1
|
Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
Collapse
|
2
|
Siddique MH, Bhutta ME, Siddique Z. Letter to the editor: Transforming cancer care: The vital role of prehabilitation in colorectal surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108694. [PMID: 39298923 DOI: 10.1016/j.ejso.2024.108694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 09/13/2024] [Indexed: 09/22/2024]
Affiliation(s)
| | - Muhammad Eeman Bhutta
- Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan.
| | - Zainab Siddique
- Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
| |
Collapse
|
3
|
Vetsch T, Eggmann S, Jardot F, von Gernler M, Engel D, Beilstein CM, Wuethrich PY, Eser P, Wilhelm M. Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review. Br J Anaesth 2024; 133:178-189. [PMID: 38644158 DOI: 10.1016/j.bja.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022369944).
Collapse
Affiliation(s)
- Thomas Vetsch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Sabrina Eggmann
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, Switzerland
| | - François Jardot
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prisca Eser
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Ten Cate DWG, Molenaar CJL, Garcia RS, Bojesen RD, Tahasildar BLR, Jansen L, López-Baamonde M, Feo CV, Martínez-Palli G, Gögenur I, Carli F, Slooter GD. Multimodal prehabilitation in elective oncological colorectal surgery enhances postoperative functional recovery: A secondary analysis of the PREHAB randomized clinical trial. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108270. [PMID: 38520782 DOI: 10.1016/j.ejso.2024.108270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION Colorectal cancer (CRC) ranks as the second leading cause of cancer-related deaths. The PREHAB trial revealed that prehabilitation in colorectal surgery leads to a reduction of severe complications and enhanced functional capacity. Nevertheless, risk selection for prehabilitation and the potential benefits for patients without postoperative complications remains unclear. This study aims to assess postoperative functional capacity, also in patients without postoperative complications. MATERIALS & METHODS This study was a secondary analysis of the PREHAB trial. Functional capacity tests, including cardiopulmonary exercise testing (CPET), steep ramp test (SRT), 6-min walking test (6MWT), stair climb test (SCT), 30" sit-to-stand test (STS), timed-up-and-go test (TUG), and muscle strength assessments, were conducted at baseline (T0) and 4 weeks postoperatively (T3). The primary outcome was the relative change in functional capacity from baseline to postoperative (ΔT0-T3) per group (i.e., prehabilitation vs control). Secondary, identical analysis were performed for patients without postoperative complications in each group. RESULTS Intention-to-treat analysis included 251 patients. For postoperative functional capacity, prehabilitation patients showed improvements in VO2peak (p = 0.024), VO2AT (p = 0.017), SRT (p = 0.001), 6MWT (p = 0.049), SCT (p = 0.012), and STS (p = 0.001) compared to the control group. Regarding muscle strength, prehabilitation patients showed improvements in estimated 1RM lateral pull down (p = 0.016), 1RM chest press (p = 0.001), 1RM leg press (p = 0.001) and HGS (p = 0.005) compared to controls. Additionally, prehabilitation patients more often reached baseline levels at T3 in VO2AT (p = 0.037), SRT (p = 0.008), 6MWT (p = 0.013), STS (p = 0.012), estimated 1RM lateral pull down (p = 0.002), 1RM chest press (p = 0.001) and 1RM leg press (p = 0.001) compared to controls. Moreover, even patients without postoperative complications in the prehabilitation group showed better postoperative functional capacity and more often reached baseline levels at T3, compared to controls. CONCLUSION Multimodal prehabilitation in CRC surgery is associated with improved postoperative functional capacity, even in patients without postoperative complications.
Collapse
Affiliation(s)
- David W G Ten Cate
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands; Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6629 ER, Maastricht, the Netherlands.
| | - Charlotte J L Molenaar
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Raquel Sebio Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rasmus D Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark; Department of Surgery, Slagelse Hospital, Slagelse, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Loes Jansen
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Manuel López-Baamonde
- Department of Anesthesia, Hospital Clinic Barcelona, FRCB-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy; Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | - Graciela Martínez-Palli
- Department of Anesthesia, Hospital Clinic Barcelona, FRCB-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
| |
Collapse
|
5
|
Cuijpers ACM, Lubbers T, Dronkers JJ, Heldens AFJM, Zoethout SB, Leistra D, van Kuijk SMJ, van Meeteren NLU, Stassen LPS, Bongers BC. Development and external validation of preoperative clinical prediction models for postoperative outcomes including preoperative aerobic fitness in patients approaching elective colorectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108338. [PMID: 38728861 DOI: 10.1016/j.ejso.2024.108338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/01/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Preoperative aerobic fitness is associated with postoperative outcomes after elective colorectal cancer (CRC) surgery. This study aimed to develop and externally validate two clinical prediction models incorporating a practical test to assess preoperative aerobic fitness to distinguish between patients with and without an increased risk for 1) postoperative complications and 2) a prolonged time to in-hospital recovery of physical functioning after elective colorectal cancer (CRC) surgery. MATERIALS AND METHODS Models were developed using prospective data from 256 patients and externally validated using prospective data of 291 patients. Postoperative complications were classified according to Clavien-Dindo. The modified Iowa level of assistance scale (mILAS) was used to determine time to postoperative in-hospital physical recovery. Aerobic fitness, age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, neoadjuvant treatment, surgical approach, tumour location, and preoperative haemoglobin level were potential predictors. Areas under the curve (AUC), calibration plots, and Hosmer-Lemeshow tests evaluated predictive performance. RESULTS Aerobic fitness, sex, age, ASA, tumour location, and surgical approach were included in the final models. External validation of the model for complications and postoperative recovery presented moderate to fair discrimination (AUC 0.666 (0.598-0.733) and 0.722 (0.651-0.794), respectively) and good calibration. High sensitivity and high negative predictive values were observed in the lower predicted risk categories (<40 %). CONCLUSION Both models identify patients with and without an increased risk of complications or a prolonged time to in-hospital physical recovery. They might be used for improving patient-tailored preoperative risk assessment and targeted and cost-effective application of prehabilitation interventions.
Collapse
Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Jaap J Dronkers
- Expertise Centre Healthy Urban Living, Research Group Innovation of Human Movement Care, HU University of Applied Sciences Utrecht, Utrecht, the Netherlands.
| | - Aniek F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Siebrand B Zoethout
- Department of Physical Therapy, Deventer Hospital, Deventer, the Netherlands.
| | - Duncan Leistra
- Department of Physical Therapy, Nij Smellinghe Hospital, Drachten, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), The Hague, the Netherlands; Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands.
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - Bart C Bongers
- Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands; Department of Nutrition and Movement Sciences, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| |
Collapse
|
6
|
Hajibandeh S, Gilham I, Tam W, Kirby E, Babs-Osibodu AO, Jones W, Rose GA, Bailey DM, Morris C, Hargest R, Clayton A, Davies RG. Association between psoas major muscle mass and CPET performance and long-term survival following major colorectal surgery: A retrospective cohort study. Surgeon 2024; 22:158-165. [PMID: 38653641 DOI: 10.1016/j.surge.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES To evaluate whether computed tomography (CT)-derived psoas major muscle measurements could predict preoperative cardiopulmonary exercise testing (CPET) performance and long-term mortality in patients undergoing major colorectal surgery and to compare predictive performance of psoas muscle measurements using 2D approach and 3D approach. METHODS A retrospective cohort study compliant with STROCSS standards was conducted. Consecutive patients undergoing major colorectal surgery between January 2011 and January 2017 following CPET as part of their preoperative assessment were included. Regression analyses were modelled to investigate association between the CT-derived psoas major muscle mass variables [total psoas muscle area (TPMA), total psoas muscle volume (TPMV) and psoas muscle index (PMI)] and CPET performance and mortality (1-year and 5-year). Discriminative performances of the variables were evaluated using Receiver Operating Characteristic (ROC) curve analysis. RESULTS A total of 457 eligible patients were included. The median TPMA and TPMV were 21 cm2 (IQR: 15-27) and 274 cm3 (IQR: 201-362), respectively. The median PMI measured via 2D and 3D approaches were 7 cm2/m2 (IQR: 6-9) and 99 cm3/m2 (IQR: 76-120), respectively. The risks of 1-year and 5-year mortality were 7.4% and 27.1%, respectively. Regression analyses showed TPMA, TPMV, and PMI can predict preoperative CPET performance and long-term mortality. However, ROC curve analyses showed no significant difference in predictive performance amongst TPMA, TPMV, and PMI. CONCLUSION Radiologically-measured psoas muscle mass variables may predict preoperative CPET performance and may be helpful with informing more objective selection of patients for preoperative CPET and prehabilitation.
Collapse
Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK.
| | - Iain Gilham
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Winnie Tam
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Emma Kirby
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | | | - William Jones
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - George A Rose
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Christopher Morris
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Rachel Hargest
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Amy Clayton
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Richard G Davies
- Department of Anaesthetics, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
7
|
Onerup A, Li Y, Afshari K, Angenete E, de la Croix H, Ehrencrona C, Wedin A, Haglind E. Long-term results of a short-term home-based pre- and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG-C): a randomized clinical trial. Colorectal Dis 2024; 26:545-553. [PMID: 38225857 DOI: 10.1111/codi.16860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/17/2024]
Abstract
AIM The aim of this work was to assess the effect of a short-term, home-based exercise intervention before and after colorectal cancer surgery on 12-month physical recovery within a previously reported randomized control trial (RCT). METHOD PHYSSURG-C is an RCT in six participating hospitals in Sweden. Patients aged ≥20 years planned for elective colorectal cancer surgery were eligible. The intervention consisted of unsupervised moderate-intensity physical activity 2 weeks preoperatively and 4 weeks postoperatively. Usual care was control. The primary outcome measure in PHYSSURG-C was self-assessed physical recovery 4 weeks postoperatively. The predefined long-term follow-up outcomes included: self-assessed physical recovery 12 months postoperatively and reoperations and readmissions 91-365 days postoperatively. The statistical models were adjusted with tumour site (colon or rectum), neoadjuvant therapy (none, radiotherapy or chemo/radiotherapy) and type of surgery (open or laparoscopic). RESULTS A total of 616 participants were available for the 12-month follow-up. Groups were balanced at baseline regarding demographic and treatment variables. There was no effect from the intervention on self-reported physical recovery [adjusted odds ratio (OR) 0.91, p = 0.60], the risk of reoperation (OR 0.97, p = 0.91) or readmission (OR 0.88, p = 0.58). CONCLUSION The pre- and postoperative unsupervised moderate-intensity exercise intervention had no effect on long-term physical recovery after elective colorectal cancer surgery. There is still not enough evidence to support clinical guidelines on preoperative exercise to improve outcome after colorectal cancer surgery.
