze the effects of exercise and dietary intervention on physical fitness, quality of life and immune response in PLWHA.

METHODS

This was an experimental study, with a sample of 25 male PLWHA divided into two groups: the intervention group (IG: 12 participants) and the control group (CG: 13 participants). All participants have not had any exercise habits and nutritional supplements in the past six months. The participants in the IG completed 45 min of exercise (60-80% HRmax) 4 times per week for 4 weeks. The exercise was in the form of brisk walking or running. They were also given a nutritional dietary supplement 3 times a day for 4 weeks. The 13 individuals in the CG continued their normal daily life (physical activity and diet). The following parameters were evaluated before and after the intervention: body composition, physical fitness, immune response, quality of life (QoL), stress, dietary behavior, dietary habits, exercise motivation, and physical self-efficacy.

RESULTS

The significant changes were observed in burnout of stress variables and physical efficiency index (PEI) of physical fitness in the IG (p =.023). Moreover, in the saliva samples, sal-T levels significantly increased only after the intervention in the IG (p =.012). Additionally, regarding the analysis of the interaction (group × time), there was a significant improvement in the reaction speed (p =.001) and grip strength (left: p =.002, right: p =.030) and a significant difference in physical satisfaction in QoL (p =.001), stress burnout (p =.043), self-confidence in physical efficacy (p =.045), external display (p =.008), and fulfillment (p =.047) in exercise motivation. Moreover, the significant effect of the intervention on emotional eating in dietary behavior was shown in the comparison of the IG before and after intervention (p =.001) and in the comparison of the IG group with the CG after the experiment (p =.013). However, there was no significant effect of time or interaction between the condition and time on body composition.

CONCLUSIONS

In conclusion, exercise training and diet therapy caused changes in physical fitness and Sal-T levels, which had positive effects on the health promotion of PLWHA.

Participation in Virtual Prehabilitation and Outcomes Following Thoracic Cancer Surgery

This cohort study evaluates the association of a virtual synchronized prehabilitation program with perioperative outcomes among patients undergoing thoracic cancer surgery.

Esophageal cancer in octogenarians: Should esophagectomy be done?

INTRODUCTION

Esophagectomy is the treatment of choice for esophageal cancer. In octogenarians data is conflicting. We evaluated postoperative outcomes and long-term survival of octogenarians and their younger counterparts.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database including consecutive patients with esophageal cancer who underwent esophagectomy at a large referral, academic center between 2012 and 2021. Subgroups were designed according to age (<70, 70-79, and ≥ 80).

RESULTS

A total of 359 patients underwent esophagectomy for esophageal cancer, 223 (62%) aged <70, 107 (30%) aged 70-79 and 29 (8%) aged ≥80. Octogenarians had higher American Society of Anesthesiologists [ASA] scores (p = 0.001), and fewer received neoadjuvant therapy (p = 0.04). Octogenarians experienced more major complications (P < 0.001) with significantly higher 30-day mortality rate (P = 0.001). In a multivariable analysis, major complications were associated with higher risk of being discharged to a rehabilitation center (odds ratio [OR] 14.839, 95% confidence interval [CI] 4.921-44.747, p < 0.001) while age was not. Overall survival was reduced in octogenarians, with a 50th percentile survival of 10 months compared to 32 and 26 months in patients age < 70 and 70-79, respectively (p = 0.014). In a multivariable analysis, age ≥ 80 (hazard ratio [HR] 4.478 95% CI 2.151-9.322, p < 0.001), cancer stage (HR 1.545, 95% CI 1.095-2.179, p = 0.013), and postoperative major complications (HR 2.705 95% CI 1.913-3.823, p < 0.001) were independently associated with reduced survival.

DISCUSSION

Our study showed that octogenarians had significantly higher postoperative major complications compared to younger age groups. Overall survival was significantly reduced in these patients, probably due to an increased rate of perioperative mortality. Better patient selection and preparation may improve postoperative outcomes and increase long-term survival.

Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach

BACKGROUND

Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes.

METHODS

A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia.

RESULTS

The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27).

CONCLUSIONS

Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.

Construction of individualised care programmes for patients with pancreatic cancer with postoperative weight-loss control based on the Delphi method: a cross-sectional study in China

BACKGROUND

At present, clinical nutritional care for patients with pancreatic cancer focuses more on the observation of the effect of enteral parenteral nutrition, and there is a lack of personalised care plans for weight-loss control. We used the Delphi method to construct a set of personalised nursing programmes to effectively control the rate of postoperative weight loss in patients with pancreatic cancer.

METHODS

This study was a cross-sectional investigation. Through literature analysis, literature review and data review, a personalised nursing plan for the postoperative weight-loss control in patients with pancreatic cancer was preliminarily developed. From October to December 2022, the Delphi method was adopted to conduct two questionnaires for 32 experts working in fields related to pancreatic diseases in Grade-A tertiary hospitals from four different departments. After statistical processing, the personalised nursing plan was determined according to the perceived level of importance, coefficient of variation, full score rate and recognition rate of the indicators.

RESULTS

The recovery rates of the two rounds of consultation were 93.75% and 100%, respectively, and the overall authority coefficient of the experts was 0.918, which represented 'authoritative'. In terms of importance, the coefficient of variation was 0-0.137; in terms of feasibility, the coefficient of variation ranged from 0.09 to 0.194. Finally, a scheme consisting of 36 entries in 8 dimensions was built. This programme is comprehensive in content, meets the nutritional diagnosis and treatment needs of patients in the stage of postoperative rehabilitation, provides relatively comprehensive nutritional assessment and support and has a robust system and feasibility.

CONCLUSIONS

The individualised nursing plan for patients with pancreatic cancer with postoperative weight-loss control based on the Delphi method is highly scientific and reliable and has positive significance.

The impact of prehabilitation on outcomes in frail and high-risk patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND & AIMS

Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving surgical outcomes. The aim of this systematic review and meta-analysis was to determine the impact of prehabilitation on postoperative outcomes in frail and high-risk patients undergoing major abdominal surgery.

METHODS

Embase, Medline, CINAHAL and Cochrane databases were searched from January 2010 to January 2023 for randomised clinical trials (RCTs) and observational studies evaluating unimodal (exercise) or multimodal prehabilitation programmes. Meta-analysis was limited to length of stay (primary end point), severe postoperative complications (Clavien-Dindo Classification ≥ Grade 3) and the 6-minute walk test (6MWT). The analysis was performed using RevMan v5.4 software.

RESULTS

Sixteen studies (6 RCTs, 10 observational) reporting on 3339 patients (1468 prehabilitation group, 1871 control group) were included. The median (interquartile range) age was 74.0 (71.0-78.4) years. Multimodal prehabilitation was applied in fifteen studies and unimodal in one. Meta-analysis of nine studies showed a reduction in hospital length of stay (weighted mean difference -1.07 days, 95 % CI -1.60 to -0.53 days, P < 0.0001, I2 = 19 %). Ten studies addressed severe complications and a meta-analysis suggested a decline in occurrence by up to 44 % (odds ratio 0.56, 95 % CI 0.37 to 0.82, P < 0.004, I2 = 51 %). Four studies provided data on preoperative 6MWT. The pooled weighted mean difference was 40.1 m (95 % CI 32.7 to 47.6 m, P < 0.00001, I2 = 24 %), favouring prehabilitation.

CONCLUSION

Given the significant impact on shortening length of stay and reducing severe complications, prehabilitation should be encouraged in frail, older and high-risk adult patients undergoing major abdominal surgery.