Self-assessed preoperative level of habitual physical activity predicted postoperative complications after colorectal cancer surgery: A prospective observational cohort study

Exploring the acceptability of and adherence to prehabilitation and rehabilitation in patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND AND AIMS

Prehabilitation combines exercise, nutritional, and psychological interventions administered before surgery to improve patient outcomes. This comprehensive review and meta-analysis examined the feasibility, adherence, and effectiveness of prehabilitation in frail, high-risk individuals undergoing major abdominal surgery.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Web of Science, MEDLINE, Embase, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) databases to identify relevant studies evaluating prehabilitation programs published between 2010 and 2023, either as observational studies or randomized clinical trials (RCTs).

RESULTS

The 23 articles (13 RCTs and 10 observational studies) included 1849 older male and female patients aged 68.7 ± 7.2 years. Nineteen of the included studies reported on adherence to prehabilitation programmes, which was generally good (>75%) over different models, settings, and durations. Factors such as patients' desire for expedited surgery, self-assessment of fitness, personal and professional obligations, health issues, holidays, and advancement of surgery dates negatively affected adherence to prehabilitation programmes. When compared with rehabilitation or standard pre- and post-surgical care, prehabilitation was associated with a 25%, albeit not statistically significant reduction in postoperative complications, according to data from 14 studies reporting on postoperative complications (OR 0.75, 95% CI 0.48 to 1.17, P = 0.43; I2 = 65%). Prehabilitation has been found to improve the 6-min walk test significantly by 29.4 m (MD +29.4 m, 95% CI 5.6 to 53.3, P = 0.02; I2 = 39%), compared with rehabilitation or standard pre- and post-surgical care.

CONCLUSION

Prehabilitation was acceptable to patients, with good adherence, and improved physical function.

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

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.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Acceptability of prehabilitation for cancer surgery: a multi-perspective qualitative investigation of patient and 'clinician' experiences

BACKGROUND

'Prehabilitation' interventions aim to enhance individuals' physical fitness prior to cancer treatment, typically involve exercise training as a key component, and may continue to support physical activity, strength, and fitness during or after treatment. However, uptake of prehabilitation is variable. This study investigated how patients from diverse socio-economic status groups perceived an exemplar prehabilitation and recovery programme, aiming to understand factors impacting acceptability, engagement and referral.

METHODS

This research was conducted in the context of the Prehab4Cancer and Recovery Programme, a prehabilitation and recovery programme available across Greater Manchester, UK. Qualitative, semi-structured phone/video-call interviews were conducted with 18 adult patient participants referred to the programme (16 'engagers', 2 'non-engagers'; half the sample lived in localities with low socio-economic status scores). An online questionnaire with free-response and categorical-response questions was completed by 24 'clinician' participants involved in referral (nurses, doctors and other staff roles). An inductive, multi-perspective, thematic analysis was performed, structured using the Framework approach.

RESULTS

Discussing and referring patients to prehabilitation can be challenging due to large quantities of information for staff to cover, and for patients to absorb, around the time of diagnosis. The programme was highly valued by both participant groups; the belief that participation would improve recovery seemed a major motivator for engagement, and some 'clinicians' felt that prehabilitation should be treated as a routine part of treatment, or extended to support other patient groups. Engagers seemed to appreciate a supportive approach where they did not feel forced to do any activity and tailoring of the programme to meet individual needs and abilities was appreciated. Initial engagement could be daunting, but gaining experience with the programme seemed to increase confidence.

CONCLUSIONS

The prehabilitation programme was highly valued by engagers. Introducing prehabilitation at a challenging time means that personalised approaches might be needed to support engagement, or participation could be encouraged at a later time. Strategies to support individuals lacking in confidence, such as buddying, may be valuable.

STUDY REGISTRATION

The study protocol was uploaded onto the Open Science Framework 24 September 2020 ( https://osf.io/347qj/ ).