Collapse
Affiliation(s)
- Aron Onerup
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatric Oncology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Ying Li
- School of Public health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin Afshari
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Hanna de la Croix
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Carolina Ehrencrona
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anette Wedin
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| |
Collapse
|
8
|
Ten Cate DWG, Sabajo CR, Molenaar CJL, Janssen L, Bongers BC, Slooter GD. Multimodal prehabilitation in elective oncological colorectal surgery enhances preoperative physical fitness: a single center prospective real-world data analysis. Acta Oncol 2024; 63:35-43. [PMID: 38477370 PMCID: PMC11332481 DOI: 10.2340/1651-226x.2024.20287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/01/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Surgery can lead to curation in colorectal cancer (CRC) but is associated with significant morbidity. Prehabilitation plays an important role in increasing preoperative physical fitness to reduce morbidity risk; however, data from real-world practice is scarce. This study aimed to evaluate the change in preoperative physical fitness and to evaluate which patients benefit most from prehabilitation. MATERIALS AND METHODS In this single-arm prospective cohort study, consecutive patients undergoing elective colorectal oncological surgery were offered a 3- to 4-week multimodal prehabilitation program (supervised physical exercise training, dietary consultation, protein and vitamin supplementation, smoking cessation, and psychological support). The primary outcome was the change in preoperative aerobic fitness (steep ramp test (SRT)). Secondary outcomes were the change in functional walking capacity (6-minute walk test (6MWT)), and muscle strength (one-repetition maximum (1RM) for various muscle groups). To evaluate who benefit most from prehabilitation, participants were divided in quartiles (Q1, Q2, Q3, and Q4) based on baseline performance. RESULTS In total, 101 patients participated (51.4% male, aged 69.7 ± 12.7 years). The preoperative change in SRT was +28.3 W, +0.36 W/kg, +16.7% (P<0.001). Patients in all quartiles improved at the group level; however, the relative improvement decreased from Q1-Q2, Q2-Q3, and Q3-Q4 (P=0.049). Change in 6MWT was +37.5 m, +7.7% (P<0.001) and 1RM improved with 5.6-33.2 kg, 16.1-32.5% for the various muscle groups (P<0.001). CONCLUSION Prehabilitation in elective oncological colorectal surgery is associated with enhanced preoperative physical fitness regardless of baseline performance. Improvements were relatively larger in less fit patients.
Collapse
Affiliation(s)
- David W G Ten Cate
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands.
| | - Charissa R Sabajo
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | - Charlotte J L Molenaar
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6629 ER Maastricht, the Netherlands; Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6629 ER Maastricht, the Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, the Netherlands
| |
Collapse
|
9
|
Franssen RFW, Berkel AEM, Ten Cate DWG, van der Palen J, van Meeteren NLU, Vogelaar FJ, Slooter G, Klaase JM, Janssen-Heijnen MLG, Bongers BC. A retrospective analysis of the association of effort-independent cardiopulmonary exercise test variables with postoperative complications in patients who underwent elective colorectal surgery. Langenbecks Arch Surg 2023; 409:7. [PMID: 38093118 DOI: 10.1007/s00423-023-03197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE This study aimed to investigate the association of effort-independent variables derived from the preoperative cardiopulmonary exercise test (CPET) with 30-day postoperative complications after elective colorectal surgery. METHODS A multicenter (n=4) retrospective explorative study was performed using data of patients who completed a preoperative CPET and underwent elective colorectal surgery. The preoperative slope of the relation between minute ventilation and carbon dioxide production (VE/VCO2-slope) and the oxygen uptake efficiency slope (OUES), as well as 30-day postoperative complications, were assessed. Multivariable logistic regression analyses and receiver operating characteristic (ROC) curves were used to investigate the prognostic value of the relationship between these preoperative CPET-derived effort-independent variables and postoperative complications. RESULTS Data from 102 patients (60.1% males) with a median age of 72.0 (interquartile range 67.8-77.4) years were analyzed. Forty-four patients (43.1%) had one or more postoperative complications (of which 52.3% general and 77.3% surgical complications). Merely 10 (9.8%) patients had a general complication only. In multivariate analysis adjusted for surgical approach (open versus minimally invasive surgery), the VE/VCO2-slope (odds ratio (OR) 1.08, confidence interval (CI) 1.02-1.16) and OUES (OR 0.94, CI 0.89-1.00) were statistically significant associated with the occurrence of 30-day postoperative complications. CONCLUSION The effort-independent VE/VCO2-slope and OUES might be used to assist in future preoperative risk assessment and could especially be of added value in patients who are unable or unwilling to deliver a maximal cardiorespiratory effort. Future research should reveal the predictive value of these variables individually and/or in combination with other prognostic (CPET-derived) variables for postoperative complications. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05331196.
Collapse
Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Tegelseweg 210, 5912, BL, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- General Practice, Rijk-Berkel, Hengelo, The Netherlands
| | - David W G Ten Cate
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectum Twente, Enschede, The Netherlands
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Nico L U van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Top Sector Life Sciences & Health, The Hague, The Netherlands
| | - F Jeroen Vogelaar
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Gerrit Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Joost M Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
10
|
Alfitian J, Riedel B, Ismail H, Ho KM, Xie S, Zimmer P, Kammerer T, Wijeysundera DN, Cuthbertson BH, Schier R. Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study. EClinicalMedicine 2023; 64:102223. [PMID: 37811489 PMCID: PMC10556582 DOI: 10.1016/j.eclinm.2023.102223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
Collapse
Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Kwok M. Ho
- University of Western Australia and Murdoch University, Australia
| | - Sophia Xie
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
| | - Philipp Zimmer
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Duminda N. Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
| | - Brian H. Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
| | - the METS Study Investigators
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- University of Western Australia and Murdoch University, Australia
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
| |
Collapse
|
11
|
Wilson RL, Christopher CN, Yang EH, Barac A, Adams SC, Scott JM, Dieli-Conwright CM. Incorporating Exercise Training into Cardio-Oncology Care: Current Evidence and Opportunities: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:553-569. [PMID: 37969654 PMCID: PMC10635898 DOI: 10.1016/j.jaccao.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/30/2023] [Indexed: 11/17/2023] Open
Abstract
Cancer treatment-induced cardiotoxicities are an ongoing concern throughout the cancer care continuum from treatment initiation to survivorship. Several "standard-of-care" primary, secondary, and tertiary prevention strategies are available to prevent the development or further progression of cancer treatment-induced cardiotoxicities and their risk factors. Despite exercise's established benefits on the cardiovascular system, it has not been widely adopted as a nonpharmacologic cardioprotective strategy within cardio-oncology care. In this state-of-the-art review, the authors discuss cancer treatment-induced cardiotoxicities, review the existing evidence supporting the role of exercise in preventing and managing these sequelae in at-risk and affected individuals living after cancer diagnoses, and propose considerations for implementing exercise-based services in cardio-oncology practice.
Collapse
Affiliation(s)
- Rebekah L. Wilson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Cami N. Christopher
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Eric H. Yang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Ana Barac
- Inova Schar Heart and Vascular and Inova Schar Cancer Institute, Falls Church, Virginia, USA
| | - Scott C. Adams
- Department of Cardiology, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Ted Rogers Cardiotoxicity Prevention Program, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Jessica M. Scott
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Christina M. Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Hildebrand ND, Wijma AG, Bongers BC, Rensen SS, den Dulk M, Klaase JM, Olde Damink SWM. Supervised Home-Based Exercise Prehabilitation in Unfit Patients Scheduled for Pancreatic Surgery: Protocol for a Multicenter Feasibility Study. JMIR Res Protoc 2023; 12:e46526. [PMID: 37676715 PMCID: PMC10514766 DOI: 10.2196/46526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Morbidity rates in pancreatic surgery are high, and frail patients with low aerobic capacity are especially at risk of complications and require prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes. OBJECTIVE In this study, we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale. METHODS In this multicenter study, adult patients scheduled for elective pancreatic surgery with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min or a VO2 at peak exercise ≤18 mL/kg/min will be recruited. A total of 30 patients will be included in the 4-week, home-based, partly supervised exercise prehabilitation program. The program comprises 25-minute high-intensity interval training on an advanced cycle ergometer 3 times a week. Training intensity will be based on steep ramp test performance (ie, a short-term maximal exercise test on a cycle ergometer), aiming to improve aerobic capacity. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. A steep ramp test will be repeated weekly, and training intensity will be adjusted accordingly. Next to assessing the feasibility (participation rate, reasons for nonparticipation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this program, individual patients' responses to prehabilitation on aerobic capacity, functional mobility, body composition, quality of life, and immune system factors will be evaluated. RESULTS Recruitment for this study began in January 2022 and is expected to be completed in the summer of 2023. CONCLUSIONS Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT05496777; https://classic.clinicaltrials.gov/ct2/show/NCT05496777. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46526.
Collapse
Affiliation(s)
- Nicole D Hildebrand
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Allard G Wijma
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Bart C Bongers
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Sander S Rensen
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
- Department of General, Visceral and Transplant Surgery, Rheinish-Westphalian Technical University Hospital, Aachen, Germany
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
- Department of General, Visceral and Transplant Surgery, Rheinish-Westphalian Technical University Hospital, Aachen, Germany
| |
Collapse
|
13
|
Paladini A, Rawal N, Coca Martinez M, Trifa M, Montero A, Pergolizzi J, Pasqualucci A, Narvaez Tamayo MA, Varrassi G, De Leon Casasola O. Advances in the Management of Acute Postsurgical Pain: A Review. Cureus 2023; 15:e42974. [PMID: 37671225 PMCID: PMC10475855 DOI: 10.7759/cureus.42974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.
Collapse
Affiliation(s)
- Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Weemaes ATR, Meijer R, Beelen M, van Hooff M, Weijenberg MP, Lenssen AF, van de Poll-Franse LV, Savelberg HHCM, Schep G. Monitoring aerobic capacity in cancer survivors using self-reported questionnaires: criterion validity and responsiveness. J Patient Rep Outcomes 2023; 7:73. [PMID: 37466784 PMCID: PMC10356721 DOI: 10.1186/s41687-023-00613-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 07/04/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Evaluating the criterion validity and responsiveness of the self-reported FitMáx©-questionnaire, Duke Activity Status Index (DASI) and Veterans Specific Activity Questionnaire (VSAQ) to monitor aerobic capacity in cancer survivors. METHODS Cancer survivors participating in a 10-week supervised exercise program were included. The FitMáx©-questionnaire, DASI, VSAQ and a cardiopulmonary exercise test (CPET) were completed before (T0) and after (T1) the program. Intraclass correlation coefficients (ICC) were calculated between VO2peak estimated by the questionnaires (questionnaire-VO2peak) and VO2peak measured during CPET (CPET-VO2peak), at T0 to examine criterion validity, and between changes in questionnaire-VO2peak and CPET-VO2peak (ΔT0-T1) to determine responsiveness. Receiver operating characteristic (ROC) analyses were performed to examine the ability of the questionnaires to detect true improvements (≥ 6%) in CPET-VO2peak. RESULTS Seventy participants were included. Outcomes at T1 were available for 58 participants (83%). Mean CPET-VO2peak significantly improved at T1 (Δ1.6 mL·kg- 1·min- 1 or 8%). Agreement between questionnaire-VO2peak and CPET-VO2peak at T0 was moderate for the FitMáx©-questionnaire (ICC = 0.69) and VSAQ (ICC = 0.53), and poor for DASI (ICC = 0.36). Poor agreement was found between ΔCPET-VO2peak and Δquestionnaire-VO2peak for all questionnaires (ICC 0.43, 0.19 and 0.18 for the FitMáx©-questionnaire, VSAQ and DASI, respectively). ROC analysis showed that the FitMáx©-questionnaire was able to detect improvements in CPET-VO2peak (area under the curve, AUC = 0.77), when using a cut-off value of 1.0 mL·kg- 1·min- 1, while VSAQ (AUC = 0.66) and DASI (AUC = 0.64) could not. CONCLUSION The self-reported FitMáx©-questionnaire has sufficient validity to estimate aerobic capacity in cancer survivors at group level. The responsiveness of the FitMáx©-questionnaire for absolute change is limited, but the questionnaire is able to detect whether aerobic capacity improved. The FitMáx©-questionnaire showed substantial better values of validity and responsiveness compared to DASI and VSAQ.
