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Vetsch T, Eggmann S, Jardot F, von Gernler M, Engel D, Beilstein CM, Wuethrich PY, Eser P, Wilhelm M. Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review. Br J Anaesth 2024; 133:178-189. [PMID: 38644158 DOI: 10.1016/j.bja.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022369944).
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Affiliation(s)
- Thomas Vetsch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Sabrina Eggmann
- Department of Physiotherapy, Inselspital, Bern University Hospital, Bern, Switzerland
| | - François Jardot
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prisca Eser
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Wilhelm
- Centre for Rehabilitation & Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ten Cate DWG, Molenaar CJL, Garcia RS, Bojesen RD, Tahasildar BLR, Jansen L, López-Baamonde M, Feo CV, Martínez-Palli G, Gögenur I, Carli F, Slooter GD. Multimodal prehabilitation in elective oncological colorectal surgery enhances postoperative functional recovery: A secondary analysis of the PREHAB randomized clinical trial. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108270. [PMID: 38520782 DOI: 10.1016/j.ejso.2024.108270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION Colorectal cancer (CRC) ranks as the second leading cause of cancer-related deaths. The PREHAB trial revealed that prehabilitation in colorectal surgery leads to a reduction of severe complications and enhanced functional capacity. Nevertheless, risk selection for prehabilitation and the potential benefits for patients without postoperative complications remains unclear. This study aims to assess postoperative functional capacity, also in patients without postoperative complications. MATERIALS & METHODS This study was a secondary analysis of the PREHAB trial. Functional capacity tests, including cardiopulmonary exercise testing (CPET), steep ramp test (SRT), 6-min walking test (6MWT), stair climb test (SCT), 30" sit-to-stand test (STS), timed-up-and-go test (TUG), and muscle strength assessments, were conducted at baseline (T0) and 4 weeks postoperatively (T3). The primary outcome was the relative change in functional capacity from baseline to postoperative (ΔT0-T3) per group (i.e., prehabilitation vs control). Secondary, identical analysis were performed for patients without postoperative complications in each group. RESULTS Intention-to-treat analysis included 251 patients. For postoperative functional capacity, prehabilitation patients showed improvements in VO2peak (p = 0.024), VO2AT (p = 0.017), SRT (p = 0.001), 6MWT (p = 0.049), SCT (p = 0.012), and STS (p = 0.001) compared to the control group. Regarding muscle strength, prehabilitation patients showed improvements in estimated 1RM lateral pull down (p = 0.016), 1RM chest press (p = 0.001), 1RM leg press (p = 0.001) and HGS (p = 0.005) compared to controls. Additionally, prehabilitation patients more often reached baseline levels at T3 in VO2AT (p = 0.037), SRT (p = 0.008), 6MWT (p = 0.013), STS (p = 0.012), estimated 1RM lateral pull down (p = 0.002), 1RM chest press (p = 0.001) and 1RM leg press (p = 0.001) compared to controls. Moreover, even patients without postoperative complications in the prehabilitation group showed better postoperative functional capacity and more often reached baseline levels at T3, compared to controls. CONCLUSION Multimodal prehabilitation in CRC surgery is associated with improved postoperative functional capacity, even in patients without postoperative complications.
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Affiliation(s)
- David W G Ten Cate
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands; Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 50, 6629 ER, Maastricht, the Netherlands.
| | - Charlotte J L Molenaar
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Raquel Sebio Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rasmus D Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark; Department of Surgery, Slagelse Hospital, Slagelse, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Loes Jansen
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Manuel López-Baamonde
- Department of Anesthesia, Hospital Clinic Barcelona, FRCB-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy; Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | - Graciela Martínez-Palli
- Department of Anesthesia, Hospital Clinic Barcelona, FRCB-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands
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Cuijpers ACM, Lubbers T, Dronkers JJ, Heldens AFJM, Zoethout SB, Leistra D, van Kuijk SMJ, van Meeteren NLU, Stassen LPS, Bongers BC. Development and external validation of preoperative clinical prediction models for postoperative outcomes including preoperative aerobic fitness in patients approaching elective colorectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108338. [PMID: 38728861 DOI: 10.1016/j.ejso.2024.108338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/01/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Preoperative aerobic fitness is associated with postoperative outcomes after elective colorectal cancer (CRC) surgery. This study aimed to develop and externally validate two clinical prediction models incorporating a practical test to assess preoperative aerobic fitness to distinguish between patients with and without an increased risk for 1) postoperative complications and 2) a prolonged time to in-hospital recovery of physical functioning after elective colorectal cancer (CRC) surgery. MATERIALS AND METHODS Models were developed using prospective data from 256 patients and externally validated using prospective data of 291 patients. Postoperative complications were classified according to Clavien-Dindo. The modified Iowa level of assistance scale (mILAS) was used to determine time to postoperative in-hospital physical recovery. Aerobic fitness, age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, neoadjuvant treatment, surgical approach, tumour location, and preoperative haemoglobin level were potential predictors. Areas under the curve (AUC), calibration plots, and Hosmer-Lemeshow tests evaluated predictive performance. RESULTS Aerobic fitness, sex, age, ASA, tumour location, and surgical approach were included in the final models. External validation of the model for complications and postoperative recovery presented moderate to fair discrimination (AUC 0.666 (0.598-0.733) and 0.722 (0.651-0.794), respectively) and good calibration. High sensitivity and high negative predictive values were observed in the lower predicted risk categories (<40 %). CONCLUSION Both models identify patients with and without an increased risk of complications or a prolonged time to in-hospital physical recovery. They might be used for improving patient-tailored preoperative risk assessment and targeted and cost-effective application of prehabilitation interventions.
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Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Jaap J Dronkers
- Expertise Centre Healthy Urban Living, Research Group Innovation of Human Movement Care, HU University of Applied Sciences Utrecht, Utrecht, the Netherlands.
| | - Aniek F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Siebrand B Zoethout
- Department of Physical Therapy, Deventer Hospital, Deventer, the Netherlands.
| | - Duncan Leistra
- Department of Physical Therapy, Nij Smellinghe Hospital, Drachten, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), The Hague, the Netherlands; Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands.
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - Bart C Bongers
- Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands; Department of Nutrition and Movement Sciences, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
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Wernhart S, Rassaf T. Relevance of Cardiovascular Exercise in Cancer and Cancer Therapy-Related Cardiac Dysfunction. Curr Heart Fail Rep 2024; 21:238-251. [PMID: 38696059 PMCID: PMC11090948 DOI: 10.1007/s11897-024-00662-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE OF THE REVIEW Cancer therapy-related cardiac dysfunction (CTRCD) has been identified as a threat to overall and cancer-related survival. Although aerobic exercise training (AET) has been shown to improve cardiorespiratory fitness (CRF), the relationship between specific exercise regimens and cancer survival, heart failure development, and reduction of CTRCD is unclear. In this review, we discuss the impact of AET on molecular pathways and the current literature of sports in the field of cardio-oncology. RECENT FINDINGS Cardio-oncological exercise trials have focused on variations of AET intensity by using moderate continuous and high intensity interval training, which are applicable, safe, and effective approaches to improve CRF. AET increases CRF, reduces cardiovascular morbidity and heart failure hospitalization and should thus be implemented as an adjunct to standard cancer therapy, although its long-term effect on CTRCD remains unknown. Despite modulating diverse molecular pathways, it remains unknown which exercise regimen, including variations of AET duration and frequency, is most suited to facilitate peripheral and central adaptations to exercise and improve survival in cancer patients.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart- and Vascular Center, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Wernhart S, Rassaf T. Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights. Basic Res Cardiol 2024:10.1007/s00395-024-01034-4. [PMID: 38353711 DOI: 10.1007/s00395-024-01034-4] [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: 12/15/2023] [Revised: 01/21/2024] [Accepted: 01/21/2024] [Indexed: 03/05/2024]
Abstract
Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.
