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Liatsou E, Bellos I, Katsaros I, Michailidou S, Karela NR, Mantziari S, Rouvelas I, Schizas D. Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis. Dis Esophagus 2024:doae063. [PMID: 39137391 DOI: 10.1093/dote/doae063] [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] [Received: 03/26/2024] [Revised: 06/25/2024] [Accepted: 08/03/2024] [Indexed: 08/15/2024]
Abstract
The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.
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Affiliation(s)
- Efstathia Liatsou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Bellos
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Styliani Michailidou
- First Department of Paediatric Surgery, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Nina-Rafailia Karela
- Second Department of Internal Medicine, Elpis General Hospital of Athens, Athens, Greece
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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West MA, Rahman S, Jack S, Grocott MP, Levett DZ, Rashid Y, Griffiths J, Ezra M, Ayres L, Neville-Webbe H, Javed MS, Shrotri M, Khan I, Whitmore D, Prabhu P, Timbrell D, Allen S, Packham AO, Sharpe D, Anderson H, Minto G, McAleer S, McPhail S, Alasmar M, Hartley RA, Sultan J, Grace B, Underwood TJ, Byrne J, Noble F, Kelly J, Ansell G, Edwards M. Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study. BJA OPEN 2024; 10:100289. [PMID: 38947220 PMCID: PMC11214286 DOI: 10.1016/j.bjao.2024.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/01/2024] [Indexed: 07/02/2024]
Abstract
Background Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment. Methods Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses. Results Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien-Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival. Conclusions VO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision. Clinical trial registration NCT03637647.
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Affiliation(s)
- Malcolm A. West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
| | - Saqib Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sandy Jack
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael P.W. Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Denny Z.H. Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - the Perioperative Exercise Testing and Training Society (POETTS)
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
- Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK
- Institute of Naval Medicine, Alverstoke, UK
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Yasir Rashid
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - John Griffiths
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin Ezra
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lyndsay Ayres
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Helen Neville-Webbe
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Muhammad Shafiq Javed
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Milind Shrotri
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Iftikhar Khan
- Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - David Whitmore
- Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Pradeep Prabhu
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
| | - David Timbrell
- Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK
- Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Sophie Allen
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Andrew O. Packham
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David Sharpe
- Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Helen Anderson
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Gary Minto
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Samuel McAleer
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK
| | - Stuart McPhail
- Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Institute of Naval Medicine, Alverstoke, UK
| | - Mohamed Alasmar
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Robert A. Hartley
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Javed Sultan
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK
- Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK
| | - Ben Grace
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Timothy J. Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - James Byrne
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Fergus Noble
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Jamie Kelly
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Gillian Ansell
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
| | - Mark Edwards
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospitals Southampton, Department of Surgery, Southampton, UK
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Sivakumar J, Forshaw MJ, Lam S, Peters CJ, Allum WH, Whibley J, Sinclair RCF, Snowden CP, Hii MW, Sivakumar H, Read M. Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data. Dis Esophagus 2022; 35:6524743. [PMID: 35138383 DOI: 10.1093/dote/doac005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/28/2021] [Indexed: 12/11/2022]
Abstract
Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.
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Affiliation(s)
- Jonathan Sivakumar
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Matthew J Forshaw
- Department of Upper Gastrointestinal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Stephen Lam
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Christopher J Peters
- Department of Surgery and Cancer, Imperial College London of St Mary's Hospital, London, UK
| | | | - Jessica Whibley
- Department of Physiotherapy, Royal Marsden Hospital, London, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - Michael W Hii
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Harry Sivakumar
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
| | - Matthew Read
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
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4
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Chou W, Lam S, Kumar B. 'Clinical frailty is a risk factor of adverse outcomes in patients with esophageal cancer undergoing esophagectomy: analysis of 2011-2017 US hospitals'. Dis Esophagus 2022; 35:6547571. [PMID: 35279719 DOI: 10.1093/dote/doac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 12/11/2022]
Affiliation(s)
- W Chou
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - S Lam
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Oesophagogastric Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - B Kumar
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Oesophagogastric Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
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Bor P, Kingma BF, Kerst A, Steenhagen E, Ruurda JP, van Hillegersberg R, Valkenet K, Veenhof C. Decrease of physical fitness during neoadjuvant chemoradiotherapy predicts the risk of pneumonia after esophagectomy. Dis Esophagus 2021; 34:6133424. [PMID: 33575809 DOI: 10.1093/dote/doab008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/05/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
Although neoadjuvant chemoradiotherapy (nCRT) is frequently used in esophageal cancer patients undergoing treatment with curative intent, it can negatively impact patients' physical fitness. A decline in physical fitness during chemoradiotherapy may be an indication of vulnerability. The aim of this study was to evaluate whether changes in physical fitness, weight, and fat-free mass index (FFMI) during nCRT can predict the risk of postoperative pneumonia. A retrospective longitudinal observational cohort study was performed in patients who received curative treatment for esophageal cancer between September 2016 and September 2018 in a high-volume center for esophageal cancer surgery. Physical fitness (handgrip strength, leg extension strength, and exercise capacity), weight, and FFMI were measured before and after chemoradiotherapy. To be included in the data analyses, pre- and post-nCRT data had to be available of at least one of the outcome measures. Logistic regression analyses were performed to evaluate the predictive value of changes in physical fitness, weight, and FFMI during nCRT on postoperative pneumonia, as defined by the Uniform Pneumonia Scale. In total, 91 patients were included in the data analyses. Significant associations were found between the changes in handgrip strength (odds ratio [OR] 0.880, 95% confidence interval [CI]: 0.813-0.952) and exercise capacity (OR 0.939, 95%CI: 0.887-0.993) and the occurrence of postoperative pneumonia. All pneumonias occurred in patients with declines in handgrip strength and exercise capacity after nCRT. A decrease of handgrip strength and exercise capacity during nCRT predicts the risk of pneumonia after esophagectomy for cancer. Measuring physical fitness before and after chemoradiotherapy seems an adequate method to identify patients at risk of postoperative pneumonia.