Collapse
Affiliation(s)
- Anouk T R Weemaes
- Department of Physical Therapy, Maastricht University Medical Center+, P.O. Box 5800, Maastricht, AZ, 6202, The Netherlands.
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Renske Meijer
- Department of Sports and Exercise, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Milou Beelen
- Department of Physical Therapy, Maastricht University Medical Center+, P.O. Box 5800, Maastricht, AZ, 6202, The Netherlands
- Department of Human Biology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Martijn van Hooff
- Department of Sports and Exercise, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Matty P Weijenberg
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Antoine F Lenssen
- Department of Physical Therapy, Maastricht University Medical Center+, P.O. Box 5800, Maastricht, AZ, 6202, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Hans H C M Savelberg
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Goof Schep
- Department of Sports and Exercise, Máxima Medical Center, Veldhoven, The Netherlands
| |
Collapse
|
15
|
Plumb JOM, Otto JM, Kumar SB, Bali S, Wakatsuki M, Schmidt WFJ, Montgomery HE, Grocott MPW, Levett DZ. Cardiopulmonary exercise testing before and after intravenous iron in preoperative patients: a prospective clinical study. Perioper Med (Lond) 2023; 12:31. [PMID: 37400931 DOI: 10.1186/s13741-023-00319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/16/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Anemia is associated with impaired physical performance and adverse perioperative outcomes. Iron-deficiency anemia is increasingly treated with intravenous iron before elective surgery. We explored the relationship between exercise capacity, anemia, and total hemoglobin mass (tHb-mass) and the response to intravenous iron in anemic patients prior to surgery. METHODS A prospective clinical study was undertaken in patients having routine cardiopulmonary exercise testing (CPET) with a hemoglobin concentration ([Hb]) < 130 g.l-1 and iron deficiency/depletion. Patients underwent CPET and tHb-mass measurements before and a minimum of 14 days after receiving intravenous (i.v.) Ferric derisomaltose (Monofer®) at the baseline visit. Comparative analysis of hematological and CPET variables was performed pre and post-iron treatment. RESULTS Twenty-six subjects were recruited, of whom 6 withdrew prior to study completion. The remaining 20 (9 [45%] male; mean ± SD age 68 ± 10 years) were assessed 25 ± 7 days between baseline and the final visit. Following i.v. iron, increases were seen in [Hb] (mean ± SD) from 109 ± 14 to 116 ± 12 g l-1 (mean rise 6.4% or 7.3 g l-1, p = < 0.0001, 95% CI 4.5-10.1); tHb-mass from 497 ± 134 to 546 ± 139 g (mean rise 9.3% or 49 g, p = < 0.0001, 95% CI 29.4-69.2). Oxygen consumption at anerobic threshold ([Formula: see text] O2 AT) did not change (9.1 ± 1.7 to 9.8 ± 2.5 ml kg-1 min-1, p = 0.09, 95% CI - 0.13 - 1.3). Peak oxygen consumption ([Formula: see text] O2 peak) increased from 15.2 ± 4.1 to 16 ± 4.4 ml.kg.-1 min-1, p = 0.02, 95% CI 0.2-1.8) and peak work rate increased from 93 [67-112] watts to 96 [68-122] watts (p = 0.02, 95% CI 1.3-10.8). CONCLUSION Preoperative administration of intravenous iron to iron-deficient/deplete anemic patients is associated with increases in [Hb], tHb-mass, peak oxygen consumption, and peak work rate. Further appropriately powered prospective studies are required to ascertain whether improvements in tHb-mass and performance in turn lead to reductions in perioperative morbidity. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 033 46213.
Collapse
Affiliation(s)
- James O M Plumb
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK.
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK.
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK.
| | - James M Otto
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Shriya B Kumar
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Sitara Bali
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Mai Wakatsuki
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Walter F J Schmidt
- Department of, Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, Germany
| | - Hugh E Montgomery
- Centre for Human Health and Performance/Institute of Sport, Exercise and Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Denny Z Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| |
Collapse
|
16
|
Franssen RFW, Vos TJ, Bongers BC, van Meeteren NLU. Letter to the Editor: Should we put more emphasis on the functional impact instead of the incidence of postoperative complications to evaluate quality of care in surgical oncology? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1320-1321. [PMID: 36997413 DOI: 10.1016/j.ejso.2023.03.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo, the Netherlands; Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Tessel J Vos
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands; Top Sector Life Sciences & Health, The Hague, the Netherlands.
| |
Collapse
|
17
|
Efficacy of supervised exercise prehabilitation programs to improve major abdominal surgery outcomes: A systematic review and meta-analysis. J Clin Anesth 2023; 86:111053. [PMID: 36736208 DOI: 10.1016/j.jclinane.2023.111053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 02/04/2023]
Abstract
The optimal package of components for a prehabilitation intervention remains unclear. The aim was to determine the efficacy of supervised exercise prehabilitation programs to enhance patient fitness and improve surgical outcomes. The protocol was preregistered (PROSPERO: CRD42020180693). PubMed, MEDLINE, CINAHL, AMED, CENTRAL, PeDro, ClinicalTrials.gov and the WHO International Clinical Trials Registry were searched. Randomized controlled trials (RCTs) of supervised prehabilitation programs before major abdominal surgery were included. Physical function, cardiorespiratory capacity and surgical outcomes were the primary outcomes measures. Risk of bias was assessed according to the Cochrane Risk of Bias 1.0 tool for RCTs. Data are summarized narratively, and where possible, quantitavely. Meta-analyses results are reported as risk ratios (RR), mean difference of changes between baseline and follow-up time points or mean difference between groups and 95% confidence interval (CI). Twenty RCTs were included in the analysis with a total of 1258 patients. The average 6-min walking distance change was +33 m in the prehabilitation group compared to the usual care (UC) group after prehabilitation (95% CI: [13, 53], P < 0.01). Only in studies with more than one supervised session per week changes in 6-min-walk distance were significantly higher in the prehabilitation group compared to the UC group after prehabiliatation (Mean difference: 47 m, 95% [CI]: [20-75], P < 0.01). The change in peak volume of oxygen uptake during a maximum cardiopulmonary test was +1.47 mL·kg-1·min-1 in the prehabilitation group compared to the UC group (95% CI: [0.68, 2.25], P < 0.01). There was no significant difference in the change in oxygen uptake at anaerobic threshold between groups (Mean differences: 0.47, 95% CI: [-0.16, 1.10], P:0.14). Post-operative complications incidence was similar between groups (RR: 0.80, 95% CI: [0.61, 1.05], P:0.11), irrespective of the frequency of supervised session per week (RR: 0.67, 95% CI: [0.43, 1.03], P:0.07). In conclusion, prehabilitation programmes with more than one supervised session per week improved physical function but did not enhance surgical outcomes.
Collapse
|
18
|
Lavín-Pérez AM, Collado-Mateo D, Hinojo González C, de Juan Ferré A, Ruisánchez Villar C, Mayo X, Jiménez A. High-intensity exercise prescription guided by heart rate variability in breast cancer patients: a study protocol for a randomized controlled trial. BMC Sports Sci Med Rehabil 2023; 15:28. [PMID: 36890601 PMCID: PMC9993392 DOI: 10.1186/s13102-023-00634-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Breast cancer is a chronic disease with a large growth in its treatments, prognosis, improvements, side effects and rehabilitation therapies research. These advances have also highlighted the need to use physical exercise as a countermeasure to reduce the cardiotoxicity of pharmacological treatments, increase patients' strength and quality of life and improve body composition, physical condition and mental health. However, new investigations show the need for a closed exercise individualisation to produce higher physiological, physical and psychological benefits in remote exercise programs. To this end, the present study will use, in a novel way in this population, heart rate variability (HRV) as a measure for prescribing high-intensity training. Thus, the primary objective of this randomised clinical trial is to analyse the effects of a high-intensity exercise program daily guided by HRV, a preplanned moderate to high-intensity exercise intervention and a usual care group, in breast cancer patients after chemotherapy and radiotherapy treatments. METHODS For this purpose, a 16-week intervention will be carried out with 90 breast cancer patients distributed in 3 groups (a control group, a moderate to high-intensity preplanned exercise group and a high-intensity exercise group guided by HRV). Both physical exercise interventions will be developed remotely and supervised including strength and cardiovascular exercises. Physiological variables, such as cardiotoxicity, biomarkers, lipid profile, glucose, heart rate and blood pressure; physical measures like cardiorespiratory capacity, strength, flexibility, agility, balance and body composition; and psychosocial variables, as health-related quality of life, fatigue, functionality, self-esteem, movement fear, physical exercise level, anxiety and depression will be measure before, after the intervention and 3 and 6 months follow up. DISCUSSION Personalized high-intensity exercise could be a promising exercise intervention in contrast to moderate-intensity or usual care in breast cancer patients to reach higher clinical, physical and mental effects. In addition, the novelty of controlling HRV measures daily may reflect exercise effects and patients' adaptation in the preplanned exercise group and a new opportunity to adjust intensity. Moreover, findings may support the effectiveness and security of physical exercise remotely supervised, although with high-intensity exercise, to reach cardiotoxicity improvements and increase physical and psychosocial variables after breast cancer treatments. Trial registration ClinicalTrials.gov nº NCT05040867 ( https://clinicaltrials.gov/ct2/show/record/NCT05040867 ).
Collapse
Affiliation(s)
- Ana Myriam Lavín-Pérez
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain
- GO fitLAB, Ingesport, Madrid, Spain
- Program of Epidemiology and Public Health (Interuniversity), PhD International School of the Rey Juan Carlos University, Madrid, Spain
| | | | - Carmen Hinojo González
- Onchology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Ana de Juan Ferré
- Onchology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Cristina Ruisánchez Villar
- Cardiology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL)., Santander, Spain
| | - Xián Mayo
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain
| | - Alfonso Jiménez
- Centre for Sport Studies, Rey Juan Carlos University, Madrid, Spain
- GO fitLAB, Ingesport, Madrid, Spain
- Advanced Wellbeing Research Centre, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
| |
Collapse
|
19
|
Abstract
Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.