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Affiliation(s)
- Simon Wernhart
- West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Tienush Rassaf
- West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Blackwell JEM, Gharahdaghi N, Deane CS, Brook MS, Williams JP, Lund JN, Atherton PJ, Smith K, Wilkinson DJ, Phillips BE. Molecular mechanisms underpinning favourable physiological adaptations to exercise prehabilitation for urological cancer surgery. Prostate Cancer Prostatic Dis 2023:10.1038/s41391-023-00774-z. [PMID: 38110544 DOI: 10.1038/s41391-023-00774-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Surgery for urological cancers is associated with high complication rates and survivors commonly experience fatigue, reduced physical ability and quality of life. High-intensity interval training (HIIT) as surgical prehabilitation has been proven effective for improving the cardiorespiratory fitness (CRF) of urological cancer patients, however the mechanistic basis of this favourable adaptation is undefined. Thus, we aimed to assess the mechanisms of physiological responses to HIIT as surgical prehabilitation for urological cancer. METHODS Nineteen male patients scheduled for major urological surgery were randomised to complete 4-weeks HIIT prehabilitation (71.6 ± 0.75 years, BMI: 27.7 ± 0.9 kg·m2) or a no-intervention control (71.8 ± 1.1 years, BMI: 26.9 ± 1.3 kg·m2). Before and after the intervention period, patients underwent m. vastus lateralis biopsies to quantify the impact of HIIT on mitochondrial oxidative phosphorylation (OXPHOS) capacity, cumulative myofibrillar muscle protein synthesis (MPS) and anabolic, catabolic and insulin-related signalling. RESULTS OXPHOS capacity increased with HIIT, with increased expression of electron transport chain protein complexes (C)-II (p = 0.010) and III (p = 0.045); and a significant correlation between changes in C-I (r = 0.80, p = 0.003), C-IV (r = 0.75, p = 0.008) and C-V (r = 0.61, p = 0.046) and changes in CRF. Neither MPS (1.81 ± 0.12 to 2.04 ± 0.14%·day-1, p = 0.39) nor anabolic or catabolic proteins were upregulated by HIIT (p > 0.05). There was, however, an increase in phosphorylation of AS160Thr642 (p = 0.046) post-HIIT. CONCLUSIONS A HIIT surgical prehabilitation regime, which improved the CRF of urological cancer patients, enhanced capacity for skeletal muscle OXPHOS; offering potential mechanistic explanation for this favourable adaptation. HIIT did not stimulate MPS, synonymous with the observed lack of hypertrophy. Larger trials pairing patient-centred and clinical endpoints with mechanistic investigations are required to determine the broader impacts of HIIT prehabilitation in this cohort, and to inform on future optimisation (i.e., to increase muscle mass).
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Affiliation(s)
- James E M Blackwell
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
- Department of Surgery & Anaesthetics, Royal Derby Hospital, Derby, UK
| | - Nima Gharahdaghi
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
| | - Colleen S Deane
- Human Development & Health, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Matthew S Brook
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - John P Williams
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
- Department of Surgery & Anaesthetics, Royal Derby Hospital, Derby, UK
| | - Jonathan N Lund
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
- Department of Surgery & Anaesthetics, Royal Derby Hospital, Derby, UK
| | - Philip J Atherton
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
| | - Ken Smith
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
| | - Daniel J Wilkinson
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK
| | - Bethan E Phillips
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research and National Institute for Health Research Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, UK.
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Franssen RFW, Berkel AEM, Ten Cate DWG, van der Palen J, van Meeteren NLU, Vogelaar FJ, Slooter G, Klaase JM, Janssen-Heijnen MLG, Bongers BC. A retrospective analysis of the association of effort-independent cardiopulmonary exercise test variables with postoperative complications in patients who underwent elective colorectal surgery. Langenbecks Arch Surg 2023; 409:7. [PMID: 38093118 DOI: 10.1007/s00423-023-03197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE This study aimed to investigate the association of effort-independent variables derived from the preoperative cardiopulmonary exercise test (CPET) with 30-day postoperative complications after elective colorectal surgery. METHODS A multicenter (n=4) retrospective explorative study was performed using data of patients who completed a preoperative CPET and underwent elective colorectal surgery. The preoperative slope of the relation between minute ventilation and carbon dioxide production (VE/VCO2-slope) and the oxygen uptake efficiency slope (OUES), as well as 30-day postoperative complications, were assessed. Multivariable logistic regression analyses and receiver operating characteristic (ROC) curves were used to investigate the prognostic value of the relationship between these preoperative CPET-derived effort-independent variables and postoperative complications. RESULTS Data from 102 patients (60.1% males) with a median age of 72.0 (interquartile range 67.8-77.4) years were analyzed. Forty-four patients (43.1%) had one or more postoperative complications (of which 52.3% general and 77.3% surgical complications). Merely 10 (9.8%) patients had a general complication only. In multivariate analysis adjusted for surgical approach (open versus minimally invasive surgery), the VE/VCO2-slope (odds ratio (OR) 1.08, confidence interval (CI) 1.02-1.16) and OUES (OR 0.94, CI 0.89-1.00) were statistically significant associated with the occurrence of 30-day postoperative complications. CONCLUSION The effort-independent VE/VCO2-slope and OUES might be used to assist in future preoperative risk assessment and could especially be of added value in patients who are unable or unwilling to deliver a maximal cardiorespiratory effort. Future research should reveal the predictive value of these variables individually and/or in combination with other prognostic (CPET-derived) variables for postoperative complications. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05331196.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Tegelseweg 210, 5912, BL, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- General Practice, Rijk-Berkel, Hengelo, The Netherlands
| | - David W G Ten Cate
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medisch Spectum Twente, Enschede, The Netherlands
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Nico L U van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Top Sector Life Sciences & Health, The Hague, The Netherlands
| | - F Jeroen Vogelaar
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Gerrit Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Joost M Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Triguero-Cánovas D, López-Rodríguez-Arias F, Gómez-Martínez M, Sánchez-Guillén L, Peris-Castelló F, Alcaide-Quirós MJ, Morillas-Blasco P, Arroyo A, Ramírez JM. Home-based prehabilitation improves physical conditions measured by ergospirometry and 6MWT in colorectal cancer patients: a randomized controlled pilot study. Support Care Cancer 2023; 31:673. [PMID: 37930478 DOI: 10.1007/s00520-023-08140-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE/BACKGROUND Prehabilitation aims to improve physical condition in the preoperative period and, therefore, decrease the loss of cardiopulmonary capacity postoperatively, with the aim of reducing complications and promoting an early recovery. This study aims to evaluate the impact of home-based prehabilitation on the physical condition of patients treated surgically for colorectal cancer. METHODS A prospective and randomized clinical study was conducted on 60 patients during two periods from October 2018 to February 2019 and from September 2019 to September 2020, in a single university hospital. Patients were randomized into two study groups (30 per group): prehabilitation vs. standard care. Changes in physical condition, measured at diagnosis, the day before surgery, and at 6-8 weeks after surgery using the cardiopulmonary exercise testing (CPET) and the 6-minute walk test (6MWT) were evaluated. RESULTS Prehabilitation reduced postoperative complications (17.4% vs. 33.3%, p = 0.22) and hospital stay (5.74 vs. 6.67 days, p = 0.30). 6MWT showed a significant improvement in the prehabilitation group (+78.9 m). Six weeks after surgery, prehabilitation showed a significant improvement in the 6MWT (+68.9 m vs. -27.2 m, p = 0.01). Significant differences were also observed in the ergospirometry between the diagnosis and postoperative study (+0.79 METs vs. -0.84 METs, p = 0.001). A strong correlation was observed between CPET and 6MWT (0.767 (p < 0.001)). CONCLUSION Home prehabilitation achieved lower overall postoperative complications than standard care and reached significant improvements in 6MWT and CET. A strong correlation was observed between CET and 6MWT, which allows validation of 6MWT as a valid and reliable measure of functional exercise capacity in colorectal patients when other, more specific and expensive tests are not available. TRIAL REGISTRATION Registered in ClinicalTrials.gov in August 2018 with registration number https://clinicaltrials.gov/study/NCT03618329?cond=Prehabilitation%20cancer&term=arroyo&distance=50&rank=1 (NCT03618329). Initial results published in Supportive Care in Cancer: Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic. DOI: https://doi.org/10.1007/s00520-021-06343-1 .
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Affiliation(s)
- Daniel Triguero-Cánovas
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Francisco López-Rodríguez-Arias
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Manuel Gómez-Martínez
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Luis Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain.
| | - Franc Peris-Castelló
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - María José Alcaide-Quirós
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Pedro Morillas-Blasco
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Antonio Arroyo
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Jose Manuel Ramírez
- Department of General Surgery, Colorectal Unit, University Hospital Lozano Blesa, University of Zaragoza, Zaragoza, Spain
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Voorn MJJ, Bastiaansen EMW, Schröder CD, van Kampen-van den Boogaart VEM, Bootsma GP, Bongers BC, Janssen-Heijnen MLG. A qualitative stakeholder analysis of beliefs, facilitators, and barriers for a feasible prehabilitation program before lung cancer surgery. J Cancer Res Clin Oncol 2023; 149:15713-15726. [PMID: 37668792 PMCID: PMC10620296 DOI: 10.1007/s00432-023-05298-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND In order to develop a feasible prehabilitation program before surgery of NSCLC, this study aimed to gain insight into beliefs, facilitators, and barriers of (1) healthcare professionals to refer patients to a prehabilitation program, (2) patients to participate in and adhere to a prehabilitation program, and (3) informal caregivers to support their loved ones. METHODS Semi-structured interviews were conducted with healthcare professionals, patients who underwent surgery for NSCLC, and their informal caregivers. The capability, opportunity, and motivation for behavior-model (COM-B) guided the development of the interview questions. Results were analyzed thematically. RESULTS The interviews were conducted with twelve healthcare professionals, seventeen patients, and sixteen informal caregivers. Four main themes were identified: (1) content of prehabilitation and referral, (2) organizational factors, (3) personal factors for participation, and (4) environmental factors. Healthcare professionals mentioned that multiple professionals should facilitate the referral of patients to prehabilitation within primary and secondary healthcare involved in prehabilitation, considering the short preoperative period. Patients did not know that a better preoperative physical fitness and nutritional status would make a difference in the risk of postoperative complications. Patients indicated that they want to receive information about the aim and possibilities of prehabilitation. Most patients preferred a group-based physical exercise training program organized in their living context in primary care. Informal caregivers could support their loved one when prehabilitation takes place by doing exercises together. CONCLUSION A prehabilitation program should be started as soon as possible after the diagnosis of lung cancer. Receiving information about the purpose and effects of prehabilitation in a consult with a physician seems crucial to patients and informal caregivers to be involved in prehabilitation. Support of loved ones in the patient's own living context is essential for adherence to a prehabilitation program.