Ruiz J, Nestares T, Carneiro-Barrera A. Multidisciplinary Prehabilitation and Postoperative Rehabilitation for Avoiding Complications in Patients Undergoing Resection of Colon Cancer: Rationale, Design, and Methodology of the ONCOFIT Study

ONCOFIT is a randomized clinical trial with a two-arm parallel design aimed at determining the influence of a multidisciplinary Prehabilitation and Postoperative Program (PPP) on post-surgery complications in patients undergoing resection of colon cancer. This intervention will include supervised physical exercise, dietary behavior change, and psychological support comparing its influence to the standard care. Primary and secondary endpoints will be assessed at baseline, at preoperative conditions, at the end of the PPP intervention (after 12 weeks) and 1-year post-surgery, and will include: post-surgery complications (primary endpoint); prolonged hospital length of stay; readmissions and emergency department call within 1-year after surgery; functional capacity; patient reported outcome measures targeted; anthropometry and body composition; clinical/tumor parameters; physical activity levels and sedentariness; dietary habits; other unhealthy habits; sleep quality; and fecal microbiota diversity and composition. Considering the feasibility of the present intervention in a real-life scenario, ONCOFIT will contribute to the standardization of a cost-effective strategy for preventing and improving health-related consequences in patients undergoing resection of colon cancer with an important clinical and economic impact, not only in the scientific community, but also in clinical practice.

Effect of Short-term Homebased Pre- and Postoperative Exercise on Recovery After Colorectal Cancer Surgery (PHYSSURG-C): A Randomized Clinical Trial

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.

Fit for Surgery—feasibility of short-course multimodal individualized prehabilitation in high-risk frail colon cancer patients prior to surgery

Background

Prehabilitation is a promising modality for improving patient-related outcomes after major surgery; however, very little research has been done for those who may need it the most: the elderly and the frail. This study aimed to investigate the feasibility of a short course multimodal prehabilitation prior to primary surgery in high-risk, frail patients with colorectal cancer and WHO performance status I and II.

Methods

The study was conducted as a single-center, prospective one-arm feasibility study of eight patients with colon cancer between October 4, 2018, and January 14, 2019. The intervention consisted of a physical training program tailored to the patients with both high-intensity interval training and resistance training three times a week in sessions of approximately 1 h in length, for a duration of at least 4 weeks, nutritional support with protein and vitamins, a consultation with a dietician, and medical optimization prior to surgery. Feasibility was evaluated regarding recruitment, retention, compliance and adherence, acceptability, and safety. Retention was evaluated as the number of patients that completed the intervention, with a feasibility goal of 75% completing the intervention. Compliance with the high-intensity training was evaluated as the number of sessions in which the patient achieved a minimum of 4 min > 90% of their maximum heart rate and adherence as the attended out of the offered training sessions.

Results

During the study period, 64 patients were screened for eligibility, and out of nine eligible patients, eight patients were included and seven completed the intervention (mean age 80, range 66–88). Compliance to the high-intensity interval training using 90% of maximum heart rate as the monitor of intensity was difficult to measure in several patients; however, adherence to the training sessions was 87%. Compliance with nutritional support was 57%. Half the patients felt somewhat overwhelmed by the multiple appointments and six out of seven reported difficulties with the dosage of protein.

Conclusions

This one-arm feasibility study indicates that multimodal prehabilitation including high-intensity interval training can be performed by patients with colorectal cancer and WHO performance status I and II.

Trial registration

Clinicaltrials.gov: the study current feasibility study was conducted prior to the initiation of a full ongoing randomized trial registered by NCT04167436; date of registration: November 18, 2019. Retrospectively registered. No separate prospectively registration of the feasibility trial was conducted but outlined by the approved study protocol (Danish Scientific Ethical Committee SJ-607).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00967-8.

Attitudes to and Experiences of Physical Activity After Colon Cancer Diagnosis Amongst Physically Active Individuals - A Qualitative Study

BACKGROUND

Physical activity improves survival, reduces postoperative complications, and reduces the risk of developing colon cancer. It is important to maintain physical activity after receiving a diagnosis of colon cancer to improve postoperative recovery. Individuals who are physically active and diagnosed with colon cancer presumably have different motivations to maintain physical activity compared to their sedentary counterparts.