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Affiliation(s)
- P Bor
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B F Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Kerst
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E Steenhagen
- Department of Dietetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K Valkenet
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Veenhof
- Department of Rehabilitation, Physiotherapy Science and Sport, University Medical Center Utrecht, Utrecht, The Netherlands.,Research Group Innovation of Human Movement Care, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
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Junttila A, Helminen O, Mrena J, Sihvo E. Exercise capacity in the stair-climbing test predicts outcomes of operable esophageal cancer in minimally invasive era. Eur J Surg Oncol 2021; 48:589-596. [PMID: 34740478 DOI: 10.1016/j.ejso.2021.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/05/2021] [Accepted: 10/25/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The risk of complications after esophagectomy highlights the need for careful preoperative assessment. Aim was to assess whether stair-climbing test (SCT) could predict outcomes of patients with operable esophageal cancer in minimally invasive era. MATERIALS AND METHODS Patients with esophageal cancer were evaluated for surgical treatment in Central Finland Central Hospital from 2012 to March 2021. Of evaluated 162 patients, 138 were scheduled to eventually undergo surgery. The exercise capacity was evaluated with symptom limited SCT. Patients were divided into four study groups on intent-to-treat basis: surgery and the SCT >14 m (Group 1), surgery and the SCT <11 m (Group 2), non-surgical therapy and the SCT <11 m (Group 3) and non-surgical therapy and the SCT >14 m (Group 4). Results were adjusted for confounders. RESULTS Major complication rate was 10.1% vs 40.0% between Group 1 and 2 (p = 0.006), and 90-day mortality 0% vs 20.0% (p < 0.001). Overall survival rates in Groups 1-4 at 1-year were 92.3% vs 72.2% vs 46.8% vs 81.8%, at 3-year 68.5% vs 52.7% vs 15.6% vs 27.3% and at 5-year 58.7% vs 39.5% vs 0% vs 0%, respectively (p < 0.001). In adjusted analysis when compared to Group 1, other groups had increased 5-year mortality hazard (Group 2 HR 2.88 (95% CI 1.25-6.63), Group 3 HR 15.6 (95% CI 5.57-43.5) and Group 4 HR 5.35 (95% CI 2.08-13.7)). CONCLUSION Exercise capacity measured with SCT in esophageal cancer patients is a strong predictor of complications and survival, and is a potential parameter to be included in any risk or prognostic models.
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Affiliation(s)
- Anna Junttila
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland.
| | - Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland; Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Johanna Mrena
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
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Steffens D, Ismail H, Denehy L, Beckenkamp PR, Solomon M, Koh C, Bartyn J, Pillinger N. Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses. Ann Surg Oncol 2021; 28:7120-7146. [PMID: 34101066 PMCID: PMC8186024 DOI: 10.1245/s10434-021-10251-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUNDS There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery. METHODS A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible. RESULTS Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend. CONCLUSIONS This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia. .,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia.