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Affiliation(s)
- M J J Voorn
- Department of Clinical Epidemiology, VieCuri Medical Center, Tegelseweg 210, 5912 BL, Venlo, The Netherlands.
- Adelante Rehabilitation Center, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - E M W Bastiaansen
- Physical Therapy Practice, Tante Louise, Bergen op Zoom, The Netherlands
| | | | | | - G P Bootsma
- Department of Pulmonology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - B C Bongers
- Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - M L G Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Center, Tegelseweg 210, 5912 BL, Venlo, The Netherlands
- Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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10
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Alfitian J, Riedel B, Ismail H, Ho KM, Xie S, Zimmer P, Kammerer T, Wijeysundera DN, Cuthbertson BH, Schier R. Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study. EClinicalMedicine 2023; 64:102223. [PMID: 37811489 PMCID: PMC10556582 DOI: 10.1016/j.eclinm.2023.102223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Kwok M. Ho
- University of Western Australia and Murdoch University, Australia
| | - Sophia Xie
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
| | - Philipp Zimmer
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Duminda N. Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
| | - Brian H. Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
| | - the METS Study Investigators
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- University of Western Australia and Murdoch University, Australia
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
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11
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Wilson RL, Christopher CN, Yang EH, Barac A, Adams SC, Scott JM, Dieli-Conwright CM. Incorporating Exercise Training into Cardio-Oncology Care: Current Evidence and Opportunities: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:553-569. [PMID: 37969654 PMCID: PMC10635898 DOI: 10.1016/j.jaccao.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/30/2023] [Indexed: 11/17/2023] Open
Abstract
Cancer treatment-induced cardiotoxicities are an ongoing concern throughout the cancer care continuum from treatment initiation to survivorship. Several "standard-of-care" primary, secondary, and tertiary prevention strategies are available to prevent the development or further progression of cancer treatment-induced cardiotoxicities and their risk factors. Despite exercise's established benefits on the cardiovascular system, it has not been widely adopted as a nonpharmacologic cardioprotective strategy within cardio-oncology care. In this state-of-the-art review, the authors discuss cancer treatment-induced cardiotoxicities, review the existing evidence supporting the role of exercise in preventing and managing these sequelae in at-risk and affected individuals living after cancer diagnoses, and propose considerations for implementing exercise-based services in cardio-oncology practice.
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Affiliation(s)
- Rebekah L. Wilson
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Cami N. Christopher
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Eric H. Yang
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Ana Barac
- Inova Schar Heart and Vascular and Inova Schar Cancer Institute, Falls Church, Virginia, USA
| | - Scott C. Adams
- Department of Cardiology, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Ted Rogers Cardiotoxicity Prevention Program, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Jessica M. Scott
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Christina M. Dieli-Conwright
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
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12
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Nilsen TS, Sæter M, Sarvari SI, Reinertsen KV, Johansen SH, Edvardsen ER, Hallén J, Edvardsen E, Grydeland M, Kiserud CE, Lie HC, Solberg PA, Wisløff T, Sharples AP, Raastad T, Haugaa KH, Thorsen L. Effects of Aerobic Exercise on Cardiorespiratory Fitness, Cardiovascular Risk Factors, and Patient-Reported Outcomes in Long-Term Breast Cancer Survivors: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e45244. [PMID: 36920460 PMCID: PMC10131898 DOI: 10.2196/45244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Anthracycline-based chemotherapy has been mainstay of adjuvant breast cancer therapy for decades. Although effective, anthracyclines place long-term breast cancer survivors at risk of late effects, such as reduced cardiorespiratory fitness and increased risk of cardiovascular disease. Previous research has shown beneficial effects of exercise training on cardiorespiratory fitness, but the effects of exercise on limiting factors for cardiorespiratory fitness, cardiovascular risk factors, and patient-reported outcomes in long-term survivors are less clear. Whether previous exposure to breast cancer therapy modulates the effects of exercise is also unknown. OBJECTIVE The primary aim of the CAUSE (Cardiovascular Survivors Exercise) trial is to examine the effect of aerobic exercise on cardiorespiratory fitness in anthracycline-treated long-term breast cancer survivors. Secondary aims are to examine effects of exercise training on limiting factors for cardiorespiratory fitness, cardiovascular risk factors, and patient-reported outcomes, and to compare baseline values and effects of exercise training between similar-aged women with and those without prior breast cancer. A third aim is to examine the 24-month postintervention effects of aerobic exercise on primary and secondary outcomes. METHODS The CAUSE trial is a 2-armed randomized controlled trial, where 140 long-term breast cancer survivors, 8-12 years post diagnosis, are assigned to a 5-month nonlinear aerobic exercise program with 3 weekly sessions or to standard care. Seventy similar-aged women with no history of cancer will undergo the same exercise program. Cardiorespiratory fitness measured as peak oxygen consumption (VO2peak), limiting factors for VO2peak (eg, cardiac function, pulmonary function, hemoglobin mass, blood volume, and skeletal muscle characteristics), cardiovascular risk factors (eg, hypertension, diabetes, dyslipidemia, obesity, physical activity level, and smoking status), and patient-reported outcomes (eg, body image, fatigue, mental health, and health-related quality of life) will be assessed at baseline, post intervention, and 24 months post intervention. RESULTS A total of 209 patients were included from October 2020 to August 2022, and postintervention assessments were completed in January 2023. The 24-month follow-up will be completed in February 2025. CONCLUSIONS The findings from the CAUSE trial will provide novel scientific understanding of the potential benefits of exercise training in long-term breast cancer survivors. TRIAL REGISTRATION ClinicalTrials.gov NCT04307407; https://clinicaltrials.gov/ct2/show/NCT04307407. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45244.
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Affiliation(s)
- Tormod Skogstad Nilsen
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Mali Sæter
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Sebastian Imre Sarvari
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristin Valborg Reinertsen
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Sara Hassing Johansen
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | | | - Jostein Hallén
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Elisabeth Edvardsen
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
- Department of Pulmonary Medicine, Oslo University Hospital, Oslo, Norway
| | - May Grydeland
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Cecilie Essholt Kiserud
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Hanne Cathrine Lie
- Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Paul André Solberg
- Norwegian Olympic and Paralympic Committee and Confederation of Sports, Oslo, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Adam Philip Sharples
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Truls Raastad
- Department of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Kristina Hermann Haugaa
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Lene Thorsen
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
- Department for Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
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13
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Roxburgh BH, Cotter JD, Campbell HA, Reymann U, Wilson LC, Gwynne-Jones D, van Rij AM, Thomas KN. Physiological relationship between cardiorespiratory fitness and fitness for surgery: a narrative review. Br J Anaesth 2023; 130:122-132. [PMID: 36529576 DOI: 10.1016/j.bja.2022.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 12/23/2022] Open
Abstract
Epidemiological evidence has highlighted a strong relationship between cardiorespiratory fitness and surgical outcomes; specifically, fitter patients possess heightened resilience to withstand the surgical stress response. This narrative review draws on exercise and surgical physiology research to discuss and hypothesise the potential mechanisms by which higher fitness affords perioperative benefit. A higher fitness, as indicated by higher peak rate of oxygen consumption and ability to sustain metabolic homeostasis (i.e. higher anaerobic threshold) is beneficial postoperatively when metabolic demands are increased. However, the associated adaptations with higher fitness, and the related participation in regular exercise or physical activity, might also underpin the observed perioperative benefit through a process of hormesis, a protective adaptive response to the moderate and intermittent stress of exercise. Potential mediators discussed include greater antioxidant capacity, metabolic flexibility, glycaemic control, lean body mass, and improved mood.
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Affiliation(s)
- Brendon H Roxburgh
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; School of Physical Education, Sport and Exercise Sciences, Dunedin, University of Otago, New Zealand.
| | - James D Cotter
- School of Physical Education, Sport and Exercise Sciences, Dunedin, University of Otago, New Zealand
| | - Holly A Campbell
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ulla Reymann
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Luke C Wilson
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - David Gwynne-Jones
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Department of Orthopaedic Surgery, Southern District Health Board, Dunedin, New Zealand
| | - Andre M van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Kate N Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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14
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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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15
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 734] [Impact Index Per Article: 367.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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16
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Nawoor-Quinn Z, Oliver A, Raobaikady R, Mohammad K, Cone S, Kasivisvanathan R. The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery. Perioper Med (Lond) 2022; 11:48. [PMID: 36138428 PMCID: PMC9494857 DOI: 10.1186/s13741-022-00279-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Morbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool. Methods We conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients. Results A total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%. Conclusion Our study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.