Collapse
Affiliation(s)
- Theodore J. Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA,Theodore J. Cios, Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, 500 University Drive, H187, Hershey, PA 17033, USA.
| | - John C. Klick
- Department of Anesthesiology, The University of Vermont Medical Center, Burlington, VT, USA
| | - S. Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
20
|
Louyot C, Portran P, Schweizer R, Glerant JC, Thivolet S, Brassart O, Mewton N, Jacquet-Lagreze M, Fellahi JL. Elaboration of a French version of the Duke Activity Status Index questionnaire and performance to predict functional capacity. Anaesth Crit Care Pain Med 2023; 42:101199. [PMID: 36706990 DOI: 10.1016/j.accpm.2023.101199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Guidelines recommend detecting poor functional capacity (VO2max < 14 ml.kg-1.min-1) to assess preoperative cardiac risk. This screening is performed via a cardiopulmonary exercise test (CPET), the self-reported inability to climb two flights of stairs, or the use of the Duke Activity Status Index (DASI) questionnaire, which has shown a significant correlation with VO2max and postoperative outcomes. The objectives of the present study were: 1) to create a French version of the DASI questionnaire (FDASI); 2) to assess its diagnostic performance in predicting functional capacity. METHODS Consecutive adult patients undergoing CPET for medical or preoperative evaluation were prospectively included between May 2020 and March 2021. All patients were asked to complete FDASI as a self-questionnaire and report their inability to climb two flights of stairs. RESULTS 122 patients were included. Test-retest reliability was 0.88 and 23 (19%) patients experienced a VO2max < 14 ml.kg-1.min-1. There was a significant positive relationship between FDASI and VO2max: r2 = 0.32; p < 0.001. ROCAUC was 0.81 [95%CI: 0.73-0.89]. The best FDASI score threshold was 36 points, leading to sensitivity and specificity values of 87% [74-100] and 68% [56-79], respectively. Besides, sensitivity and specificity were 35% [17-56] and 92% [86-97] for the self-reported inability to climb two flights of stairs. CONCLUSION A FDASI score of 36 represents a reliable threshold the clinicians could routinely use to identify patients with a VO2max < 14 ml.kg-1.min-1. FDASI could advantageously replace the self-reported inability to climb two flights of stairs.
Collapse
Affiliation(s)
- Claire Louyot
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France.
| | - Philippe Portran
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France.
| | - Rémi Schweizer
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Jean-Charles Glerant
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Sophie Thivolet
- Service d'Explorations Fonctionnelles Cardiovasculaires, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Océane Brassart
- Direction de la Recherche Clinique et de l'Innovation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Nathan Mewton
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
| |
Collapse
|
21
|
Franssen RFW, Sanders BHE, Takken T, Vogelaar FJ, Janssen-Heijnen MLG, Bongers BC. Influence of different data-averaging methods on mean values of selected variables derived from preoperative cardiopulmonary exercise testing in patients scheduled for colorectal surgery. PLoS One 2023; 18:e0283129. [PMID: 36928094 PMCID: PMC10019694 DOI: 10.1371/journal.pone.0283129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Patients with a low cardiorespiratory fitness (CRF) undergoing colorectal cancer surgery have a high risk for postoperative complications. Cardiopulmonary exercise testing (CPET) to assess CRF is the gold standard for preoperative risk assessment. To aid interpretation of raw breath-by-breath data, different methods of data-averaging can be applied. This study aimed to investigate the influence of different data-averaging intervals on CPET variables used for preoperative risk assessment, as well as to evaluate whether different data-averaging intervals influence preoperative risk assessment. METHODS A total of 21 preoperative CPETs were interpreted by two exercise physiologists using stationary time-based data-averaging intervals of 10, 20, and 30 seconds and rolling average intervals of 3 and 7 breaths. Mean values of CPET variables between different data averaging intervals were compared using repeated measures ANOVA. The variables of interest were oxygen uptake at peak exercise (VO2peak), oxygen uptake at the ventilatory anaerobic threshold (VO2VAT), oxygen uptake efficiency slope (OUES), the ventilatory equivalent for carbon dioxide at the ventilatory anaerobic threshold (VE/VCO2VAT), and the slope of the relationship between the minute ventilation and carbon dioxide production (VE/VCO2-slope). RESULTS Between data-averaging intervals, no statistically significant differences were found in the mean values of CPET variables except for the ventilatory equivalent for carbon dioxide at the ventilatory anaerobic threshold (P = 0.001). No statistically significant differences were found in the proportion of patients classified as high or low risk regardless of the used data-averaging interval. CONCLUSION There appears to be no significant or clinically relevant influence of the evaluated data-averaging intervals on the mean values of CPET outcomes used for preoperative risk assessment. Clinicians may choose a data-averaging interval that is appropriate for optimal interpretation and data visualization of the preoperative CPET. Nevertheless, caution should be taken as the chosen data-averaging interval might lead to substantial within-patient variation for individual patients. CLINICAL TRIAL REGISTRATION Prospectively registered at ClinicalTrials.gov (NCT05353127).
Collapse
Affiliation(s)
- Ruud F. W. Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo, The Netherlands
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- * E-mail:
| | - Bart H. E. Sanders
- Department of Sports Medicine, VieCuri Medical Center, Venlo, The Netherlands
| | - Tim Takken
- Child Development and Exercise Center, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F. Jeroen Vogelaar
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Maryska L. G. Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C. Bongers
- Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
22
|
Chmelo J, Phillips AW, Greystoke A, Charman SJ, Avery L, Hallsworth K, Welford J, Cooper M, Sinclair RCF. A feasibility trial of prehabilitation before oesophagogastric cancer surgery using a multi-component home-based exercise programme: the ChemoFit study. Pilot Feasibility Stud 2022; 8:173. [PMID: 35945625 PMCID: PMC9360697 DOI: 10.1186/s40814-022-01137-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using 'prehabilitation' to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies. METHODS We recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises. RESULTS There were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2-100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1-100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1-88.9%) and 69.4% (IQR 52.1-84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4-99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days). CONCLUSIONS The results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation. TRIAL REGISTRATION Clinicaltrials.gov NCT04194463 . Registered on 11th December 2019-retrospectively registered.
Collapse
Affiliation(s)
- Jakub Chmelo
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK. .,Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Alexander W Phillips
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Greystoke
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Leah Avery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Kate Hallsworth
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jenny Welford
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Cooper
- Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia and Critical Care, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
23
|
Silvapulle E, Darvall J. Objective methods for preoperative assessment of functional capacity. BJA Educ 2022; 22:312-320. [PMID: 36097575 PMCID: PMC9463693 DOI: 10.1016/j.bjae.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- E. Silvapulle
- The Royal Melbourne Hospital, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - J. Darvall
- The Royal Melbourne Hospital, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
24
|
Bak MTJ, Ruiterkamp MFE, van Ruler O, Campmans-Kuijpers MJE, Bongers BC, van Meeteren NLU, van der Woude CJ, Stassen LPS, de Vries AC. Prehabilitation prior to intestinal resection in Crohn’s disease patients: An opinion review. World J Gastroenterol 2022; 28:2403-2416. [PMID: 35979261 PMCID: PMC9258284 DOI: 10.3748/wjg.v28.i22.2403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.
Collapse
Affiliation(s)
- Michiel T J Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marit F E Ruiterkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel 2906 ZC, Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Marjo J E Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen 9713 GZ, Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht 6200 MD, Netherlands
- Department of Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht 6200 MD, Netherlands
| | - Nico L U van Meeteren
- Department of Anaesthesiology, Erasmus MC University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht 6229 HX, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam 3015 GD, Netherlands
| |
Collapse
|
25
|
Birrer DL, Kuemmerli C, Obwegeser A, Liebi M, von Felten S, Pettersson K, Horisberger K. INSPIRA: study protocol for a randomized-controlled trial about the effect of spirometry-assisted preoperative inspiratory muscle training on postoperative complications in abdominal surgery. Trials 2022; 23:473. [PMID: 35672861 PMCID: PMC9172146 DOI: 10.1186/s13063-022-06254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background Rehabilitation strategies after abdominal surgery enhance recovery and improve outcome. A cornerstone of rehabilitation is respiratory physiotherapy with inspiratory muscle training to enhance pulmonary function. Pre-habilitation is the process of enhancing functional capacity before surgery in order to compensate for the stress of surgery and postoperative recovery. There is growing interest in deploying pre-habilitation interventions prior to surgery. The aim of this study is to assess the impact of preoperative inspiratory muscle training on postoperative overall morbidity. The question is, whether inspiratory muscle training prior to elective abdominal surgery reduces the number of postoperative complications and their severity grade. Methods We describe a prospective randomized-controlled single-centre trial in a tertiary referral centre. The primary outcome is the Comprehensive Complication Index (CCI) at 90 days after surgery. The CCI expresses morbidity on a continuous numeric scale from 0 (no complication) to 100 (death) by weighing all postoperative complications according to the Clavien-Dindo classification for their respective severity. In the intervention group, patients will be instructed by physiotherapists to perform inspiratory muscle training containing of 30 breaths twice a day for at least 2 weeks before surgery using Power®Breathe KHP2. Depending on the surgical schedule, training can be extended up to 6 weeks. In the control group, no preoperative inspiratory muscle training will be performed. After the operation, both groups receive the same physiotherapeutic support. Discussion Existing data about preoperative inspiratory muscle training on postoperative complications are ambiguous and study protocols are often lacking a clear design and a clearly defined endpoint. Most studies consist of multi-stage concepts, comprehensively supervised and long-term interventions, whose implementation in clinical practice is hardly possible. There is a clear need for randomized-controlled studies with a simple protocol that can be easily transferred into clinical practice. This study examines the effortless adjustment of the common respiratory physiotherapy from currently postoperative to preoperative. The external measurement by the device eliminates the diary listing of patients’ performances and allows the exercise adherence and thus the effect to be objectively recorded. Trial registration ClinicalTrials.govNCT04558151. Registered on September 15, 2020.