| | - Hilmy Ismail
- School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Denehy
- School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Paula R Beckenkamp
- Faculty of Health Sciences, Discipline of Physiotherapy, Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Neil Pillinger
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
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8
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Chmelo J, Khaw RA, Sinclair RCF, Navidi M, Phillips AW. Does Cardiopulmonary Testing Help Predict Long-Term Survival After Esophagectomy? Ann Surg Oncol 2021; 28:7291-7297. [PMID: 34041625 PMCID: PMC8519940 DOI: 10.1245/s10434-021-10136-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/21/2021] [Indexed: 11/26/2022]
Abstract
Background Esophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes of major surgery. Variables derived from cardiopulmonary exercise testing (CPET) have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing esophagectomy is associated with long-term survival. This study aimed to evaluate whether any of the CPET variables routinely derived from patients with esophageal cancer may aid in predicting long-term survival after esophagectomy. Methods Patients undergoing CPET followed by trans-thoracic esophagectomy for esophageal cancer with curative intent between January 2013 and January 2017 from single high-volume center were retrospectively analyzed. The relationship between predictive co-variables, including CPET variables and survival, was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was performed to find cutoff values for CPET variables predictive of 3-year survival. Results The study analyzed 313 patients. The ventilatory equivalent for carbon dioxide (VE/VCO2) at the anerobic threshold was the only CPET variable independently predictive of long-term survival in the multivariable analysis (hazard ratio [HR], 1.049; 95% confidence interval [CI], 1.011–1.088; p = 0.011). Pathologic stages 3 and 4 disease was the other co-variable found to be independently predictive of survival. An ROC analysis of the VE/VCO2 failed to demonstrate a predictive cutoff value of 3-year survival (area under the curve, 0.564; 95% CI, 0.499–0.629; p = 0.056). Conclusions A high VE/VCO2 before esophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for clinicians to consider when counseling patients.
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Affiliation(s)
- Jakub Chmelo
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Rachel A Khaw
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia and Critical Care Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Maziar Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle Upon Tyne, UK.
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9
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Murnane LC, Forsyth AK, Koukounaras J, Pilgrim CH, Shaw K, Brown WA, Mourtzakis M, Tierney AC, Burton PR. Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery. Eur J Surg Oncol 2021; 47:2295-2303. [PMID: 33640171 DOI: 10.1016/j.ejso.2021.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 01/01/2021] [Accepted: 02/07/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Low muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery. METHODS Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database. RESULTS Of 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ± 9.1 vs. 62.8 ± 9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ± 5.3 vs. 25.9 ± 6.7 kg/m2, p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31-6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26-14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival. CONCLUSION Myosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.
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Affiliation(s)
- Lisa C Murnane
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia; Department of Nutrition and Dietetics, Alfred Health, Melbourne, Australia.
| | - Adrienne K Forsyth
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Medicine, Monash University, Melbourne, Australia
| | - Charles Hc Pilgrim
- Hepaticopancreaticobiliary Surgery Unit, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Kalai Shaw
- Department of Surgery, Monash University, Melbourne, Australia; Oesophagogastric Bariatric Surgery Unit, Alfred Health, Melbourne, Australia
| | - Wendy A Brown
- Department of Surgery, Monash University, Melbourne, Australia; Oesophagogastric Bariatric Surgery Unit, Alfred Health, Melbourne, Australia
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Audrey C Tierney
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia; School of Allied Health, And Health Implementation Science and Technology, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Paul R Burton
- Department of Surgery, Monash University, Melbourne, Australia; Oesophagogastric Bariatric Surgery Unit, Alfred Health, Melbourne, Australia
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Sheill G, Reynolds S, O'Neill L, Mockler D, Reynolds JV, Hussey J, Guinan E. Cardiopulmonary Exercise Testing in Oesophagogastric Surgery: a Systematic Review. J Gastrointest Surg 2020; 24:2667-2678. [PMID: 32632727 DOI: 10.1007/s11605-020-04696-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/07/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery. METHODS Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool. RESULTS Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay. CONCLUSION Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity.
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Affiliation(s)
- G Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - S Reynolds
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - L O'Neill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - D Mockler
- Medical Library, Trinity College Dublin, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, Trinity College Dublin and St. James's Hospital, Dublin, Ireland
| | - J Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - E Guinan
- School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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Sivakumar J, Sivakumar H, Read M, Sinclair RCF, Snowden CP, Hii MW. The Role of Cardiopulmonary Exercise Testing as a Risk Assessment Tool in Patients Undergoing Oesophagectomy: A Systematic Review and Meta-analysis. Ann Surg Oncol 2020; 27:3783-3796. [DOI: 10.1245/s10434-020-08638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 02/06/2023]
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Stubbs DJ, Grimes LA, Ercole A. Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review. PLoS One 2020; 15:e0226480. [PMID: 32012165 PMCID: PMC6996804 DOI: 10.1371/journal.pone.0226480] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.
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Affiliation(s)
- Daniel J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Lisa A. Grimes
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Ari Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
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