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Affiliation(s)
- Z Nawoor-Quinn
- Department of Anaesthesia and Critical Care, The Royal Marsden, London, UK.
| | - A Oliver
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - R Raobaikady
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - K Mohammad
- Department of Anaesthesia, University College London Hospitals, London, UK
| | - S Cone
- The Royal Marsden Hospital and The Royal Marsden NHS Foundation Trust, Fulham Road, Chelsea, London, SW3 6JJ, UK
| | - R Kasivisvanathan
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
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17
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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18
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Waterland JL, Ismail H, Granger CL, Patrick C, Denehy L, Riedel B. Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study. Perioper Med (Lond) 2022; 11:32. [PMID: 35996196 PMCID: PMC9396890 DOI: 10.1186/s13741-022-00263-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery. Methods Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications. Results Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63–77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low—with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions. Conclusion Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12620000073909) retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-022-00263-2.
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Affiliation(s)
- Jamie L Waterland
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia. .,Department of Physiotherapy, The University of Melbourne, Melbourne, Australia. .,Peter MacCallum Cancer Centre, Division of Allied Health, Melbourne, Australia.
| | - Hilmy Ismail
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia.,The University of Melbourne, Centre for Integrated Critical Care, Melbourne, Australia
| | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.,Physiotherapy Department, The Royal Melbourne Hospital, Melbourne, Australia
| | - Cameron Patrick
- The University of Melbourne, Statistical Consulting Centre, School of Mathematics and Statistics, Melbourne, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Division of Allied Health, Melbourne, Australia
| | - Bernhard Riedel
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia.,The University of Melbourne, Centre for Integrated Critical Care, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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19
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Lee DU, Hastie DJ, Fan GH, Addonizio EA, Han J, Karagozian R. 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; 35:6514795. [PMID: 35077548 DOI: 10.1093/dote/doac002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 12/11/2022]
Abstract
Frailty is an aggregate of medical and geriatric conditions that affect elderly and vulnerable patients; as frailty is known to affect postoperative outcomes, we evaluate the effects of frailty in patients undergoing esophageal resection surgery for esophageal cancer. 2011-2017 National Inpatient Sample was used to isolate younger (18 to <65) and older (65 or greater) patients undergoing esophagectomy for esophageal cancer, substratified using frailty (defined by Johns-Hopkins ACG frailty indicator) into frail patients and non-frail controls; the controls were 1:1 matched with frail patients using propensity score. Endpoints included mortality, length of stay (LOS), costs, discharge disposition, and postsurgical complications. Following the match, there were 363 and equal number controls in younger cohort; 383 and equal number controls in older cohort. For younger cohort, frail patients had higher mortality (odds ratio [OR] 3.14 95% confidence interval [CI] 1.39-7.09), LOS (20.5 vs. 13.6 days), costs ($320,074 vs. $190,235) and were likely to be discharged to skilled nursing facilities; however, there was no difference in postsurgical complications. In multivariate, frail patients had higher mortality (aOR 3.00 95%CI 1.29-6.99). In older cohort, frail patients had higher mortality (OR 1.96 95%CI 1.07-3.60), LOS (19.9 vs. 14.3 days), costs ($301,335 vs. $206,648) and were more likely to be discharged to short-term hospitals or skilled nursing facilities; the frail patients were more likely to suffer postsurgical respiratory failure (OR 2.03 95%CI 1.31-3.15). In multivariate, frail patients had higher mortality (aOR 1.93 95%CI 1.04-3.58). Clinical frailty adversely affects both younger and older patients undergoing esophagectomy for esophageal cancer.
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Affiliation(s)
- David Uihwan Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - David Jeffrey Hastie
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Gregory Hongyuan Fan
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Elyse Ann Addonizio
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - John Han
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Raffi Karagozian
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
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20
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Chmelo J, Phillips AW, Greystoke A, Charman SJ, Avery L, Hallsworth K, Welford J, Cooper M, Sinclair RCF. A feasibility trial of prehabilitation before oesophagogastric cancer surgery using a multi-component home-based exercise programme: the ChemoFit study. Pilot Feasibility Stud 2022; 8:173. [PMID: 35945625 PMCID: PMC9360697 DOI: 10.1186/s40814-022-01137-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using 'prehabilitation' to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies. METHODS We recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises. RESULTS There were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2-100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1-100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1-88.9%) and 69.4% (IQR 52.1-84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4-99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days). CONCLUSIONS The results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation. TRIAL REGISTRATION Clinicaltrials.gov NCT04194463 . Registered on 11th December 2019-retrospectively registered.
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Affiliation(s)
- Jakub Chmelo
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK. .,Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Alexander W Phillips
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Greystoke
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Leah Avery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Kate Hallsworth
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jenny Welford
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Cooper
- Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia and Critical Care, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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21
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West M, Bates A, Grimmett C, Allen C, Green R, Hawkins L, Moyses H, Leggett S, Z H Levett D, Rickard S, Varkonyi-Sepp J, Williams F, Wootton S, Hayes M, P W Grocott M, Jack S. The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra–cavity cancer surgery. F1000Res 2022; 10:952. [PMID: 36247802 PMCID: PMC9490280 DOI: 10.12688/f1000research.55324.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post–operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic
, 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018)
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Affiliation(s)
- Malcolm West
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Andrew Bates
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Chloe Grimmett
- School of Health Sciences, University of Southampton, Southampton, SO22 1BJ, UK
| | - Cait Allen
- Wessex Cancer Trust, Registered charity 1110216, Chandlers Ford, SO53 2GG, UK
| | - Richard Green
- Anaesthetic Department (Royal Bournemouth Site), University Hospitals Dorset, Bournmouth, BH77DW, UK
| | - Lesley Hawkins
- Critical Care/Anaesthesia and Perioperative Medicine Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Helen Moyses
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Samantha Leggett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Denny Z H Levett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sally Rickard
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Judit Varkonyi-Sepp
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fran Williams
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Stephen Wootton
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Matthew Hayes
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Micheal P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sandy Jack
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
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22
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Objective methods for preoperative assessment of functional capacity. BJA Educ 2022; 22:312-320. [PMID: 36097575 PMCID: PMC9463693 DOI: 10.1016/j.bjae.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
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23
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Franssen RFW, Eversdijk AJJ, Kuikhoven M, Klaase JM, Vogelaar FJ, Janssen-Heijnen MLG, Bongers BC. Inter-observer agreement of preoperative cardiopulmonary exercise test interpretation in major abdominal surgery. BMC Anesthesiol 2022; 22:131. [PMID: 35490221 PMCID: PMC9055752 DOI: 10.1186/s12871-022-01680-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate determination of cardiopulmonary exercise test (CPET) derived parameters is essential to allow for uniform preoperative risk assessment. The objective of this prospective observational study was to evaluate the inter-observer agreement of preoperative CPET-derived variables by comparing a self-preferred approach with a systematic guideline-based approach. METHODS Twenty-six professionals from multiple centers across the Netherlands interpreted 12 preoperative CPETs of patients scheduled for hepatopancreatobiliary surgery. Outcome parameters of interest were oxygen uptake at the ventilatory anaerobic threshold (V̇O2VAT) and at peak exercise (V̇O2peak), the slope of the relationship between the minute ventilation and carbon dioxide production (V̇E/V̇CO2-slope), and the oxygen uptake efficiency slope (OUES). Inter-observer agreement of the self-preferred approach and the guideline-based approach was quantified by means of the intra-class correlation coefficient. RESULTS Across the complete cohort, inter-observer agreement intraclass correlation coefficient (ICC) was 0.76 (95% confidence interval (CI) 0.57-0.93) for V̇O2VAT, 0.98 (95% CI 0.95-0.99) for V̇O2peak, and 0.86 (95% CI 0.75-0.95) for the V̇E/V̇CO2-slope when using the self-preferred approach. By using a systematic guideline-based approach, ICCs were 0.88 (95% CI 0.74-0.97) for V̇O2VAT, 0.99 (95% CI 0.99-1.00) for V̇O2peak, 0.97 (95% CI 0.94-0.99) for the V̇E/V̇CO2-slope, and 0.98 (95% CI 0.96-0.99) for the OUES. CONCLUSIONS Inter-observer agreement of numerical values of CPET-derived parameters can be improved by using a systematic guideline-based approach. Effort-independent variables such as the V̇E/V̇CO2-slope and the OUES might be useful to further improve uniformity in preoperative risk assessment in addition to, or in case V̇O2VAT and V̇O2peak are not determinable.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Tegelseweg 210, 5912, BL, Venlo, the Netherlands. .,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Anne J J Eversdijk
- Department of Sports Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Mayella Kuikhoven
- Fanaticus Sports Medicine, Sports Medical Center, Groningen and Arnhem, the Netherlands
| | - Joost M Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | - Bart C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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24
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Guinan EM, Devenney K, Quinn C, Sheill G, Eochagáin CM, Kennedy MJ, McDermott R, Balding L. Associations Among Physical Activity, Skeletal Related Events, and Patient Reported Outcomes in Patients with Bone Metastases. Semin Oncol Nurs 2022; 38:151274. [DOI: 10.1016/j.soncn.2022.151274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Patel J, Jones CN. Anaesthesia for Major Urological Surgery. Anesthesiol Clin 2022; 40:175-197. [PMID: 35236579 DOI: 10.1016/j.anclin.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This article focuses on the anesthetic considerations for major cancer urology surgeries such as cystectomies, nephrectomies, and radical prostatectomies. It aims to explore the anesthetic considerations for both open and minimally invasive techniques.