OBJECTIVE

Enlighten how the diagnosis of colon cancer might affect physically active individuals in their attitude and experiences towards physical activity.

METHODS

A qualitative study using content analysis was conducted in northern Sweden based on semi-structured telephone interviews of twenty patients diagnosed with colon cancer. All participants met the recommendations for physical activity issued by the World Health Organization.

RESULTS

Participants were between 50 and 88 years and 50% were male. Three main categories were identified: I'll fight the cancer and come out stronger; The diagnosis makes no difference; and The diagnosis is an obstacle for physical activity. These main categories represent the ways the individuals reacted to the diagnosis of colon cancer regarding their physical activity.

CONCLUSION

Attitudes to and experience of physical activity after colon cancer diagnosis varied from a will to increase physical activity and fight the cancer, to the diagnosis putting a stop to physical activity. It is important that healthcare professionals recommend physical activity even in already physically active individuals, to encourage continued physical activity after diagnosis of colon cancer.

Association between self-assessed preoperative level of physical activity and postoperative complications - An observational cohort analysis within a randomized controlled trial (PHYSSURG-C)

INTRODUCTION

Physical activity has been suggested as a modifiable risk factor for postoperative recovery after major surgery. We aimed to further define the association between self-reported leisure time physical activity and postoperative complications and recovery on a group level.

MATERIALS AND METHODS

An observational cohort analysis was performed within a randomized controlled trial. Patients ≥20 years with colorectal cancer were eligible. Between January 2015 and May 2020, 761 participants were recruited. Leisure time physical activity was self-assessed on a four-grade scale. The primary outcome in this analysis was postoperative complications within 90 days, measured with the comprehensive complication index (CCI). Secondary outcomes were CCI for the index hospital stay, CCI 30 days postoperatively, specific types of complications, length of hospital stay, and self-assessed physical recovery. Analyses were adjusted for gender, age, study center, alcohol consumption, tumor stage, colon/rectal cancer, neoadjuvant therapy, and open or laparoscopic surgery.

RESULTS

Data on preoperative physical activity was available for 614 participants. Participants who reported some physical activity had on average a lower CCI 90 days postoperatively than sedentary participants (odds ratio 0.63, 95% CI 0.43-0.92). Similar patterns were shown for complications during hospital stay and within 30 days. There were trends towards lower risk for several types of complications, reoperations and length of hospital stay but the only difference shown was for respiratory insufficiency.

CONCLUSION

Physically active participants experienced fewer postoperative complications, which suggests the information has a potential prognostic value. The work for increasing physical activity in the general population should continue.

The Association Between Modifiable Lifestyle Factors and Postoperative Complications of Elective Surgery in Patients With Colorectal Cancer

BACKGROUND

Research has demonstrated a possible relation between patients' preoperative lifestyle and postoperative complications.

OBJECTIVE

This study aimed to assess associations between modifiable preoperative lifestyle factors and postoperative complications in patients undergoing elective surgery for colorectal cancer.

DESIGN

This is a retrospective study of a prospectively maintained database.

SETTING

At diagnosis, data on smoking habits, alcohol consumption, BMI, and physical activity were collected by using questionnaires. Postoperative data were gathered from the nationwide database of the Dutch ColoRectal Audit.

PATIENTS

Patients (n = 1564) with newly diagnosed stage I to IV colorectal cancer from 11 Dutch hospitals were included in a prospective observational cohort study (COLON) between 2010 and 2018.

MAIN OUTCOME MEASURES

Multivariable logistic regression models were used to identify which preoperative lifestyle factors were associated with postoperative complications.

RESULTS

Postoperative complications occurred in 28.5%, resulting in a substantially prolonged hospital stay (12 vs 5 days, p < 0.001). Independently associated with higher postoperative complication rates were ASA class II (OR, 1.46; 95% CI, 1.05-2.04; p = 0.03) and III to IV (OR, 3.17; 95% CI, 1.96-5.12; p < 0.001), current smoking (OR, 1.62; 95% CI, 1.02-2.56; p = 0.04), and rectal tumors (OR, 1.81; 95%CI, 1.28-2.55; p = 0.001). Body mass index, alcohol consumption, and physical activity did not show an association with postoperative complications. However, in a subgroup analysis of 200 patients with ASA III to IV, preoperative high physical activity was associated with fewer postoperative complications (OR, 0.17; 95% CI, 0.03-0.87; p = 0.04).