Collapse
Affiliation(s)
- D L Birrer
- Department of Transplantation and Surgery, University Hospital of Zurich, Zurich, Switzerland.
| | - C Kuemmerli
- Department of Surgery, Clarunis-University Centre for Gastrointestinal and Liver Diseases Basel, Basel, Switzerland
| | - A Obwegeser
- Department of Physiotherapy and Occupational Therapy, University Hospital of Zurich, Zurich, Switzerland
| | - M Liebi
- Department of Physiotherapy and Occupational Therapy, University Hospital of Zurich, Zurich, Switzerland
| | - S von Felten
- Department of Biostatistics, Epidemiology and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - K Pettersson
- Department of Transplantation and Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - K Horisberger
- Department of Transplantation and Surgery, University Hospital of Zurich, Zurich, Switzerland.,Department of Surgery and Transplantation, University Hospital Mainz, Mainz, Germany
| |
Collapse
|
26
|
Franssen RFW, Eversdijk AJJ, Kuikhoven M, Klaase JM, Vogelaar FJ, Janssen-Heijnen MLG, Bongers BC. Inter-observer agreement of preoperative cardiopulmonary exercise test interpretation in major abdominal surgery. BMC Anesthesiol 2022; 22:131. [PMID: 35490221 PMCID: PMC9055752 DOI: 10.1186/s12871-022-01680-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate determination of cardiopulmonary exercise test (CPET) derived parameters is essential to allow for uniform preoperative risk assessment. The objective of this prospective observational study was to evaluate the inter-observer agreement of preoperative CPET-derived variables by comparing a self-preferred approach with a systematic guideline-based approach. METHODS Twenty-six professionals from multiple centers across the Netherlands interpreted 12 preoperative CPETs of patients scheduled for hepatopancreatobiliary surgery. Outcome parameters of interest were oxygen uptake at the ventilatory anaerobic threshold (V̇O2VAT) and at peak exercise (V̇O2peak), the slope of the relationship between the minute ventilation and carbon dioxide production (V̇E/V̇CO2-slope), and the oxygen uptake efficiency slope (OUES). Inter-observer agreement of the self-preferred approach and the guideline-based approach was quantified by means of the intra-class correlation coefficient. RESULTS Across the complete cohort, inter-observer agreement intraclass correlation coefficient (ICC) was 0.76 (95% confidence interval (CI) 0.57-0.93) for V̇O2VAT, 0.98 (95% CI 0.95-0.99) for V̇O2peak, and 0.86 (95% CI 0.75-0.95) for the V̇E/V̇CO2-slope when using the self-preferred approach. By using a systematic guideline-based approach, ICCs were 0.88 (95% CI 0.74-0.97) for V̇O2VAT, 0.99 (95% CI 0.99-1.00) for V̇O2peak, 0.97 (95% CI 0.94-0.99) for the V̇E/V̇CO2-slope, and 0.98 (95% CI 0.96-0.99) for the OUES. CONCLUSIONS Inter-observer agreement of numerical values of CPET-derived parameters can be improved by using a systematic guideline-based approach. Effort-independent variables such as the V̇E/V̇CO2-slope and the OUES might be useful to further improve uniformity in preoperative risk assessment in addition to, or in case V̇O2VAT and V̇O2peak are not determinable.
Collapse
Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Tegelseweg 210, 5912, BL, Venlo, the Netherlands. .,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Anne J J Eversdijk
- Department of Sports Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Mayella Kuikhoven
- Fanaticus Sports Medicine, Sports Medical Center, Groningen and Arnhem, the Netherlands
| | - Joost M Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | - Bart C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
27
|
Cuijpers ACM, Linskens FG, Bongers BC, Stassen LPS, Lubbers T, van Meeteren NLU. Quality and clinical generalizability of feasibility outcomes in exercise prehabilitation before colorectal cancer surgery - A systematic review. Eur J Surg Oncol 2022; 48:1483-1497. [PMID: 35491361 DOI: 10.1016/j.ejso.2022.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 02/13/2022] [Accepted: 04/19/2022] [Indexed: 01/10/2023] Open
Abstract
Suboptimal quality of feasibility assessments might partially explain inconsistencies observed in the effectiveness of exercise prehabilitation before colorectal cancer (CRC) surgery. This systematic review aimed to assess the reporting quality and clinical generalizability of feasibility outcomes in feasibility studies addressing exercise prehabilitation before CRC surgery. PubMed/Medline, Embase, Cochrane, and CINAHL were searched to identify all feasibility studies focussing on exercise prehabilitation in CRC surgery. Reporting quality was assessed using the Thabane et al. checklist and the Consolidated Standards of Reporting Trials extension for feasibility studies. Clinical generalizability was evaluated by appraising patient participation in all steps of the study and intervention. Twelve studies were included. The main feasibility outcome in all studies was adherence to the intervention by the study sample. Based on adherence, 10 studies (83%) concluded exercise prehabilitation to be feasible. Six studies (50%) reported all details to assess patient participation showing retention rates between 18.4% and 58.2%, which was caused by non-participation and drop-out. Three feasibility studies (25%) discussed patient-reported barriers to participation and five additional studies (41%) described potential selection bias. Four studies (33%) reported lessons learned to solve issues hampering feasibility and clinical generalizability. Results suggest that true feasibility of exercise prehabilitation before CRC surgery remains questionable due to poor reporting quality, insufficient clarity regarding the representativeness of the study sample for the target population, and limited attention for clinical generalizability. Feasibility of exercise prehabilitation might be improved by offering supervised community- or home-based interventions tailored to the physical and mental abilities of the patient.
Collapse
Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery - Maastricht University Medical Centre +, PO Box 5800, 6202, AZ, Maastricht, the Netherlands; Department of Surgery - School for Oncology and Developmental Biology (GROW) - Faculty of Health, Medicine and Life Sciences - Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.
| | - Fieke G Linskens
- Physiotherapy Sciences, Program in Clinical Health Sciences, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences - School of Nutrition and Translational Research in Metabolism (NUTRIM) - Faculty of Health, Medicine and Life Sciences - Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands; Department of Epidemiology - Care and Public Health Research Institute (CAPHRI) - Faculty of Health, Medicine and Life Sciences - Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.
| | - Laurents P S Stassen
- Department of Surgery - Maastricht University Medical Centre +, PO Box 5800, 6202, AZ, Maastricht, the Netherlands; Department of Surgery - School of Nutrition and Translational Research in Metabolism (NUTRIM) - Faculty of Health, Medicine and Life Sciences - Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.
| | - Tim Lubbers
- Department of Surgery - Maastricht University Medical Centre +, PO Box 5800, 6202, AZ, Maastricht, the Netherlands; Department of Surgery - School for Oncology and Developmental Biology (GROW) - Faculty of Health, Medicine and Life Sciences - Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), Wilhelmina van Pruisenweg 104, 2595, AN, The Hague, the Netherlands; Department of Anaesthesiology - Erasmus Medical Centre, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.
| |
Collapse
|
28
|
Onerup A, Andersson J, Angenete E, Bock D, Börjesson M, Ehrencrona C, Fagevik Olsén M, Larsson PA, de la Croix H, Wedin A, Haglind E. Effect of Short-term Homebased Pre- and Postoperative Exercise on Recovery After Colorectal Cancer Surgery (PHYSSURG-C): A Randomized Clinical Trial. Ann Surg 2022; 275:448-455. [PMID: 33843798 PMCID: PMC8820776 DOI: 10.1097/sla.0000000000004901] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the effect of a short-term, unsupervised exercise intervention before and after colorectal cancer surgery on self-assessed physical recovery. SUMMARY OF BACKGROUND DATA Preoperative exercise interventions could help improve recovery after colorectal cancer surgery and is currently recommended. METHODS A randomized, parallel, open-label trial in six university or regional hospitals in Sweden. Inclusion criteria were age ≥20 years and planned elective colorectal cancer surgery. Participants were randomized to either a physical activity intervention with aerobic activity and inspiratory muscle training 2 weeks pre- and 4 weeks postoperatively or usual care. The primary outcome measure was self-assessed physical recovery 4 weeks postoperatively. Analyses were performed according to intention to treat. Outcome assessors were masked regarding the intervention while both participants and physiotherapists were informed due to the nature of the intervention. RESULTS Between January 22, 2015, and May 28, 2020, 761 participants were recruited and assigned to either intervention (I) (n = 379) or control (C) (n = 382). After exclusions 668 participants (I = 317, C = 351) were included in the primary analysis. There was no effect from the intervention on the primary outcome measure (adjusted odds ratio 0.84, 95% confidence interval 0.62-1.15) with 13% and 15% of participants feeling fully physically recovered in I and C, respectively. There were no reported adverse events. CONCLUSIONS There was no effect from a physical activity intervention before and after colorectal cancer surgery on short-term self-assessed physical recovery. The results from this study call for reconsiderations regarding current recommendations for preoperative physical activity interventions.
Collapse
Affiliation(s)
- Aron Onerup
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatric Oncology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - John Andersson
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Alingsås Hospital, Alingsås, Sweden
| | - Eva Angenete
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Bock
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Börjesson
- Center for Health and Performance, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carolina Ehrencrona
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Monika Fagevik Olsén
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Hanna de la Croix
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anette Wedin
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Haglind
- Scandinavian Surgical Outcomes Research Group (SSORG), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
29
|
Cuijpers ACM, Bongers BC, Heldens AFJM, Bours MJL, van Meeteren NLU, Stassen LPS, Lubbers T. Aerobic fitness and muscle density play a vital role in postoperative complications in colorectal cancer surgery. J Surg Oncol 2022; 125:1013-1023. [PMID: 35147981 PMCID: PMC9305785 DOI: 10.1002/jso.26817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/24/2021] [Accepted: 02/02/2022] [Indexed: 12/11/2022]
Abstract
Background and Objectives To assess the association of preoperative aerobic fitness and body composition variables with a patient's resilience to the development and impact of postoperative complications after elective colorectal cancer (CRC) surgery. Methods Preoperative aerobic fitness was assessed by steep ramp test performance. Preoperative body composition was assessed by muscle mass and density determined from preoperative computed tomography scan analysis at the L3‐level. Complication development and severity was graded according to Clavien‐Dindo. Complication impact was assessed by the time to recovery of physical functioning after complications. Multivariable logistic regression analyses adjusted for age, sex, comorbidities and tumour location was performed. Results Of 238 included patients, 96 (40.3%) developed postoperative complications. Better preoperative aerobic fitness decreased the likelihood to develop complications, independent of muscle mass (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.35−0.85) or muscle density (OR: 0.57, 95% CI: 0.36−0.89). A prolonged time to recovery following complications was associated with lower preoperative muscle density (OR: 4.14, 95% CI: 1.28−13.41), independent of aerobic fitness. Conclusions Lower aerobic fitness increases the risk of complication development, while low muscle density seems associated with a prolonged recovery from complications. Aerobic fitness and muscle density could be valuable additives to preoperative risk assessment.
Collapse
Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences,School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Aniek F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Martijn J L Bours
- Department of Epidemiology, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health~Holland), The Hague, The Netherlands.,Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
30
|
Berkel AEM, Bongers BC, Kotte H, Weltevreden P, de Jongh FHC, Eijsvogel MMM, Wymenga M, Bigirwamungu-Bargeman M, van der Palen J, van Det MJ, van Meeteren NLU, Klaase JM. Effects of Community-based Exercise Prehabilitation for Patients Scheduled for Colorectal Surgery With High Risk for Postoperative Complications: Results of a Randomized Clinical Trial. Ann Surg 2022; 275:e299-e306. [PMID: 33443905 PMCID: PMC8746915 DOI: 10.1097/sla.0000000000004702] [Citation(s) in RCA: 134] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in high-risk patients scheduled for elective colorectal resection for (pre)malignancy. SUMMARY BACKGROUND DATA Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications. METHODS This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold <11 mL/kg/min at the baseline cardiopulmonary exercise test was the final inclusion criterion. Inclusion was based on a power analysis. Patients in the prehabilitation group participated in a personalized 3-week (3 sessions per week, nine sessions in total) supervised exercise program given in community physical therapy practices before colorectal resection. Patients in the reference group received usual care. The primary outcome was the number of patients with one or more complications within 30 days of surgery, graded according to the Clavien-Dindo classification. Data were analyzed on an intention-to-treat basis. RESULTS Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024). CONCLUSIONS Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.