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Affiliation(s)
- Jaishel Patel
- Royal Surrey NHS Foundation Trust, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Christopher N Jones
- Royal Surrey NHS Foundation Trust, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK
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26
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Hannan E, Kelly ME, Fahy MR, Winter DC. Prehabilitation in rectal surgery: a narrative review. Int J Colorectal Dis 2022; 37:293-299. [PMID: 35006332 DOI: 10.1007/s00384-021-04092-5] [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] [Accepted: 12/29/2021] [Indexed: 02/04/2023]
Abstract
AIM Neoadjuvant chemotherapy (NACRT) can make decompensated patients more vulnerable prior to rectal surgery. Prehabilitation is an intervention which enhances functional capacity to withstand the stress of surgery. The aim of this review was to evaluate the impact of prehabilitation for patients undergoing rectal surgery on physical fitness and clinical outcomes and to establish feasibility of prehabilitation. METHODS An analysis of the literature was conducted of PubMed, the Cochrane Library, MEDLINE, EMBASE and ScienceDirect. Articles were initially included based on their title and abstracts reviewed. Full-text copies of those selected were obtained for confirmation of inclusion. RESULTS Eight studies were included. Heterogenicity was observed in the structure of exercise programmes. Improvements in physical fitness were observed in six studies. One study demonstrated a statistically significant improvement in quality of life. The prehabilitation programmes were shown to be feasible, with high completion rates. No adverse events were reported. There was limited data regarding the impact of prehabilitation on postoperative outcomes. CONCLUSION Current evidence on prehabilitation in rectal surgery has considerable heterogenicity in both structure of programmes and outcome measures. Standardisation is required for future evaluation of the impact on outcomes. A trimodal approach of exercise, nutritional and psychological interventions has been employed in similar programmes, and should be used in rectal surgery. The intervention should be tailored to the patient and environment. This review highlights the benefits, safety and feasibility of prehabilitation and provides a platform for consensus-building for international trials.
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Affiliation(s)
- E Hannan
- Department of Surgery, St Vincent's University Hospital, Dublin 4, Ireland.
| | - M E Kelly
- Department of Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - M R Fahy
- Department of Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - D C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin 4, Ireland
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27
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Association of Preoperative Physical Activity with Short- and Long-Term Outcomes in Patients Undergoing Palliative Resection for Metastatic Colorectal Cancer: An Inverse Probability of Treatment Weighting Analysis. Cancers (Basel) 2022; 14:cancers14030489. [PMID: 35158757 PMCID: PMC8833797 DOI: 10.3390/cancers14030489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/07/2022] [Accepted: 01/15/2022] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Physical activity is linked to the risk and the prognosis of colorectal cancer. However, the impact of preoperative physical activity on postoperative short-term and long-term outcomes is limited. The aim of our study was to elucidate the relationship of preoperative physical activity and postoperative outcomes in metastatic colorectal cancer patients who underwent palliative resection. After the inverse probability of the treatment weighting process, the metabolic equivalent of task < 12 group had a higher postoperative morbidity rate and mortality rate. No significant difference was found in overall survival. In patients undergoing palliative resection for metastatic colorectal cancer, preoperative leisure-time physical activity with the metabolic equivalent of task ≥ 12 was associated with reduced short-term postoperative morbidity and mortality; however, no difference was detected in long-term survival. Abstract A lack of physical activity is a generally accepted risk factor for colorectal cancer. However, research on the effect of preoperative physical activity on postoperative and long-term outcomes is limited, especially in patients with stage IV colorectal cancer who underwent palliative surgery. Patients who underwent bowel resection for stage IV primary colorectal cancer between January 1995 and December 2016 were retrospectively enrolled. A total of 2185 patients were divided into two groups according to preoperative leisure-time weekly physical activity as assessed by metabolic equivalent of task (MET) values: MET < 12 (n = 1845) and MET ≥ 12 (n = 340). Inverse probability of treatment weighting (IPTW) was used to reduce imbalance and selection biases between the two groups. After the IPTW process, the MET < 12 group showed a higher postoperative morbidity rate (18.7% vs. 10.6%; p < 0.001) and mortality rate (2.4% vs. 0.6%; p < 0.001) than the MET ≥ 12 group. No significant difference was found in overall survival. Weekly preoperative leisure-time physical activity with MET ≥ 12 was associated with reduced short-term postoperative morbidity and mortality in patients undergoing palliative resection for metastatic colorectal cancer. However, no difference was detected in long-term survival.
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28
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Berkel AEM, van Wijk L, van Dijk DPJ, Prins SN, van der Palen J, van Meeteren NLU, Olde Damink SWM, Klaase JM, Bongers BC. The association between preoperative body composition and aerobic fitness in patients scheduled for colorectal surgery. Colorectal Dis 2022; 24:93-101. [PMID: 34612581 PMCID: PMC9298406 DOI: 10.1111/codi.15941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/24/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
AIM Although cardiopulmonary exercise testing (CPET) is considered the gold standard, a preoperative abdominal CT scan might also provide information concerning preoperative aerobic fitness for risk assessment. This study aimed to investigate the association between preoperative CT-scan-derived body composition variables and preoperative CPET variables of aerobic fitness in colorectal surgery. METHOD In this retrospective cohort study, CT images at level L3 were analysed for skeletal muscle mass, skeletal muscle radiation attenuation, visceral adipose tissue (VAT) mass and subcutaneous adipose tissue mass. Regression analyses were performed to investigate the relation between CT-scan-derived body composition variables, CPET-derived aerobic fitness and other preoperative patient-related variables. Logistic regression analysis was performed to predict a preoperative anaerobic threshold (AT) ≤ 11.1 ml/kg/min as cut-off for having a high risk for postoperative complications. RESULTS Data from 78 patients (45 men; mean [SD] age 74.5 [6.4 years]) were analysed. A correlation coefficient of 0.55 was observed between absolute AT and skeletal muscle mass index. Absolute AT (R2 of 51.1%) was lower in patients with a lower skeletal muscle mass index, together with higher age, lower body mass and higher American Society of Anesthesiologists (ASA) score. Higher ASA score (odds ratio 5.64; P = 0.033) and higher VAT mass (odds ratio 1.02; P = 0.036) were associated with an increased risk of an AT ≤ 11.1 ml/kg/min. CONCLUSION Body composition variables from the preoperative CT scan were moderately associated with preoperative CPET-derived aerobic fitness. Higher ASA score and higher VAT mass were associated with an increased risk of an AT ≤ 11.1 ml/kg/min.
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Affiliation(s)
| | - Laura van Wijk
- Department of Hepatobiliary Surgery and Liver TransplantationUniversity Medical Center GroningenGroningenThe Netherlands
| | - David P. J. van Dijk
- Department of SurgeryNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Sanne N. Prins
- Department of SurgeryMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Job van der Palen
- Medical School TwenteMedisch Spectrum TwenteEnschedeThe Netherlands,Department of Research MethodologyMeasurement and Data AnalysisUniversity of TwenteEnschedeThe Netherlands
| | - Nico L. U. van Meeteren
- Top Sector Life Sciences and Health (Health~Holland)The HagueThe Netherlands,Department of AnesthesiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Steven W. M. Olde Damink
- Department of SurgeryNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Joost M. Klaase
- Department of Hepatobiliary Surgery and Liver TransplantationUniversity Medical Center GroningenGroningenThe Netherlands
| | - Bart C. Bongers
- Department of EpidemiologyCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastrichtThe Netherlands,Department of Nutrition and Movement SciencesNUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
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29
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Milliken D, Rooms M, Moonesinghe SR, Jhanji S. Peak power output testing: novel method for preoperative assessment of exercise capacity. Br J Surg 2021; 109:220-226. [PMID: 34931236 DOI: 10.1093/bjs/znab408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 10/28/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Assessment of exercise capacity is an important component of risk assessment before major surgery. Cardiopulmonary exercise testing (CPET) provides comprehensive assessment but is resource-intensive, limiting widespread adoption. Measurement of a patient's peak power output (PPO) using a simplified test on a cycle ergometer has the potential to identify patients likely to have abnormal CPET findings and to be at increased perioperative risk. The aim of this study was to investigate the potential for PPO to identify those with abnormal CPET and to determine whether PPO predicted the risk of adverse postoperative outcomes. METHODS In a retrospective analysis of a single-centre cohort, the ability of PPO to predict a high-risk CPET result in patients undergoing major cancer surgery was analysed. The assessment was validated in patients undergoing major abdominal surgery from a UK national multicentre cohort. The association between PPO and adverse postoperative outcomes to traditional CPET-derived variables were compared. RESULTS In 2262 patients from a single centre, PPO was an excellent discriminator of high-risk CPET, with an area under the receiver operating characteristic curve (AUROC) of 0.901 (95 per cent c.i. 0.888 to 0.913). In the national cohort of 2742 patients, there was excellent discrimination, with an AUROC of 0.856 (0.842 to 0.871). A PPO cut-off of 1.5 W/kg may be appropriate for use in screening, with a sensitivity of 90 per cent in both cohorts. PPO and traditional CPET-derived predictors demonstrated similar discrimination of major postoperative complications and death. The association between PPO and major postoperative complications persisted on multivariable analysis. CONCLUSION These results suggest a role for the PPO test in preoperative screening and risk stratification for major surgery. Prospective evaluation is recommended.