LIMITATIONS

Compared with most studied colorectal cancer populations, this study describes a relatively healthy study population with 87.2% of the included patients classified as ASA I to II.

CONCLUSIONS

Modifiable lifestyle factors such as current smoking and physical activity are associated with postoperative complications after colorectal cancer surgery. Current smoking is associated with an increased risk of postoperative complications in the overall study population, whereas preoperative high physical activity is only associated with a reduced risk of postoperative complications in patients with ASA III to IV. See Video Abstract at http://links.lww.com/DCR/B632.

LA ASOCIACIN ENTRE FACTORES MODIFICABLES DEL ESTILO DE VIDA Y COMPLICACIONES POSOPERATORIAS EN CIRUGA ELECTIVA EN PACIENTES CON CNCER COLORECTAL

ANTECEDENTES:Estudios han demostrado una posible relación entre el estilo de vida preoperatorio de los pacientes y las complicaciones posoperatorias.OBJETIVO:Evaluar las asociaciones entre los factores de estilo de vida preoperatorios modificables y las complicaciones posoperatorias en pacientes llevados a cirugía electiva por cáncer colorrectal.DISEÑO:Estudio retrospectivo de una base de datos continua de forma prospectiva.ESCENARIO:En el momento del diagnóstico se recopilaron mediante cuestionarios datos sobre tabaquismo, consumo de alcohol, el IMC y la actividad física. Los datos posoperatorios se obtuvieron de la base de datos nacional de la Auditoría Colorectal Holandesa.PACIENTES:Se incluyeron pacientes (n = 1564) de once hospitales holandeses con cáncer colorrectal en estadio I-IV recién diagnosticado incluidos en un estudio de cohorte observacional prospectivo (COLON) entre 2010 y 2018.PRINCIPALES VARIABLES ANALIZADAS:Se utilizaron modelos de regresión logística multivariable para identificar qué factores de estilo de vida preoperatorios y se asociaron con complicaciones posoperatorias.RESULTADOS:Las complicaciones posoperatorias se presentaron en el 28,5%, lo que resultó en una estancia hospitalaria considerablemente mayor (12 contra 5 días, p <0,001). De manera independiente se asociaron con mayores tasas de complicaciones posoperatorias la clasificación ASA II (OR 1,46; 95% IC 1,05-2,04, p = 0,03) y III-IV (OR 3,17; 95% IC 1,96-5,12, p <0,001), tabaquismo presente (OR 1,62; IC 95% 1,02-2,56, p = 0,04) y tumores rectales (OR 1,81; IC 95% 1,28-2,55, p = 0,001). El IMC, el consumo de alcohol y la actividad física no mostraron asociación con complicaciones posoperatorias. Sin embargo, en un análisis de subgrupos de 200 pacientes ASA III-IV, la actividad física íntensa preoperatoria se asoció con menos complicaciones posoperatorias (OR 0,17; IC del 95%: 0,03-0,87, p = 0,04).LIMITACIONES:En comparación con las poblaciones de cáncer colorrectal más estudiadas, este estudio incluyó una población relativamente sana con el 87,2% de los pacientes incluidos clasificados como ASA I-II.CONCLUSIONES:Los factores modificables del estilo de vida, como son el encontrarse fumando y la actividad física, se asocian con complicaciones posoperatorias después de la cirugía de cáncer colorrectal. El encontrarse fumando se asocia con un mayor riesgo de complicaciones posoperatorias en la población general del estudio, mientras que la actividad física íntensa preoperatoria se asocia con un menor riesgo de complicaciones posoperatorias únicamente en pacientes ASA III-IV. Consulte Video Resumen en http://links.lww.com/DCR/B632.

