Skeletal muscle enzyme activities and metabolic substrates during exercise in patients with postoperative fatigue

The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Fatigue is one of the main complaints after surgery and may last longer than physical symptoms. It prevents return to normal function and activity. Relaxation interventions, performed prior to abdominal surgery, have been shown to reduce pain, wound erythema, and systemic cortisol levels. However, there is a lack of data on the impact of this intervention on patient well-being, functional recovery, activities of daily living, and fatigue after discharge from hospital.

METHODS

The study was a randomised single-blinded trial. Patients who were to undergo elective laparoscopic cholecystectomy for any indication between April 2008 and May 2010 were screened for inclusion. Those in the intervention group attended a standardised 45 min relaxation session with a health psychologist and were given relaxation exercise CDs to take home. The control group did not have the intervention. Patients were followed for 30 days. Fatigue was measured using the identity-consequence fatigue scale.

RESULTS

Seventy-five patients were randomised. Fifteen patients were excluded after randomization for various reasons; hence, 60 patients were followed up and analysed. Both groups had similar fatigue at baseline. There was improved fatigue and consequence of fatigue on postoperative day 30 in the intervention group. There was no difference in fatigue at any other time point postoperatively.

CONCLUSION

This was the first interventional study targeting fatigue after laparoscopic cholecystectomy by using a brief psychological relaxation intervention. It has shown a reduction of fatigue and impact of fatigue at 30 days postoperatively in the intervention group.

Psychological factors in postoperative fatigue

OBJECTIVE

To assess whether the fatigue commonly reported by patients following surgery is partly a result of somatization and/or cognitive-behavioral factors.

METHODS

One hundred eighty-three patients completed questionnaires before surgery and then 2 days, 3 weeks and 6 months afterward. Multiple regressions were used to assess which of the following factors were important in predicting self-reported postoperative fatigue, controlling for preoperative fatigue and for various demographic and surgical variables: negative mood, history of mood disorder, preoperative expectations of fatigue, preoperative worry or optimism about surgery, preoperative beliefs about the benefits of activity or rest, self-reported postoperative activity, self-reported cardiovascular deconditioning, and availability of social support.

RESULTS

Controlling for demographic and surgical variables and preoperative fatigue, postoperative fatigue showed significant associations with negative mood at each stage of follow-up (p < .001) and was significantly predicted by history of mood disorder at 2 days postoperatively (p = .02). Higher fatigue expectations were self-fulfilling at 3 weeks after surgery (p = .02), whereas preoperative belief in physical activity as being beneficial to recovery predicted reduced fatigue at 6 months (p < .001). Finally, self-reported breathlessness after exercise, an indicator of cardiovascular deconditioning, was also significantly associated with greater fatigue at 6 months (p = .02).

CONCLUSION

The results indicate that psychological processes may well be relevant in the etiology of postoperative fatigue. In particular, the results relating to mood and expectations suggest that somatization may be particularly important in the first few weeks following surgery, whereas cognitive-behavioral factors and cardiovascular deconditioning may be more important in determining later-stage recovery.

A systematic review and meta-analysis of the incidence and severity of postoperative fatigue

OBJECTIVE

Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues.

METHOD

Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses.

RESULTS

Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue.

CONCLUSION

Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.

Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery

OBJECTIVE

A postoperative regimen using a multimodal approach with enforced mobilization and early oral nutrition has been reported to improve convalescence but has not been compared with other postoperative regimens.

METHODS

Forty patients undergoing elective colorectal surgery were randomly allocated to an intervention group receiving comprehensive information on the importance of mobilization, balanced anesthesia, and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics, postoperative analgesia with epidural morphine, and mobilization without fixed goals. All patients were offered early oral nutrition. The regimens were compared by means of ambulation time and physical activity, voluntary muscle strength, pulmonary function, and body composition.

RESULTS

The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 (P = 0.0004) and within 8 h versus 2 h on day 4 (P = 0.0003). The voluntary strength of the quadriceps muscle decreased by 3% in the intervention group versus 15% in the control group on day 7 (P = 0.04). Two months postoperatively, the difference between groups was the same (P = 0.02).

CONCLUSION

This active per- and postoperative regimen based on a multimodal approach improved ambulation time and muscle function during admission and late convalescence.

Laparoscopic cholecystectomy minimally impairs postoperative cardiorespiratory and muscle performance

Surgery elicits a subjective feeling of postoperative fatigue, at least partly related to an impairment in cardiorespiratory function and muscle performance. Laparoscopic surgery is reported to impair the patient's condition minimally. The aim of this study was to assess exercise performance in patients scheduled for elective laparoscopic cholecystectomy. Nine patients assessed as having American Society of Anesthesiologists (ASA) grade I were enrolled in the study. Subjective feelings of fatigue (measured on a visual analogue scale), and heart rate, systemic arterial pressure oxygen consumption and carbon dioxide production responses to graded exercise testing, were assessed before operation and on days 3 and 10 after operation. There were no significant differences in any of these measurements, at rest or during exercise, between the preoperative and postoperative values. Uncomplicated laparoscopic cholecystectomy does not impair postoperative cardiorespiratory and muscle performance or induce significant postoperative fatigue in patients with ASA I, allowing rapid recovery.

Postoperative fatigue

Uncomplicated major surgery is followed by a pronounced increased feeling of fatigue extending throughout the first month in about one-third of patients. Postoperative fatigue correlates with the degree of surgical trauma but is not related to duration of general anesthesia and surgery or to preoperative nutritional status, age, or sex. Fatigue also correlates with postoperative deterioration in nutritional parameters and impaired adaptability of heart rate during exercise. Furthermore, a postoperative decrease in muscle force and endurance is related to postoperative fatigue, whereas psychological factors are of minor importance. These findings suggest postoperative fatigue to be mediated by the endocrine-metabolic response to surgery, impaired nutritional intake, or immobilization, but the relative role of these factors remains to be established. Until then, therapeutic measures against the development of postoperative fatigue should aim at reducing the surgical stress response, effective treatment of pain to facilitate mobilization, and exercise to increase postoperative nutritional intake.

Post-operative fatigue — a real phenomenon attributable to the metabolic effects of surgery on body nutritional stores

Ambulatory monitoring of activity was undertaken in 97 patients before and at intervals following surgery employing a lightweight recorder and sensors to monitor posture and movement over 24h periods. A subjective assessment of fatigue, anthropometric measurements and clinical details were noted prior to each recording. Results were assessed using multiple regression analysis. Few patients exhibited any subjective feeling of fatigue. However, objective assessment did show a reduction in activity, several of the changes correlating with factors related to surgical stress and post-operative nutritional depletion. Reduction in time standing was related to both weight change at 2 weeks (p < 0.005) and duration of surgery (p < 0.05). Increase in time spent lying correlated with muscle loss at 2 weeks (p < 0.005). Number of steps walked was only influenced by weight change at 2 weeks (p < 0.05). Reduction in post-operative mobility may be related to the metabolic consequences of the surgery and its effects on depletion of nutritional stores. Manipulation of the response and aggressive nutritional support might well reduce post-operative fatigue.