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Affiliation(s)
- Don Milliken
- Department of Perioperative Medicine, Anaesthesia, Pain and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
| | - Martin Rooms
- Department of Perioperative Medicine, Anaesthesia, Pain and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre, Centre for Perioperative Medicine, University College London, London, UK
| | - Shaman Jhanji
- Anaesthesia, Perioperative and Critical Care Medicine, Royal Marsden NHS Foundation Trust, London, UK.,Perioperative and Critical Care Outcomes Group, Division of Cancer Biology, Institute of Cancer Research, London, UK
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30
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Ferguson M, Shulman M. Cardiopulmonary Exercise Testing and Other Tests of Functional Capacity. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:26-33. [PMID: 34840532 PMCID: PMC8605465 DOI: 10.1007/s40140-021-00499-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review Assessment of functional capacity is a cornerstone of preoperative risk assessment. While subjective clinician assessment of functional capacity is poorly predictive of postoperative outcomes, other objective functional assessment measures may provide more useful information. Recent Findings Cardiopulmonary exercise testing (CPET) is generally accepted as the gold standard for functional capacity assessment. However, CPET is resource-intensive and not universally available. Simpler objective tests of functional capacity such as the Duke Activity Status Index (DASI) and the 6-min walk test (6MWT) are cheap and efficient. In addition, they predict important postoperative outcomes including death, disability, and myocardial infarction. Summary Simple preoperative tests such as the DASI may be useful for routine preoperative assessment. CPET may be helpful to investigate further patients with functional status limitation, and to guide prehabilitation and perioperative shared decision-making in high-risk patients.
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Affiliation(s)
| | - Mark Shulman
- Austin Hospital, 145 Studley Rd, Heidelberg, VIC Australia
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31
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Allen SK, Brown V, White D, King D, Hunt J, Wainwright J, Emery A, Hodge E, Kehinde A, Prabhu P, Rockall TA, Preston SR, Sultan J. Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial. Ann Surg Oncol 2021; 29:1839-1850. [PMID: 34725764 DOI: 10.1245/s10434-021-11002-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO2), skeletal muscle mass, QOL, and neoadjuvant therapy completion. METHODS This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months. RESULTS Fifty-four participants were randomized (prehabilitation group, n = 26; control group, n = 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO2 decline {-0.4 [95% confidence interval (CI) -0.8 to 0.1] vs. -2.5 [95% CI -2.8 to -2.2] mL/kg/min; p = 0.022}, less muscle loss [-11.6 (95% CI -14.2 to -9.0) vs. -15.6 (95% CI -18.7 to -15.4) cm2/m2; p = 0.049], and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose [prehabilitation group, 18 (75%) vs. control group, 13 (46%); p = 0.036]. No adverse events were reported. CONCLUSIONS This study has demonstrated some retention of cardiopulmonary fitness (peak VO2), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes. Trial Registration ClinicalTrials.gov NCT02950324.
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Affiliation(s)
- Sophie K Allen
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Vanessa Brown
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Daniel White
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - David King
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Julie Hunt
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Joe Wainwright
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Annabelle Emery
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Emily Hodge
- The Fountain Centre, St Luke's Cancer Centre, Guildford, UK
| | - Aga Kehinde
- The Fountain Centre, St Luke's Cancer Centre, Guildford, UK
| | - Pradeep Prabhu
- Department of Anaesthetics, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK
| | - Timothy A Rockall
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.,Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - Shaun R Preston
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK
| | - Javed Sultan
- Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Guildford, UK.
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32
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Murdoch J, Varley A, McCulloch J, Jones M, Thomas LB, Clark A, Stirling S, Turner D, Swart AM, Dresser K, Howard G, Saxton J, Hernon J. Implementing supportive exercise interventions in the colorectal cancer care pathway: a process evaluation of the PREPARE-ABC randomised controlled trial. BMC Cancer 2021; 21:1137. [PMID: 34688257 PMCID: PMC8542291 DOI: 10.1186/s12885-021-08880-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
Background A colorectal resection is standard treatment for patients with colorectal cancer (CRC). However, the procedure results in significant post-operative mortality and reduced quality of life. Maximising pre-operative cardiopulmonary fitness could improve post-surgical outcomes. PREPARE-ABC is a multi-centre, three-armed, randomised controlled trial investigating the effects of exercise interventions, with motivational support on short and longer-term recovery outcomes in CRC patients undergoing major lower-gastrointestinal surgery. The trial included an internal pilot phase with parallel process evaluation. The aim of the process evaluation was to optimise intervention implementation for the main trial. Methods Mixed methods process evaluation conducted in 14 UK hospitals between November 2016 and March 2018. Data included a site profile questionnaire and telephone scoping interview with hospital staff, 34 qualitative observations of standard care and 14 observations of intervention delivery, 13 semi-structured interviews with healthcare professionals (HCPs) and 28 semi-structured interviews with patients. Data analysis focused on describing intervention delivery within each arm, assessing fidelity, acceptability and how variation in delivery was linked to contextual characteristics. Results Standard care exercise advice was typically limited to maintaining current activity levels, and with lead-in time to surgery affecting whether any exercise advice was provided. Variation in HCP capacity affected the ability of colorectal units to deploy staff to deliver the intervention. Patients’ exercise history and motivation prior to surgery influenced HCP perceptions and delivery of the motivational components. Observations indicated a high level of fidelity to delivery of the exercise interventions. All but one of the 28 interviewed patients reported increasing exercise levels as a result of receiving the intervention, with most finding them motivational and greatly valuing the enhanced level of social support (versus standard care) provided by staff. Conclusion Hospital-supervised and home-based exercise interventions were highly acceptable for most patients undergoing surgery for CRC. Delivery of pre- and post-operative exercise within the CRC care pathway is feasible but systematic planning of capacity and resources is required to optimise implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08880-8.
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Affiliation(s)
- Jamie Murdoch
- Department of Population Health Sciences, King's College London, London, SE1 9NH, UK.
| | - Anna Varley
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Jane McCulloch
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Megan Jones
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Laura B Thomas
- School of Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Allan Clark
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Susan Stirling
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - David Turner
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Ann Marie Swart
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Kerry Dresser
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Gregory Howard
- Norwich Clinical Trials Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - John Saxton
- Department of Sport, Health and Exercise Science, University of Hull, Hull, HU6 7RX, UK
| | - James Hernon
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
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Zopf EM, Schulz H, Poeschko J, Aschenbroich K, Wilhelm T, Eypasch E, Kleimann E, Severin K, Benz J, Liu E, Bloch W, Baumann FT. Effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy-a pilot study. Support Care Cancer 2021; 30:1945-1955. [PMID: 34623488 PMCID: PMC8795052 DOI: 10.1007/s00520-021-06608-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 09/29/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Colorectal cancer and its treatment are associated with debilitating side effects. Exercise may improve the physical and psychological wellbeing of cancer patients; however, evidence in colorectal cancer patients undergoing adjuvant chemotherapy is limited. This pilot study aimed to explore the effects of supervised aerobic exercise on cardiorespiratory fitness and patient-reported health outcomes in colorectal cancer patients undergoing adjuvant chemotherapy. METHODS Patients who had undergone curative resection for colorectal cancer (stages II-III) and were scheduled to receive adjuvant chemotherapy were enrolled into this non-randomized controlled trial. Patients in the intervention group (IG) took part in a 6-month supervised aerobic exercise program, while the control group (CG) received usual care. Cardiorespiratory fitness (measured by peak oxygen consumption) was assessed at baseline and 6 months. Fatigue, quality of life, and physical activity levels were additionally assessed at 3 months. RESULTS In total, 59 patients (33 in IG vs. 26 in CG) were enrolled into this study. Eighteen patients (9 in IG vs. 9 in CG) dropped out of the study prior to the 6-month follow-up. Significant improvements in cardiorespiratory fitness (p = .002) and selected patient-reported health outcomes, such as reduced motivation (p = .015) and mental fatigue (p = .018), were observed in the IG when compared to the CG. CONCLUSION To our knowledge, this is the first study to investigate the effects of a supervised aerobic exercise program in colorectal cancer patients undergoing adjuvant chemotherapy. The significant and clinically meaningful improvements in CRF warrant further randomized controlled trials to confirm these findings. TRIALS REGISTRATION German Clinical Trials Register Identifier: DRKS00005793, 11/03/2014, retrospectively registered.
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Affiliation(s)
- Eva M Zopf
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Holger Schulz
- Praxis Internistischer Onkologie und Hämatologie (Pioh), Frechen, Germany
| | - Jonas Poeschko
- Augustinian Hospital, Cologne, Germany.,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | - Kerstin Aschenbroich
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany.,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany
| | | | - Ernst Eypasch
- Heilig Geist-Hospital Cologne-Longerich, Cologne, Germany
| | | | - Kai Severin
- MV-Zentrum für Hämatologie und Onkologie, Cologne, Germany
| | - Jutta Benz
- St. Elisabeth-Hospital Cologne-Hohenlind, Cologne, Germany
| | - Enwu Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Freerk T Baumann
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Cologne, Germany. .,Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital of Cologne, Cologne, Germany.
