Short-term postoperative physical decline and patient-reported recovery in people aged 70 or older undergoing abdominal cancer resection– A prospective cohort study

Responsiveness and minimal clinically important difference of the 6-minute walk distance in patients undergoing colorectal cancer surgery

PURPOSE

This study aimed to clarify the responsiveness and minimal clinically important difference (MCID) of the 6-minute walk distance (6MWD) from before and 1 week after surgery in patients with colorectal cancer (CRC).

METHODS

This retrospective cohort study enrolled 97 patients with primary CRC scheduled for surgery. An anchor-based approach estimated the MCID of the 6MWD, with postoperative physical recovery and EuroQol 5-dimension 5L questionnaire assessments serving as anchors. Effect size (ES) and standardized response mean (SRM) of the 6MWD were calculated to evaluate responsiveness, and the receiver operating characteristic (ROC) curve was used to estimate the MCID of the 6MWD.

RESULTS

Of the 97 patients, 72 were included in the analysis. The absolute value of ES and SRM of the 6MWD were 0.69 and 0.91, respectively. The ROC curve indicated that the optimal cut-off values for estimating the MCID of the 6MWD were -60 m (area under the curve [AUC] = 0.753 [95% CI: 0.640-0.866]) and -75 m (AUC = 0.870 [95% CI: 0.779-0.961]) at each anchor.

CONCLUSION

From before to 1 week after surgery, the responsiveness of the 6MWD was favorable, and the MCID of the 6MWD was -75 to -60 m in patients with CRC.

Short course radiotherapy versus radiochemotherapy for locally advanced rectal cancers in the elderly (UNICANCER PRODIGE 42/GERICO 12 study): Quality of life and comprehensive geriatric assessment

BACKGROUND

The results of the PRODIGE 42/GERICO 12 study showed that short course radiotherapy had a better tolerance profile than radiochemotherapy, with comparable oncological results. We have included Quality of Life analyses and oncogeriatric evaluations in this study.

PATIENTS AND METHODS

In all, 101 patients ≥75 years of age with resectable T3-T4 rectal adenocarcinoma less than 12 cm from the anal margin received short course radiotherapy (5X5 Gy in one week) or radiochemotherapy (50 Gy, 2 y/f and capecitabine 800 mg/m2, 5 days/week) with delayed surgery (7 weeks ± 1) in both groups. The Quality of Life analyses (EORTC QLQ C-30 et ELD14) were conducted upon inclusion, pre-operatively, at 3, 6 and 12 months post-op, together with the oncogeriatric evaluations, including an evaluation of the IADL and ADL scores, walking speed, GDS15, MMSE, MNA.

RESULTS

We did not highlight any statistical difference for the global EORTC QLQ-C30 score; several factors are statistically in favor of the short course radiotherapy group at 3 months post-op (cognitive functions, fatigue, appetite). In the case of the ELD14 score, the disease burden is perceived as more negative at 3, 6 and 12 months postop in the radiochemotherapy group. The IADL score deteriorated in 44.8 % of the radiochemotherapy group and 14.8 % of the radiotherapy group (p = 0.032); similarly, the GDS15 depression score was better preserved in the short course radiotherapy group (p = 0.05). An analysis of the other scores: ADL, walking speed, MNA, MMSE did not highlight any statistical difference.

CONCLUSION

Short course radiotherapy achieves better results in terms of Quality of Life and preservation of autonomy in patients aged ≥75 treated for locally advanced rectal cancer.

Efficacy of neuromuscular electrical stimulation for thoracic and abdominal surgery: A systematic review and meta-analysis

This systematic review and meta-analysis examined the efficacy of neuromuscular electrical stimulation (NMES) on lower limb muscle strength and health-related quality of life (HR-QOL) after thoracic and abdominal surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE via PubMed, Excerpta Medica Database via Elsevier, Physiotherapy Evidence Database, Cumulative Index to Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform via their dedicated search portal, and ClinicalTrials.gov on November 2021 and updated in April 2023 to identify randomized controlled trials that examined the effects of NMES after thoracic and abdominal surgery. The primary outcomes were lower limb muscle strength, HR-QOL, and adverse events. We used the Cochrane Risk of Bias Tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach to assess the certainty of evidence. A total of 18 randomized control trials involving 915 participants, including 10 on cardiovascular surgery, two on pulmonary surgery, five on digestive system surgery, and one on other surgery, were included. NMES slightly increased lower limb muscle strength and adverse events in cardiovascular surgery. Adverse events (hypotension, pain, and muscle discomfort) occurred in seven patients. HR-QOL was measured in two studies on cardiovascular surgery, but these were not pooled due to concept heterogeneity. Overall, NMES slightly increases lower limb muscle strength after cardiovascular surgery without serious adverse events. However, higher-quality randomized control trials in thoracic and abdominal surgeries are needed.