Low physical activity in patients diagnosed with head and neck cancer

BACKGROUND

This pilot study aimed to describe physical activity (PA) and self-perceived function, health and quality of life (QoL) prior to oncological treatment in patients with head and neck cancer (HNC).

METHODS

In a prospective study including 49 patients, self-perceived PA (Saltin-Grimby scale) and health-related QoL (European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 and EQ-5D) were assessed. Further, PA was also measured by an accelerometer attached to the thigh for eight consecutive days. The accelerometer PA was compared to the PA of a reference population assessed with the same method. Results presented are from data collected before start of oncological treatment.

RESULTS

The patients (44-79 years, 65% males) spent most of their time in sedentary behavior: a median of 555 minutes/day in bed (39% of total) and 606 minutes/day sitting (41%). Only 129 minutes/day were spent moving/walking. Patients with higher education, reduced physical function and higher fatigue were less physically active (P ≤ .01). Further, the different PA measures demonstrated a pattern of being less physically active compared to the reference population.

CONCLUSIONS

Patients diagnosed for HNC may have low PA level. Assessment of PA from accelerometer data may be an important component of oncological treatment to identify patients in need for PA intervention that may enhance treatment outcome.

Preoperative Physical Activity Predicts Surgical Outcomes Following Lung Cancer Resection

Objectives:

To assess whether preoperative levels of physical activity predict the incidence of post-operative complications following anatomical lung resection.

Methods:

Levels of physical activity (daily steps) were measured for 15 consecutive days using pedometers in 90 consecutive patients (prior to admission). Outcomes measured were cardiac and respiratory complications, length of stay, and 30-day re-admission rate.

Results:

A total of 78 patients’ datasets were analysed (12 patients were excluded due to non-compliance). Based on steps performed they were divided into quartiles; 1 (low physical activity) to 4 (high physical activity). There were no significant differences in age, smoking history, COPD, BMI, percentage predicted FEV1 and KCO and cardiovascular risk factors between the groups. There were significantly fewer total complications in quartiles 3 and 4 (high physical activity) compared to quartiles 1 and 2 (low physical activity) (8 vs 22; P = .01). There was a trend (P > .05) towards shorter hospital length of stay in quartiles 3 and 4 (median values of 4 and 5 days, respectively) compared to quartiles 1 and 2 (6 days for both groups).

Conclusions:

Preoperative physical activity can help to predict postoperative outcome and can be used to stratify risk of postoperative complications and to monitor impact of preoperative interventions, ultimately improving short term outcomes.

Preoperative Sedentary Time Predicts Postoperative Complications in Gastrointestinal Cancer

Background:

Gastrointestinal cancer has a high global prevalence. Postoperative complications (PCs) affect the length of hospital stay and long-term outcomes. However, it is unclear whether preoperative sedentary time is associated with PCs, independently of physical activity (PA). We aimed to investigate the association between preoperative sedentary time and PCs independently of PA in patients who underwent surgery for gastrointestinal cancer.

Methods:

In this prospective study, we included 112 patients who underwent colorectal cancer or gastric cancer surgery. Patient characteristics and surgery-related variables were collected. The Japanese version of the International Physical Activity Questionnaire (the usual 7-day short version) was used to assess preoperative PA and sedentary time. Patients were classified into two groups according to the grade of PCs: Clavien-Dindo (CD) grade <2 and ≥2. Multivariate logistic regression analysis was performed to identify the risk factors for CD grade ≥2 PCs. Receiver operating characteristic curve analysis was used to determine the optimal cutoff point of sedentary time for predicting PCs with CD grade ≥2.

Results:

PCs occurred in 38 patients (33.9%). Sedentary time (odds ratio [OR] 1.29, 95% confidence interval [CI]: 1.09-1.53; p<0.01) and body mass index (OR 1.17, 95% CI: 1.01-1.36; p=0.03) were associated with PCs independently of total PA. The optimal cutoff point of sedentary time for predicting PCs was 6 h/day (sensitivity 0.662, specificity 0.658).

Conclusion:

Preoperative sedentary time is a predictor of PCs in patients who undergo gastrointestinal cancer surgery.