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34
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Machado P, Pimenta S, Oliveiros B, Ferreira JP, Martins RA, Cruz J. Effect of Exercise Training on Quality of Life after Colorectal and Lung Cancer Surgery: A Meta-Analysis. Cancers (Basel) 2021; 13:4975. [PMID: 34638459 PMCID: PMC8508091 DOI: 10.3390/cancers13194975] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 01/01/2023] Open
Abstract
Surgical treatment affects health-related quality of life (HRQoL) and increases fatigue symptoms in patients with lung cancer (LC) and colorectal cancer (CRC). We aimed to systematically review the effect of exercise training on HRQoL and fatigue after LC and CRC surgery. Randomized controlled trials published before 21 March 2021, were searched in PubMed, Scopus, Web of Science, SPORTDiscus and PEDro. Eligible trials compared the effect of exercise interventions initiated preoperatively or in the first 3 months after surgery versus usual care on postoperative HRQoL and fatigue. Standardized mean differences (SMD) were pooled using random-effects models. Twelve studies with a total of 777 patients were included. In LC patients (10 studies, n = 651), exercise training in general led to a moderate improvement in the physical domain of HRQoL (0.68: 95% CI: [0.47; 0.89]) and a small reduction in fatigue levels after surgery (SMD = 0.28: 95% CI: [0.02; 0.53]), while no effects were found in other HRQoL domains. In CRC (two studies, n = 126), exercise training showed no effects on HRQoL and fatigue after surgery. Exercise training is an effective intervention to improve physical function and fatigue after LC surgery. Further studies are necessary to clarify the effects of exercise on HRQoL and fatigue after CRC surgery.
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Affiliation(s)
- Pedro Machado
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Sara Pimenta
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
| | - Bárbara Oliveiros
- Laboratory of Biostatistics and Medical Informatics (LBIM), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal;
- Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3000-548 Coimbra, Portugal
- Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, 3000-548 Coimbra, Portugal
| | - José Pedro Ferreira
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Raul A. Martins
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
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35
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Argillander TE, Heil TC, Melis RJF, van Duijvendijk P, Klaase JM, van Munster BC. Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery: A systematic review. Eur J Surg Oncol 2021; 48:570-581. [PMID: 34629224 DOI: 10.1016/j.ejso.2021.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/02/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- T E Argillander
- Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, the Netherlands; University Center for Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - T C Heil
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R J F Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - J M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B C van Munster
- University Center for Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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36
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SupPoRtive Exercise Programmes for Accelerating REcovery after major ABdominal Cancer surgery trial (PREPARE-ABC): Study protocol for a multicentre randomized controlled trial. Colorectal Dis 2021; 23:2750-2760. [PMID: 34245094 DOI: 10.1111/codi.15805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Exercise programmes can increase cardiopulmonary reserve and functional capacity prior to surgery and can improve clinical, functional and survival outcomes after a colorectal cancer diagnosis. However, the impact of pre- and postoperative exercise on postoperative recovery outcomes and longer-term health-related quality of life are unknown; thus, there is a need for high-quality randomized controlled trials. METHOD SupPoRtive Exercise Programmes for Accelerating REcovery after major Abdominal Cancer surgery (PREPARE-ABC) is a three-arm multicentre randomized controlled trial with internal pilot. The primary objective is to assess the effects of pre- and postoperative exercise on surgical outcomes and longer-term health-related quality of life in cancer patients undergoing colorectal resection. The aim of PREPARE-ABC is to randomize 1146 patients at the individual level (1:1:1) to hospital-supervised exercise, home-supported exercise or treatment as usual. The primary outcomes are short-term (30-day) morbidity, assessed using the Clavien-Dindo classification, and longer-term health-related quality of life, assessed using the Medical Outcomes Study Health Questionnaire (36-item Short-Form Survey [SF-36]). Secondary outcomes include cardiopulmonary fitness, physical activity behaviour change, psychological health status and cost-effectiveness. A process evaluation of intervention delivery and usual care also will be undertaken. DISCUSSION This is the first UK-based definitive randomized controlled trial to investigate the effects of pre- and postoperative exercise on short-term postoperative health outcomes and longer-term health-related quality of life in colorectal cancer patients. The trial will yield robust clinical and cost-effectiveness data to underpin clinical guidance on how exercise programmes should be implemented in the routine management of patients undergoing major colorectal cancer surgery.
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37
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West M, Bates A, Grimmett C, Allen C, Green R, Hawkins L, Moyses H, Leggett S, Z H Levett D, Rickard S, Varkonyi-Sepp J, Williams F, Wootton S, Hayes M, P W Grocott M, Jack S. The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra-cavity cancer surgery. F1000Res 2021; 10:952. [PMID: 36247802 PMCID: PMC9490280 DOI: 10.12688/f1000research.55324.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 07/21/2023] Open
Abstract
Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post-operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic , 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018).
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Affiliation(s)
- Malcolm West
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Andrew Bates
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Chloe Grimmett
- School of Health Sciences, University of Southampton, Southampton, SO22 1BJ, UK
| | - Cait Allen
- Wessex Cancer Trust, Registered charity 1110216, Chandlers Ford, SO53 2GG, UK
| | - Richard Green
- Anaesthetic Department (Royal Bournemouth Site), University Hospitals Dorset, Bournmouth, BH77DW, UK
| | - Lesley Hawkins
- Critical Care/Anaesthesia and Perioperative Medicine Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Helen Moyses
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Samantha Leggett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Denny Z H Levett
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sally Rickard
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Judit Varkonyi-Sepp
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fran Williams
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Stephen Wootton
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Matthew Hayes
- Wessex Cancer Alliance, Oakley Road, Southampton, SO16 4GX, UK
| | - Micheal P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - Sandy Jack
- School of Clinical and Experimental Science, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
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Franssen RFW, Janssen-Heijnen MLG, Barberan-Garcia A, Vogelaar FJ, Van Meeteren NLU, Bongers BC. Moderate-intensity exercise training or high-intensity interval training to improve aerobic fitness during exercise prehabilitation in patients planned for elective abdominal cancer surgery? Eur J Surg Oncol 2021; 48:3-13. [PMID: 34600787 DOI: 10.1016/j.ejso.2021.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/27/2021] [Accepted: 08/22/2021] [Indexed: 01/01/2023] Open
Abstract
Low preoperative aerobic fitness is associated with an increased risk of postoperative complications and delayed recovery in patients with abdominal cancer. Surgical prehabilitation aims to increase aerobic fitness preoperatively to improve patient- and treatment-related outcomes. However, an optimal physical exercise training program that is effective within the short time period available for prehabilitation (<6 weeks) has not yet been established. In this comparative review, studies (n = 8) evaluating the effect of short-term (<6 weeks) moderate-intensity exercise training (MIET) or high-intensity interval training (HIIT) on objectively measured aerobic fitness were summarized. The content of exercise interventions was critically appraised regarding the frequency, intensity, time, type, volume, and - monitoring of - progression (FITT-VP) principles. Three out of four studies evaluating HIIT showed statistically significant improvements in oxygen uptake at peak exercise (VO2peak) by more than 4.9%, the coefficient of variation for VO2peak. None of the two studies investigating short-term MIET showed statistically significant pre-post changes in VO2peak. Although short-term HIIT seems to be a promising intervention, concise description of performed exercise based on the FITT-VP principles was rather inconsistent in studies. Hence, interpretation of the results is challenging, and a translation into practical recommendations is premature. More emphasis should be given to individual responses to physical exercise training. Therefore, adequate risk assessment, personalized physical exercise training prescription using the FITT-VP principles, full reporting of physical exercise training adherence, and objective monitoring of training progression and recovery is needed to ensure for a personalized and effective physical exercise training program within a multimodal prehabilitation program.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo, the Netherlands; Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, the Netherlands
| | - Anael Barberan-Garcia
- Respiratory Medicine Department, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Spain
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - Nico L U Van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands; Top Sector Life Sciences and Health (Health∼Holland), The Hague, the Netherlands
| | - Bart C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Physical Fitness and Skeletal Muscle Mass During Neoadjuvant Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer: An Observational Study. REHABILITATION ONCOLOGY 2021. [DOI: 10.1097/01.reo.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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West MA, Anastasiou Z, Ambler G, Loughney L, Mythen MG, Owen T, Danjoux G, Levett DZ, Calverley PM, Kelly JJ, Jack S, Grocott MP. The effects of cancer therapies on physical fitness before oesophagogastric cancer surgery: a prospective, blinded, multi-centre, observational, cohort study. NIHR OPEN RESEARCH 2021; 1:1. [PMID: 35106479 PMCID: PMC7612293 DOI: 10.3310/nihropenres.13217.1] [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] [Accepted: 05/31/2021] [Indexed: 12/05/2022]
Abstract
Background Neoadjuvant cancer treatment is associated with improved survival following major oesophagogastric cancer surgery. The impact of neoadjuvant chemo/chemoradiotherapy on physical fitness and operative outcomes is however unclear. This study aims to investigate the impact of neoadjuvant chemo/chemoradiotherapy on fitness and post-operative mortality. Methods Patients with oesophagogastric cancer scheduled for chemo/chemoradiotherapy and surgery were recruited to a prospective, blinded, multi-centre, observational cohort study. Primary outcomes were changes in fitness with chemo/chemoradiotherapy, measured using cardiopulmonary exercise testing and its association with mortality one-year after surgery. Patients were followed up for re-admission at 30-days, in-hospital morbidity and quality of life (exploratory outcomes). Results In total, 384 patients were screened, 217 met the inclusion criteria, 160 consented and 159 were included (72% male, mean age 65 years). A total of 132 patients (83%) underwent chemo/chemoradiotherapy, 109 (71%) underwent chemo/chemoradiotherapy and two exercise tests, 100 (63%) completed surgery and follow-up. A significant decline in oxygen uptake at anaerobic threshold and oxygen uptake peak was observed following chemo/chemoradiotherapy: -1.25ml.kg -1.min -1 (-1.80 to -0.69) and -3.02ml.kg -1.min -1 (-3.85 to -2.20); p<0.0001). Baseline chemo/chemoradiotherapy anaerobic threshold and peak were associated with one-year mortality (HR=0.72, 95%CI 0.59 to 0.88; p=0.001 and HR=0.85, 0.76 to 0.95; p=0.005). The change in physical fitness was not associated with one-year mortality. Conclusions Chemo/chemoradiotherapy prior to oesophagogastric cancer surgery reduced physical fitness. Lower baseline fitness was associated with reduced overall survival at one-year. Careful consideration of fitness prior to chemo/chemoradiotherapy and surgery is urgently needed.