The feasibility of using a digital tool to enhance mobilisation following abdominal cancer surgery-a non-randomised controlled trial

BACKGROUND

Early mobilisation is strongly recommended following abdominal cancer surgery, but evidence on how to structure early mobilisation to improve outcomes and support patient adherence is lacking. Pedatim® (Phystec) is a novel digital tool designed to support mobilisation in hospital settings using prescribed activities and goals on a tablet. The aim of this study was to evaluate the feasibility of the Pedatim tablet to enhance mobilisation following abdominal cancer surgery.

METHODS

In a non-randomised feasibility trial design, participants were recruited between January and May 2022 at Karolinska University Hospital, Sweden. Participants used a Pedatim tablet from postoperative day 1 (POD 1) until hospital discharge. The primary objective was to evaluate process feasibility, regarding recruitment, compliance, and acceptability. Recruitment was measured by percentage of available patients included, eligibility criteria sufficiency, and number of dropouts. Compliance was measured by number of patients using versus not using the board. Acceptability was measured using the System Usability Scale. The secondary objective was to evaluate scientific feasibility, defined as an indication of treatment effects where physical activity was assessed using an activPAL accelerometer. Unforeseen events relating to the tablet were also registered.

RESULTS

Based on predetermined feasibility criteria, the overall study design was determined to be feasible regarding recruitment as 69% accepted participation (n = 20), compliance was 95%, and the acceptability mean score was high (77/100). Eligibility criteria were not feasible as 79% (n = 108) of available patients were excluded. The intervention was determined to be scientifically feasible, mean steps per day increased from 623 (SD 766) to 1823 (SD 1446), and mean sit-to-stand transitions per day increased from 11 (SD 8) to 29 (SD 12) POD 1-4. Technical issues emerged, highlighting the need for available technical support and "user champions" among healthcare professionals on the ward.

CONCLUSIONS

Using the Pedatim tablet to enhance mobilisation following abdominal cancer surgery was deemed feasible, but a randomised controlled trial is needed to determine the tool's effectiveness. The study process was determined to be feasible with revisions of the eligibility criteria needed before a future trial. Involving healthcare professionals and providing available technical support are important for future implementation.

Physical and Quality of Life Changes in Elderly Patients after Laparoscopic Surgery for Colorectal Cancer-A Prospective Cohort Study

Background-The incidence of colorectal cancer is increasing among elderly people, where postoperative complications are frequent. Methods-We evaluated postoperative physical and quality of life changes in elderly patients undergoing laparoscopic surgery for colorectal cancer. A prospective cohort study was performed in 31 colorectal cancer patients ≥60 years who were scheduled for laparoscopic surgery due to colorectal cancer. Outcomes were measured one month preoperative (T1), three days postoperative (T2) and one month postoperative (T3). Results-The largest early postoperative (from T1 to T2) declines were observed for isometric knee extension strength (33.1%), 30 s Chair Stand Test (27.9%) and handgrip strength (16.9%). Significant reductions in quality of life measured with the QLQ-C30 summary score and the EQ 5D index score were found between T1-T3 and T1-T2, respectively. Conclusions-A decline in isometric knee extension strength, 30 s Chair Stand Test, handgrip strength and quality of life is evident in elderly patients in the days following laparoscopic surgery for colorectal cancer. Preoperative values are recovered one month after surgery for all the outcomes, except for isometric knee extension, which should receive especial attention.

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.

Associations between a composite score of hemoglobin, CRP and albumin and physical performance in older patients undergoing gastrointestinal cancer surgery

BACKGROUND & AIMS

Abnormal levels of hemoglobin, C-reactive protein (CRP) and albumin are common in people with gastrointestinal cancer. The hypothesis was that this is of importance for physical performance in older persons in the perioperative context. Thus, the aim was to evaluate the association between hemoglobin, CRP and albumin and physical performance before and after abdominal cancer surgery in older patients.