Collapse
Affiliation(s)
- Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, PO Box 616, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, Maastricht, The Netherlands
| | - Hayke Kotte
- Fysio Twente, J.J. van Deinselaan 34a, Enschede, The Netherlands
| | | | - Frans H C de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Michiel M M Eijsvogel
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Machteld Wymenga
- Department of Internal Medicine, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | | | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, Almelo, The Netherlands
| | - Nico L U van Meeteren
- Top Sector Life Sciences & Health (Health∼Holland), PO Box 93035, The Hague, The Netherlands
- Department of Anesthesiology, Erasmus Medical Center, PO Box 2040, Rotterdam, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, Groningen, The Netherlands
| |
Collapse
|
31
|
Berkel AEM, van Wijk L, van Dijk DPJ, Prins SN, van der Palen J, van Meeteren NLU, Olde Damink SWM, Klaase JM, Bongers BC. The association between preoperative body composition and aerobic fitness in patients scheduled for colorectal surgery. Colorectal Dis 2022; 24:93-101. [PMID: 34612581 PMCID: PMC9298406 DOI: 10.1111/codi.15941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/24/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
AIM Although cardiopulmonary exercise testing (CPET) is considered the gold standard, a preoperative abdominal CT scan might also provide information concerning preoperative aerobic fitness for risk assessment. This study aimed to investigate the association between preoperative CT-scan-derived body composition variables and preoperative CPET variables of aerobic fitness in colorectal surgery. METHOD In this retrospective cohort study, CT images at level L3 were analysed for skeletal muscle mass, skeletal muscle radiation attenuation, visceral adipose tissue (VAT) mass and subcutaneous adipose tissue mass. Regression analyses were performed to investigate the relation between CT-scan-derived body composition variables, CPET-derived aerobic fitness and other preoperative patient-related variables. Logistic regression analysis was performed to predict a preoperative anaerobic threshold (AT) ≤ 11.1 ml/kg/min as cut-off for having a high risk for postoperative complications. RESULTS Data from 78 patients (45 men; mean [SD] age 74.5 [6.4 years]) were analysed. A correlation coefficient of 0.55 was observed between absolute AT and skeletal muscle mass index. Absolute AT (R2 of 51.1%) was lower in patients with a lower skeletal muscle mass index, together with higher age, lower body mass and higher American Society of Anesthesiologists (ASA) score. Higher ASA score (odds ratio 5.64; P = 0.033) and higher VAT mass (odds ratio 1.02; P = 0.036) were associated with an increased risk of an AT ≤ 11.1 ml/kg/min. CONCLUSION Body composition variables from the preoperative CT scan were moderately associated with preoperative CPET-derived aerobic fitness. Higher ASA score and higher VAT mass were associated with an increased risk of an AT ≤ 11.1 ml/kg/min.
Collapse
Affiliation(s)
| | - Laura van Wijk
- Department of Hepatobiliary Surgery and Liver TransplantationUniversity Medical Center GroningenGroningenThe Netherlands
| | - David P. J. van Dijk
- Department of SurgeryNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Sanne N. Prins
- Department of SurgeryMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Job van der Palen
- Medical School TwenteMedisch Spectrum TwenteEnschedeThe Netherlands,Department of Research MethodologyMeasurement and Data AnalysisUniversity of TwenteEnschedeThe Netherlands
| | - Nico L. U. van Meeteren
- Top Sector Life Sciences and Health (Health~Holland)The HagueThe Netherlands,Department of AnesthesiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Steven W. M. Olde Damink
- Department of SurgeryNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Joost M. Klaase
- Department of Hepatobiliary Surgery and Liver TransplantationUniversity Medical Center GroningenGroningenThe Netherlands
| | - Bart C. Bongers
- Department of EpidemiologyCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Department of Nutrition and Movement SciencesNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| |
Collapse
|
32
|
Hagberg J. A Personal Biography of a Physiological Misnomer: The Anaerobic Threshold. Int J Sports Med 2021; 43:391-400. [PMID: 34879397 DOI: 10.1055/a-1664-8854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In 1973 Wasserman, Whipp, Koyal, and Beaver published a groundbreaking study titled "Anaerobic threshold and respiratory gas analysis during exercise". At that time, respiratory gas analysis and laboratory computers had evolved such that more advanced respiratory exercise physiology studies were possible. The initial publications from this group on the onset of anaerobic metabolism in cardiac patients, the first breath-by-breath VO2 system, the first description of the anaerobic threshold, and then later new methods to detect the anaerobic threshold have been and continue to be highly cited. In fact, their 1973 anaerobic threshold paper is the sixth and their 1986 paper is the second most cited paper ever published in the Journal of Applied Physiology. The anaerobic threshold concept has also generated>5500 publications with the rates increasing over time. The publication of two papers that help to refute the "anaerobic" explanation for this phenomenon had no effect on the rates of citations of the original anaerobic threshold papers or the number of anaerobic threshold papers published since. Thus, despite now substantial evidence refuting the proposed anaerobic mechanisms underlying this phenomenon, these papers continue to be highly influential in the discipline of exercise physiology and, perhaps even more explicitly, clinical exercise physiology.
Collapse
Affiliation(s)
- James Hagberg
- Department of Kinesiology, University of Maryland, College Park, United States
| |
Collapse
|
33
|
West MA, Jack S, Grocott MPW. Prehabilitation before surgery: Is it for all patients? Best Pract Res Clin Anaesthesiol 2021; 35:507-516. [PMID: 34801213 DOI: 10.1016/j.bpa.2021.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate the role of prehabilitation interventions in adult patients before elective major surgery. RECENT FINDINGS Exercise training before elective adult major surgery is feasible and safe. Efficacy has been determined but the clinical effectiveness remains uncertain. Early data suggest a reduction in morbidity, length of stay, and an improvement in the quality of life. Nutritional and psychological interventions are less well evaluated, and when they are, it is often in combination with exercise interventions as part of multimodal prehabilitation. SUMMARY Studies evaluating multimodal prehabilitation interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical effectiveness is currently very limited. Future research should focus on refining interventions, exploring mechanisms, establishing minimum dosage, interrogating interactions between therapies, and urgent implementation of large-scale clinical effectiveness studies.
Collapse
Affiliation(s)
- Malcolm A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Sandy Jack
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Michael P W Grocott
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Biomedical Research Centre, Southampton, University Hospital Southampton NHS Foundation Trust, UK; Anaesthesia, Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
34
|
Allen SK, Brown V, White D, King D, Hunt J, Wainwright J, Emery A, Hodge E, Kehinde A, Prabhu P, Rockall TA, Preston SR, Sultan J. Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial. Ann Surg Oncol 2021; 29:1839-1850. [PMID: 34725764 DOI: 10.1245/s10434-021-11002-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO2), skeletal muscle mass, QOL, and neoadjuvant therapy completion. METHODS This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months. RESULTS Fifty-four participants were randomized (prehabilitation group, n = 26; control group, n = 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO2 decline {-0.4 [95% confidence interval (CI) -0.8 to 0.1] vs. -2.5 [95% CI -2.8 to -2.2] mL/kg/min; p = 0.022}, less muscle loss [-11.6 (95% CI -14.2 to -9.0) vs. -15.6 (95% CI -18.7 to -15.4) cm2/m2; p = 0.049], and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose [prehabilitation group, 18 (75%) vs. control group, 13 (46%); p = 0.036]. No adverse events were reported. CONCLUSIONS This study has demonstrated some retention of cardiopulmonary fitness (peak VO2), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes. Trial Registration ClinicalTrials.gov NCT02950324.
Collapse
Affiliation(s)
- Sophie K Allen
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Vanessa Brown
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Daniel White
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - David King
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Julie Hunt
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Joe Wainwright
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Annabelle Emery
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Emily Hodge
- The Fountain Centre, St Luke's Cancer Centre, Guildford, UK
| | - Aga Kehinde
- The Fountain Centre, St Luke's Cancer Centre, Guildford, UK
| | - Pradeep Prabhu
- Department of Anaesthetics, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK
| | - Timothy A Rockall
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Shaun R Preston
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK
| | - Javed Sultan
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.
| |
Collapse
|
35
|
Zopf EM, Schulz H, Poeschko J, Aschenbroich K, Wilhelm T, Eypasch E, Kleimann E, Severin K, Benz J, Liu E, Bloch W, Baumann FT. Effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy-a pilot study. Support Care Cancer 2021; 30:1945-1955. [PMID: 34623488 PMCID: PMC8795052 DOI: 10.1007/s00520-021-06608-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 09/29/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Colorectal cancer and its treatment are associated with debilitating side effects. Exercise may improve the physical and psychological wellbeing of cancer patients; however, evidence in colorectal cancer patients undergoing adjuvant chemotherapy is limited. This pilot study aimed to explore the effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy. METHODS Patients who had undergone curative resection for colorectal cancer (stages II-III) and were scheduled to receive adjuvant chemotherapy were enrolled into this non-randomized controlled trial. Patients in the intervention group (IG) took part in a 6-month supervised aerobic exercise program, while the control group (CG) received usual care. Cardiorespiratory fitness (measured by peak oxygen consumption) was assessed at baseline and 6 months. Fatigue, quality of life, and physical activity levels were additionally assessed at 3 months. RESULTS In total, 59 patients (33 in IG vs. 26 in CG) were enrolled into this study. Eighteen patients (9 in IG vs. 9 in CG) dropped out of the study prior to the 6-month follow-up. Significant improvements in cardiorespiratory fitness (p = .002) and selected patient-reported health outcomes, such as reduced motivation (p = .015) and mental fatigue (p = .018), were observed in the IG when compared to the CG. CONCLUSION To our knowledge, this is the first study to investigate the effects of a supervised aerobic exercise program in colorectal cancer patients undergoing adjuvant chemotherapy. The significant and clinically meaningful improvements in CRF warrant further randomized controlled trials to confirm these findings. TRIALS REGISTRATION German Clinical Trials Register Identifier: DRKS00005793, 11/03/2014, retrospectively registered.
Collapse
Affiliation(s)
- Eva M Zopf
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Holger Schulz
- Praxis Internistischer Onkologie und Hämatologie (Pioh), Frechen, Germany
| | - Jonas Poeschko
- Augustinian Hospital, Cologne, Germany.,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Kerstin Aschenbroich
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany.,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | | | - Ernst Eypasch
- Heilig Geist-Hospital Cologne-Longerich, Cologne, Germany
| | | | - Kai Severin
- MV-Zentrum für Hämatologie und Onkologie, Cologne, Germany
| | - Jutta Benz
- St. Elisabeth-Hospital Cologne-Hohenlind, Cologne, Germany
| | - Enwu Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Freerk T Baumann
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany. .,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany.
| |
Collapse
|
36
|
West M, Bates A, Grimmett C, Allen C, Green R, Hawkins L, Moyses H, Leggett S, Z H Levett D, Rickard S, Varkonyi-Sepp J, Williams F, Wootton S, Hayes M, P W Grocott M, Jack S. The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra-cavity cancer surgery. F1000Res 2021; 10:952. [PMID: 36247802 PMCID: PMC9490280 DOI: 10.12688/f1000research.55324.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post-operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic , 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018).
Collapse
Affiliation(s)
- Malcolm West
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Andrew Bates
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Chloe Grimmett
- School of Health Sciences, University of Southampton, Southampton, SO22 1BJ, UK
| | - Cait Allen
- Wessex Cancer Trust, Registered charity 1110216, Chandlers Ford, SO53 2GG, UK
| | - Richard Green
- Anaesthetic Department (Royal Bournemouth Site), University Hospitals Dorset, Bournmouth, BH77DW, UK
| | - Lesley Hawkins
- Critical Care/Anaesthesia and Perioperative Medicine Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Helen Moyses
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Samantha Leggett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Denny Z H Levett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sally Rickard
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Judit Varkonyi-Sepp
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fran Williams
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Stephen Wootton
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Matthew Hayes
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Micheal P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sandy Jack
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| |
Collapse
|
37
|
West M, Bates A, Grimmett C, Allen C, Green R, Hawkins L, Moyses H, Leggett S, Z H Levett D, Rickard S, Varkonyi-Sepp J, Williams F, Wootton S, Hayes M, P W Grocott M, Jack S. The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra-cavity cancer surgery. F1000Res 2021; 10:952. [PMID: 36247802 PMCID: PMC9490280 DOI: 10.12688/f1000research.55324.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 07/21/2023] Open
Abstract
Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post-operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic , 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be the first randomised controlled study investigating whether an exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018).
Collapse
Affiliation(s)
- Malcolm West
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Andrew Bates
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Chloe Grimmett
- School of Health Sciences, University of Southampton, Southampton, SO22 1BJ, UK
| | - Cait Allen
- Wessex Cancer Trust, Registered charity 1110216, Chandlers Ford, SO53 2GG, UK
| | - Richard Green
- Anaesthetic Department (Royal Bournemouth Site), University Hospitals Dorset, Bournmouth, BH77DW, UK
| | - Lesley Hawkins
- Critical Care/Anaesthesia and Perioperative Medicine Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Helen Moyses
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Samantha Leggett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Denny Z H Levett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sally Rickard
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Judit Varkonyi-Sepp
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fran Williams
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Stephen Wootton
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Matthew Hayes
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Micheal P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sandy Jack
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| |
Collapse
|
38
|
Cuijpers ACM, Heldens AFJM, Bours MJL, van Meeteren NLU, Stassen LPS, Lubbers T, Bongers BC. Relation between preoperative aerobic fitness estimated by steep ramp test performance and postoperative morbidity in colorectal cancer surgery: prospective observational study. Br J Surg 2021; 109:155-159. [PMID: 34536001 PMCID: PMC10364754 DOI: 10.1093/bjs/znab292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/21/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
Steep ramp test (SRT) performance provides an estimation of preoperative aerobic fitness that is associated with postoperative outcomes. Patients with a better SRT-estimated aerobic fitness are less likely to develop postoperative complications and more likely to experience a shorter time to recovery. The SRT might be a useful and clinically accessible tool in preoperative risk assessment to identify patients at risk of postoperative morbidity and who might benefit from preoperative exercise interventions.
Collapse
Affiliation(s)
- A C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - A F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M J L Bours
- Department of Epidemiology, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - N L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), the Hague, the Netherlands.,Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - T Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - B C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
39
|
Franssen RFW, Janssen-Heijnen MLG, Barberan-Garcia A, Vogelaar FJ, Van Meeteren NLU, Bongers BC. Moderate-intensity exercise training or high-intensity interval training to improve aerobic fitness during exercise prehabilitation in patients planned for elective abdominal cancer surgery? Eur J Surg Oncol 2021; 48:3-13. [PMID: 34600787 DOI: 10.1016/j.ejso.2021.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/27/2021] [Accepted: 08/22/2021] [Indexed: 01/01/2023] Open
Abstract
Low preoperative aerobic fitness is associated with an increased risk of postoperative complications and delayed recovery in patients with abdominal cancer. Surgical prehabilitation aims to increase aerobic fitness preoperatively to improve patient- and treatment-related outcomes. However, an optimal physical exercise training program that is effective within the short time period available for prehabilitation (<6 weeks) has not yet been established. In this comparative review, studies (n = 8) evaluating the effect of short-term (<6 weeks) moderate-intensity exercise training (MIET) or high-intensity interval training (HIIT) on objectively measured aerobic fitness were summarized. The content of exercise interventions was critically appraised regarding the frequency, intensity, time, type, volume, and - monitoring of - progression (FITT-VP) principles. Three out of four studies evaluating HIIT showed statistically significant improvements in oxygen uptake at peak exercise (VO2peak) by more than 4.9%, the coefficient of variation for VO2peak. None of the two studies investigating short-term MIET showed statistically significant pre-post changes in VO2peak. Although short-term HIIT seems to be a promising intervention, concise description of performed exercise based on the FITT-VP principles was rather inconsistent in studies. Hence, interpretation of the results is challenging, and a translation into practical recommendations is premature. More emphasis should be given to individual responses to physical exercise training. Therefore, adequate risk assessment, personalized physical exercise training prescription using the FITT-VP principles, full reporting of physical exercise training adherence, and objective monitoring of training progression and recovery is needed to ensure for a personalized and effective physical exercise training program within a multimodal prehabilitation program.
Collapse
Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo, the Netherlands; Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | - Anael Barberan-Garcia
- Respiratory Medicine Department, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Spain
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - Nico L U Van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands; Top Sector Life Sciences and Health (Health∼Holland), The Hague, the Netherlands
| | - Bart C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
40
|
D'Ascenzi F, Anselmi F, Fiorentini C, Mannucci R, Bonifazi M, Mondillo S. The benefits of exercise in cancer patients and the criteria for exercise prescription in cardio-oncology. Eur J Prev Cardiol 2021; 28:725-735. [PMID: 31587570 DOI: 10.1177/2047487319874900] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022]
Abstract
Cancer and cardiovascular diseases are the leading causes of death in high-income countries. Cardiovascular complications can be found in cancer patients, being the result of so-called 'cardio-toxicity'. Therefore, it becomes essential to thoroughly investigate the origin of cardiac damage and the strategy to prevent it or to reverse the negative remodelling associated with cardiotoxicity. In this review the beneficial effects of physical exercise in cancer patients were analysed, particularly to prevent cardio-toxicity before its clinical manifestation. According to the relevance of exercise, we suggest strategies for exercise prescription with a tailored approach in these patients. In conclusion, physical exercise seems to be a promising and effective treatment for cancer patients during and after therapy and seems to counteract the negative effects induced by drugs on the cardiovascular system. Exercise prescription should be tailored according to patient's individual characteristics, to the drugs administered, to the personal history, and to his/her response to exercise, taking into account that different types of training can be prescribed according also to the patient's choice. A cardiological evaluation including exercise testing is essential for an appropriate prescription of exercise in these patients.
Collapse
Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, University of Siena, Italy
- Department of Medicine, University of Pittsburgh, USA
| | | | | | - Roberta Mannucci
- Institute for Health, University of Pittsburgh Medical Center, C. Terme (Siena), Italy
| | - Marco Bonifazi
- Department of Medicine, Science, and Neurosciences, University of Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, University of Siena, Italy
| |
Collapse
|
41
|
Loughney L, West MA, Moyses H, Bates A, Kemp GJ, Hawkins L, Varkonyi-Sepp J, Burke S, Barben CP, Calverley PM, Cox T, Palmer DH, Mythen MG, Grocott MPW, Jack S. The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial). Perioper Med (Lond) 2021; 10:23. [PMID: 34154675 PMCID: PMC8216760 DOI: 10.1186/s13741-021-00190-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/22/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health. METHODS Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling. RESULTS Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011. CONCLUSION A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery. TRIAL REGISTRATION ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.
Collapse
Affiliation(s)
- Lisa Loughney
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- ExWell Medical, Dublin, Ireland
| | - Malcolm A West
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen Moyses
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
| | - Andrew Bates
- Departments of Anaesthesia and Critical Care, Royal Bournemouth NHS Foundation Trust, Bournemouth, UK
| | - Graham J Kemp
- Department of Musculoskeletal Biology and MRC - Arthritis Research UK Centre for Integrated research into Musculoskeletal Ageing (CIMA), Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Lesley Hawkins
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Judit Varkonyi-Sepp
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
| | - Shaunna Burke
- Faculty of Biological Sciences, School of Biomedical Sciences, University of Leeds, Leeds, UK
| | - Christopher P Barben
- Department of Colorectal Surgery, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter M Calverley
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Trevor Cox
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Daniel H Palmer
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Michael G Mythen
- Anaesthesia and Critical Care, University College London, London, UK
| | - Michael P W Grocott
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK.
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Sandy Jack
- Anaesthesia and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Road, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
42
|
Affiliation(s)
- Harry B Rossiter
- Rehabilitation Clinical Trials Center, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA; and Faculty of Biological Sciences, University of Leeds, Leeds, UNITED KINGDOM
| |
Collapse
|
43
|
Pillon NJ, Loos RJF, Marshall SM, Zierath JR. Metabolic consequences of obesity and type 2 diabetes: Balancing genes and environment for personalized care. Cell 2021; 184:1530-1544. [PMID: 33675692 PMCID: PMC9191863 DOI: 10.1016/j.cell.2021.02.012] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/25/2020] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
The prevalence of type 2 diabetes and obesity has risen dramatically for decades and is expected to rise further, secondary to the growing aging, sedentary population. The strain on global health care is projected to be colossal. This review explores the latest work and emerging ideas related to genetic and environmental factors influencing metabolism. Translational research and clinical applications, including the impact of the COVID-19 pandemic, are highlighted. Looking forward, strategies to personalize all aspects of prevention, management and care are necessary to improve health outcomes and reduce the impact of these metabolic diseases.