METHODS

Patients ≥70 years of age scheduled for abdominal cancer surgery were invited to take part in the study. Data on levels of hemoglobin, CRP and albumin and physical performance (Six-Minute Walk Test, functional leg strength [chair-stands completed in 30 s], and maximal inspiratory muscle strength), were collected at baseline (n = 178) and physical performance was reassessed before discharge (n = 120). A composite score of 0-3 points was used, based on the presence or not of anemia, elevated CRP or hypoalbuminemia. Multivariable linear regressions were used for statistical analysis.

RESULTS

Before surgery, walking distance in patients scoring 2-3 (presence of 2 or 3 abnormal values) was shorter in comparison to patients scoring 0 (all values within normal range) in the multivariable model (-39.1 m; 95% CI -74.2, -3.9, p = 0.030). The number of chair stands performed during 30 s was lower in patients scoring 1 (-1.7; 95% CI -3.2, -0.2, p = 0.028) and 2-3 (-1.6; 95% CI -3.0, -0.1, p = 0.037) compared to patients scoring 0. No significant differences were seen between score groups and inspiratory muscle strength. After surgery, no differences were seen in walking distance or chair stands between patients with different scores.

CONCLUSIONS

Older patients with abnormal concentrations of hemoglobin, CRP and albumin before gastrointestinal cancer surgery showed impaired physical performance before surgery. Knowledge about potentially modifiable factors prior to cancer surgery increases the possibility to prepare the individual, which in turn might contribute to reduced morbidity and faster recovery after surgery.

Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery: A systematic review

BACKGROUND

Abdominal cancer surgery is associated with considerable morbidity in older patients. Assessment of preoperative physical status is therefore essential. The aim of this review was to describe and compare the objective physical tests that are currently used in abdominal cancer surgery in the older patient population with regard to postoperative outcomes.

METHODS

Medline, Embase, CINAHL and Web of Science were searched until 31 December 2020. Non-interventional cohort studies were eligible if they included patients ≥65 years undergoing abdominal cancer surgery, reported results on objective preoperative physical assessment such as Cardiopulmonary Exercise Testing (CPET), field walk tests or muscle strength, and on postoperative outcomes.

RESULTS

23 publications were included (10 CPET, 13 non-CPET including Timed Up & Go, grip strength, 6-minute walking test (6MWT) and incremental shuttle walk test (ISWT)). Meta-analysis was precluded due to heterogeneity between study cohorts, different cut-off points, and inconsistent reporting of outcomes. In CPET studies, ventilatory anaerobic threshold and minute ventilation/carbon dioxide production gradient were associated with adverse outcomes. ISWT and 6MWT predicted outcomes in two studies. Tests addressing muscle strength and function were of limited value. No study compared different physical tests.

DISCUSSION

CPET has the ability to predict adverse postoperative outcomes, but it is time-consuming and requires expert assessment. ISWT or 6MWT might be a feasible alternative to estimate aerobic capacity. Muscle strength and function tests currently have limited value in risk prediction. Future research should compare the predictive value of different physical instruments with regard to postoperative outcomes in older surgical patients.

Preoperative physical activity predicts postoperative functional recovery in gastrointestinal cancer patients

PURPOSE

The present study aimed to investigate the association between preoperative physical activity (PA) and postoperative functional recovery in gastrointestinal cancer patients.

MATERIALS AND METHODS

In this prospective study, we included 101 patients who underwent colorectal or gastric cancer surgery. Primary outcome was 6-minute walk distance (6MWD) decline ratio ((postoperative 6MWD value - preoperative 6MWD value)/preoperative 6MWD value × 100 (%)), which was determined as postoperative functional recovery. Patients were divided into two groups according to the median of 6MWD decline ratio: above the median (non-decline group) and below the median (decline group). The International Physical Activity Questionnaire (IPAQ-SV) (the usual seven-day short version) was used to assess preoperative PA and sedentary time. Multivariate logistic regression analysis was performed to identify predictive factors of postoperative functional recovery.

RESULTS

Preoperative PA (odds ratio (OR): 3.812; 95% confidence interval (CI): 1.326-10.956; p = 0.01), 6MWD (OR: 1.006; 95% CI: 1.002-1.011; p < 0.01), C-reactive protein (OR: 4.138; 95% CI: 1.383-12.377; p = 0.01), and combined resection (OR: 3.425; 95% CI: 1.101-10.649; p = 0.03) were associated with postoperative functional recovery.