Collapse
Affiliation(s)
- Nicolas J Pillon
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sally M Marshall
- Diabetes Research Group, Translational and Clinical Research Institute, Faculty of Clinical Medical Sciences, Newcastle University, 4(th) Floor William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Juleen R Zierath
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark.
| |
Collapse
|
44
|
Coca-Martinez M, Lopez-Hernandez A, Montane-Muntane M, Arguis MJ, Gimeno-Santos E, Navarro-Ripoll R, Perdomo J, Lopez-Baamonde M, Rios J, Moises J, Sanz de la Garza M, Sandoval E, Romano B, Sebio R, Dana F, Martinez-Palli G. Multimodal prehabilitation as strategy for reduction of postoperative complications after cardiac surgery: a randomised controlled trial protocol. BMJ Open 2020; 10:e039885. [PMID: 33371022 PMCID: PMC7757458 DOI: 10.1136/bmjopen-2020-039885] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Prehabilitation programmes that combine exercise training, nutritional support and emotional reinforcement (multimodal prehabilitation) have demonstrated efficacy reducing postoperative complications in the context of abdominal surgery. However, such programmes have seldom been studied in cardiac surgery, one of the surgeries associated with higher postoperative morbidity and mortality. This trial will assess the feasibility and efficacy in terms of reduction of postoperative complications and cost-effectiveness of a multimodal prehabilitation programme comparing to the standard of care in cardiac surgical patients. METHODS AND ANALYSIS This is a single-centre, randomised, open-label, controlled trial with a 1:1 ratio. Consecutive 160 elective valve replacement and/or coronary revascularisation surgical patients will be randomised to either standard of care or 4-6 weeks of multimodal prehabilitation that will consist in (1) two times/week supervised endurance and strength exercise training sessions, (2) promotion of physical activity and healthy lifestyle, (3) respiratory physiotherapy, (4) nutrition counselling and supplementation if needed, and (5) weekly mindfulness sessions. Baseline, preoperative and 3-month postoperative data will be collected by an independent blinded evaluator. The primary outcome of this study will be the incidence of postoperative complications. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of Clinical investigation of Hospital Clinic de Barcelona (HCB/2017/0708). The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03466606.
Collapse
Affiliation(s)
- Miquel Coca-Martinez
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Antonio Lopez-Hernandez
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Mar Montane-Muntane
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Maria Jose Arguis
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
| | - Elena Gimeno-Santos
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Ricard Navarro-Ripoll
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Juan Perdomo
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Manuel Lopez-Baamonde
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jose Rios
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
- Biostatistics Unit, Universitat Autonoma de Barcelona Facultat de Medicina, Bellaterra, Catalunya, Spain
| | - Jorge Moises
- Respiratory Medicine, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Maria Sanz de la Garza
- Department of Cardiology, Cardiovascular Institute, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Elena Sandoval
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Barbara Romano
- Nutrition and Clinical Dietetics, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Raquel Sebio
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Fernando Dana
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Graciela Martinez-Palli
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
| |
Collapse
|
45
|
Sase K, Kida K, Furukawa Y. Cardio-Oncology rehabilitation- challenges and opportunities to improve cardiovascular outcomes in cancer patients and survivors. J Cardiol 2020; 76:559-567. [DOI: 10.1016/j.jjcc.2020.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 12/17/2022]
|
46
|
Poole DC, Rossiter HB, Brooks GA, Gladden LB. The anaerobic threshold: 50+ years of controversy. J Physiol 2020; 599:737-767. [PMID: 33112439 DOI: 10.1113/jp279963] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/16/2020] [Indexed: 12/23/2022] Open
Abstract
The anaerobic threshold (AT) remains a widely recognized, and contentious, concept in exercise physiology and medicine. As conceived by Karlman Wasserman, the AT coalesced the increase of blood lactate concentration ([La- ]), during a progressive exercise test, with an excess pulmonary carbon dioxide output ( V ̇ C O 2 ). Its principal tenets were: limiting oxygen (O2 ) delivery to exercising muscle→increased glycolysis, La- and H+ production→decreased muscle and blood pH→with increased H+ buffered by blood [HCO3 - ]→increased CO2 release from blood→increased V ̇ C O 2 and pulmonary ventilation. This schema stimulated scientific scrutiny which challenged the fundamental premise that muscle anoxia was requisite for increased muscle and blood [La- ]. It is now recognized that insufficient O2 is not the primary basis for lactataemia. Increased production and utilization of La- represent the response to increased glycolytic flux elicited by increasing work rate, and determine the oxygen uptake ( V ̇ O 2 ) at which La- accumulates in the arterial blood (the lactate threshold; LT). However, the threshold for a sustained non-oxidative contribution to exercise energetics is the critical power, which occurs at a metabolic rate often far above the LT and separates heavy from very heavy/severe-intensity exercise. Lactate is now appreciated as a crucial energy source, major gluconeogenic precursor and signalling molecule but there is no ipso facto evidence for muscle dysoxia or anoxia. Non-invasive estimation of LT using the gas exchange threshold (non-linear increase of V ̇ C O 2 versus V ̇ O 2 ) remains important in exercise training and in the clinic, but its conceptual basis should now be understood in light of lactate shuttle biology.
Collapse
Affiliation(s)
- David C Poole
- Departments of Kinesiology and Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Harry B Rossiter
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, and The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - George A Brooks
- Department of Integrative Biology, Exercise Physiology Laboratory, University of California, Berkeley, CA, USA
| | | |
Collapse
|
47
|
Lavín‐Pérez AM, Collado‐Mateo D, Mayo X, Humphreys L, Liguori G, James Copeland R, Del Villar Álvarez F, Jiménez A. High‐intensity exercise to improve cardiorespiratory fitness in cancer patients and survivors: A systematic review and meta‐analysis. Scand J Med Sci Sports 2020; 31:265-294. [DOI: 10.1111/sms.13861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Ana Myriam Lavín‐Pérez
- Program of Epidemiology and Public Health (Interuniversity) PhD International School of the Rey Juan Carlos University Madrid Spain
- Centre for Sport Studies Rey Juan Carlos University Madrid Spain
- GO fitLAB Ingesport Madrid Spain
| | | | - Xián Mayo
- Centre for Sport Studies Rey Juan Carlos University Madrid Spain
| | - Liam Humphreys
- Advanced Wellbeing Research Centre College of Health Wellbeing and Life Sciences Sheffield Hallam University Sheffield UK
| | | | - Robert James Copeland
- Advanced Wellbeing Research Centre College of Health Wellbeing and Life Sciences Sheffield Hallam University Sheffield UK
| | | | - Alfonso Jiménez
- Centre for Sport Studies Rey Juan Carlos University Madrid Spain
- GO fitLAB Ingesport Madrid Spain
- Advanced Wellbeing Research Centre College of Health Wellbeing and Life Sciences Sheffield Hallam University Sheffield UK
| |
Collapse
|
48
|
Groehs RV, Negrao MV, Hajjar LA, Jordão CP, Carvalho BP, Toschi-Dias E, Andrade AC, Hodas FP, Alves MJNN, Sarmento AO, Testa L, Hoff PMG, Negrao CE, Filho RK. Adjuvant Treatment with 5-Fluorouracil and Oxaliplatin Does Not Influence Cardiac Function, Neurovascular Control, and Physical Capacity in Patients with Colon Cancer. Oncologist 2020; 25:e1956-e1967. [PMID: 32762143 DOI: 10.1634/theoncologist.2020-0225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Adjuvant chemotherapy with 5-fluorouracil (5-FU) and oxaliplatin increases recurrence-free and overall survival in patients with colon adenocarcinoma. It is known that these drugs have been associated with cardio- and neurotoxicity. We investigated the effects of 5-FU ± oxaliplatin on cardiac function, vascular responses, neurovascular control, and physical capacity in patients with colon cancer. METHODS Twenty-nine patients with prior colectomy for stage II-III adenocarcinoma and clinical indication for adjuvant chemotherapy were allocated to receive 5-FU (n = 12) or 5-FU + oxaliplatin (n = 17), according to the oncologist's decision. All the analyses were performed just before and after the end of chemotherapy. Cardiac function was assessed by echocardiography and speckle tracking, and cardiac autonomic control was assessed by heart rate variability (HRV). Vascular endothelial function was assessed by flow-mediated dilation (FMD). Muscle sympathetic nerve activity (MSNA) was directly recorded by microneurography technique, and muscle blood flow by venous occlusion plethysmography. Physical capacity was evaluated by cardiopulmonary exercise test. RESULTS Chemotherapy (pooled data) did not significantly change left ventricular ejection fraction (58 ± 1 vs. 55 ± 2%, p = .14), longitudinal strain (-18 ± 1 vs. -18 ± 1%, p = .66), and HRV. Likewise, chemotherapy did not significantly change FMD, muscle blood flow, and MSNA (33 ± 2 vs. 32 ± 1 bursts/min, p = .31). Physical capacity was not significantly changed in both groups. Similar findings were observed when the patients were subdivided in 5-FU and 5-FU + oxaliplatin treatment groups. 5-FU and 5-FU + oxaliplatin did not significantly change cardiac function, HRV, vascular responses, MSNA, and physical capacity. CONCLUSION This study provides evidence that adjuvant treatment with 5-FU ± oxaliplatin is well tolerated and does not promote changes compatible with long-term cardiotoxicity. IMPLICATIONS FOR PRACTICE Adjuvant chemotherapy with 5-fluorouracil (5-FU) and oxaliplatin increases recurrence-free and overall survival in patients with colon adenocarcinoma; however, these drugs have been associated with cardio- and neurotoxicity. This study investigated the effects of these drugs on cardiac function, vascular responses, neurovascular control, and physical capacity in patients with colon cancer. It was found that 5-FU and oxaliplatin did not significantly change cardiac function, cardiac autonomic control, vascular endothelial function, muscle sympathetic nerve activity, and physical capacity. This study provides evidence that adjuvant treatment with 5-FU ± oxaliplatin is well tolerated and does not promote changes compatible with long-term cardiotoxicity.
Collapse
Affiliation(s)
- Raphaela V Groehs
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo V Negrao
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ludhmila A Hajjar
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
- Cancer Institute of the State of São Paulo do Hospital, Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Camila P Jordão
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Bruna P Carvalho
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Edgar Toschi-Dias
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Ana C Andrade
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Fabiana P Hodas
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Maria J N N Alves
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Adriana O Sarmento
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
| | - Laura Testa
- Cancer Institute of the State of São Paulo do Hospital, Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
- D'Or Institute for Research and Education (IDOR), São Paulo, Brazil
| | - Paulo M G Hoff
- Cancer Institute of the State of São Paulo do Hospital, Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
- D'Or Institute for Research and Education (IDOR), São Paulo, Brazil
| | - Carlos E Negrao
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
- School of Physical Education and Sport, Universidade de São Paulo, São Paulo, Brasil
| | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Universidade de São Paulo, São Paulo, Brasil
- Sírio-Libanês Hospital, São Paulo, Brazil
| |
Collapse
|
49
|
Essential elements of anaesthesia practice in ERAS programs. World J Urol 2020; 40:1299-1309. [PMID: 32839862 DOI: 10.1007/s00345-020-03410-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. METHODS After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. RESULTS Patients should be permitted to drink clear fluids up to 2 h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. CONCLUSION Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.
Collapse
|
50
|
A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study. Br J Anaesth 2020; 126:181-190. [PMID: 32690247 DOI: 10.1016/j.bja.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/13/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. METHODS In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg-1 min-1 and peak oxygen consumption (VO2 peak) >16 ml kg-1 min-1, cut-points that represent a reduced risk of postoperative complications. RESULTS Five questions were identified to have dominance in predicting AT>11 ml kg-1 min-1 and VO2 peak>16 ml.kg-1min-1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg-1.min-1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO2 peak>16 ml.kg-1.min-1 and VO2 peak<16 ml.kg-1.min-1. CONCLUSIONS The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management.
Collapse
|