CONCLUSIONS

Preoperative PA is a predictor of postoperative functional recovery in patients who undergoing gastrointestinal cancer surgery.Implications for rehabilitationThe association between preoperative physical activity (PA) and postoperative functional recovery has been unclear in gastrointestinal cancer patients.We indicated that preoperative PA predicts postoperative functional recovery.Patients who low preoperative PA need to be monitored carefully in the postoperative course.Patients with low preoperative PA may need enhanced postoperative rehabilitation to reduce postoperative functional decline.

Preoperative physical exercise strategies for patients undergoing major abdominal cancer surgery: a scoping review

BACKGROUND

Although preoperative physical exercise has been demonstrated to be associated with clinical improvements among abdominal cancer patients, there remains heterogeneity in exercise strategies and uncertainty of what the optimal strategies should be.

PURPOSE

This scoping review aimed to review and summarize the existing knowledge about preoperative exercise strategies for abdominal cancer patients.

METHODS

The Joanna Briggs Institute (JBI) framework for conducting scoping reviews was adopted to investigate preoperative physical exercise strategies for patients undergoing major abdominal cancer surgery.

RESULTS

A total of 1563 studies were identified and 24 were included in this review. Most of the study populations were colorectal cancer (n = 14). The most common type of exercise was a combination of aerobic and resistance exercises (n = 19). The most common form of aerobic exercise was walking (n = 13) or cycling (n = 12). Most resistance exercises were targeting at major muscle groups (n = 12). Most of the studies were performed at moderate intensity (n = 14) with frequency of 2 ~ 3 times/week (n = 14). The time of a training session was 30 ~ 60 min in half studies (n = 12). The intervention duration for most studies was less than 4 weeks (n = 11). Exercise locations included home (n = 10), facility (n = 7), and a combination of home and facility (n = 5). Phone calls were utilized by nearly half of the home-based exercise studies to supervise the exercise adherence (n = 7).

CONCLUSIONS

This review provides a comprehensive summary of preoperative physical exercise strategies. It has the potential to inform clinical practice and future studies.

Patient-reported recovery in upper abdominal cancer surgery care: A prospective study

The study aimed to describe and analyse patient-reported recovery in patients after upper abdominal cancer surgery. This study had a quantitative design and patients were consecutively included in a university hospital in southern Sweden. Twenty-four patients answered the Postoperative Recovery Profile (PRP) questionnaire at three measurement points. All five dimensions were affected. In the physical symptoms dimension, the majority of patients reported a lack of energy upon discharge. High levels of anxiety were reported. Over 50% of patients reported some degree of depressed mood at all three measurement points. In the social dimension, the majority of patients reported some degree of being dependent on help from others in everyday life at 4 weeks after discharge. Few patients are fully recovered at 4 weeks after discharge. Individual patient-reported recovery estimates may be valuable in identifying and planning interventions tailored to each patient's needs throughout the care process.

Postoperative delirium is associated with decreased recovery of ambulation one-month after surgery

BACKGROUND

We hypothesized that postoperative delirium is associated with diminished recovery toward baseline preoperative ambulation levels one-month postoperatively.

METHODS

Patients included were ≥60 years old undergoing inpatient operations. Ambulation was measured as steps/day using an accelerometer worn for ≥3-days preoperatively and ≥28-days postoperatively. Primary outcome was the percent recovery of preoperative steps.

RESULTS

109 patients were included; 17 (16%) developed postoperative delirium. Recovery of ambulation toward preoperative baseline at postoperative day-28 was decreased in delirium group (34% vs. 69%; p < 0.01). Immediate postoperative ambulation was similar in the delirium vs. no-delirium groups (p = 0.79). Delirium occurred on average on postoperative 3 ± 4 days. Subsequently, ambulation was decreased in the delirium group compared to non-delirium group at postoperative week-1 (p = 0.01), week-2 (p = 0.02), week-3 (p < 0.01) and week-4 (p < 0.01).

CONCLUSION

Patients undergoing inpatient operations who develop delirium recover only one-third of their baseline steps one-month postoperatively. Postoperative delirium results in a decreased recovery towards baseline ambulation for at least 4-weeks following major operations in comparison to non-delirious patients. The decrease in ambulation in the delirium versus no-delirium groups occurred after the occurrence of postoperative delirium.