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Affiliation(s)
- Malcolm A. West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Zachos Anastasiou
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
| | - Lisa Loughney
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Michael G. Mythen
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, W1T 7HA, UK
| | - Thomas Owen
- Department of Critical Care and Anaesthesia, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, PR7 1PP, UK
| | - Gerard Danjoux
- Department of Critical Care and Anaesthesia, The James Cook University Hospital, Middlesborough, TS4 3BW, UK
| | - Denny Z.H. Levett
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Peter M.A. Calverley
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Liverpool, L9 7AL, UK
| | - Jamie J. Kelly
- Department of Upper Gastro-intestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Sandy Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Michael P.W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Fit4Surgery Consortium
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
- Acute Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
- Department of Statistical Science, University College London, London, W1T 7PJ, UK
- Centre for Anaesthesia, Institute of Sport Exercise and Health, University College London Hospitals NIHR Biomedical Research Centre, London, W1T 7HA, UK
- Department of Critical Care and Anaesthesia, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, PR7 1PP, UK
- Department of Critical Care and Anaesthesia, The James Cook University Hospital, Middlesborough, TS4 3BW, UK
- Department of Respiratory Research, University of Liverpool, University Hospitals Aintree, Liverpool, L9 7AL, UK
- Department of Upper Gastro-intestinal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
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Smyth E, O'Connor L, Mockler D, Reynolds JV, Hussey J, Guinan E. Preoperative high intensity interval training for oncological resections: A systematic review and meta-analysis. Surg Oncol 2021; 38:101620. [PMID: 34161894 DOI: 10.1016/j.suronc.2021.101620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/13/2021] [Accepted: 06/06/2021] [Indexed: 12/25/2022]
Abstract
Exercise prehabilitation prior to major surgery targets a reduction in postoperative complications through improved conditioning and respiratory function. However its effectiveness in cancer surgery is unclear. The objective of this review was to determine if preoperative high-intensity interval training (HIIT) improves preoperative fitness in patients scheduled for oncologic resection, and whether postoperative complications are impacted. METHODS: CINAHL, AMED, PEDro, EMBASE, The Cochrane Library and PubMed/MEDLINE were searched until April 2021 using predefined search strategy and accompanied by manual forward and backwards citation review. Screening of titles, abstracts, full-texts, data extraction, risk of bias assessment and methodologic quality was performed independently by two reviewers. Mean difference (MD) with 95% confidence intervals (CI) was compared and heterogeneity assessed using Chi Squared Test and I2 statistic. Six randomised controlled trials (RCTs) were included in the systematic review. Interventions prescribed bouts of high-intensity exercise [80-115% peak work rate (WRp)] interspaced with low-intensity (rest-50% WRp) exercise. The meta-analysis included five RCTs reporting peak oxygen consumption (VO2peak). Preoperative HIIT did not result in significantly higher VO2peak in comparison to usual care or moderate intensity exercise (MD 0.83, 95%CI-0.51-2.17) kg/ml/min, p = 0.12). Studies were insufficiently powered with respect to postoperative complications, but there is no evidence of significant impact. No adverse events occurred and high adherence rates were reported. Results of this systematic review and meta-analysis demonstrate there is insufficient evidence to support HIIT as a method of improving preoperative fitness prior to oncologic resection. Further work is needed to determine if specific HIIT parameters can be adapted to improve efficacy over short time-frames.
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Affiliation(s)
- Emily Smyth
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Louise O'Connor
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - David Mockler
- John Stearne Medical Library, Trinity College Dublin, Trinity Centre for Health Sciences, Dublin, Ireland
| | - John V Reynolds
- Trinity Translational Medicine Institute, Department of Surgery, Trinity College Dublin and St. James's Hospital, Dublin 8, Ireland
| | - Juliette Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Emer Guinan
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Associations between pretreatment physical performance tests and treatment complications in patients with non-small cell lung cancer: A systematic review. Crit Rev Oncol Hematol 2021; 158:103207. [PMID: 33383208 DOI: 10.1016/j.critrevonc.2020.103207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 12/25/2022] Open
Abstract
This systematic review evaluated which outcome variables and cut-off values of pretreatment exercise tests are associated with treatment complications in patients with stage I-III non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. A total of 38 studies with adult patients undergoing treatment for stage I-III NSCLC who completed pretreatment exercise tests, and of whom treatment-related complications were recorded were included. A lower oxygen uptake at peak exercise amongst several other variables on the cardiopulmonary exercise test and a lower performance on field tests, such as the incremental shuttle walk test, stair-climb test, and 6-minute walk test, were associated with a higher risk for postoperative complications and/or postoperative mortality. Cut-off values were reported in a limited number of studies and were inconsistent. Due to the variety in outcomes, further research is needed to evaluate which outcomes and cut-off values of physical exercise tests are most clinically relevant.
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Bar S, Boivin P, El Amine Y, Descamps R, Moussa M, Abou Arab O, Fischer MO, Dupont H, Lorne E, Guinot PG. Individualized hemodynamic optimization guided by indirect measurement of the respiratory exchange ratio in major surgery: study protocol for a randomized controlled trial (the OPHIQUE study). Trials 2020; 21:958. [PMID: 33228773 PMCID: PMC7682128 DOI: 10.1186/s13063-020-04879-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Observational studies have suggested that a high respiratory exchange ratio (RER) is associated with the occurrence of postoperative complications. The study's primary objective is to demonstrate that the incidence of postoperative complications is lower in an interventional group (patients monitored using a hemodynamic algorithm that incorporates the RER) than in a control group (treated according to standard practice). METHODS We shall perform a prospective, multicenter, randomized, open-label, superiority trial of consecutive patients undergoing major noncardiac surgery (i.e., abdominal, vascular, and orthopedic surgery). The control group will be treated according to the current guidelines on standard hemodynamic care. The interventional group will be treated according to an algorithm based on the RER. The primary outcome will be the occurrence of at least one complication in the 7 days following surgery. The secondary outcomes will be the length of hospital stay, the total number of complications per patient, the 30-day mortality, the total intraoperative volume of fluids administered, and the Sequential [sepsis-related] Organ Failure Assessment (SOFA) score and laboratory data measured on postoperative days 1, 2, and 7. A total of 350 patients will be included. DISCUSSION In the operating theater, the RER is potentially a continuously available, easy-to-read, indirect marker of tissue hypoperfusion and postoperative complications. If the RER does predict the occurrence of tissue hypoperfusion, it will help the physician to provide personalized hemodynamic management and limit the side effects associated with excessive hemodynamic optimization (volume overload, vasoconstriction, etc.). TRIAL REGISTRATION ClinicalTrials.gov NCT03852147 . Registered on February 25, 2019.
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Affiliation(s)
- Stéphane Bar
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Rond-point du Professeur Christian Cabrol, F-80000, Amiens, France.
| | - Pierre Boivin
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Rond-point du Professeur Christian Cabrol, F-80000, Amiens, France
| | - Younes El Amine
- Anesthesiology and Critical Care Department, Valenciennes General Medical Center, Avenue Désandrouins, F-59322, Valenciennes, France
| | - Richard Descamps
- Anesthesiology and Critical Care Department, Normandie University Medical Center, UNICAEN, F-14000, Caen, France
| | - Mouhamed Moussa
- Anesthesiology and Critical Care Department, Lille University Medical Center, Oscar Lambret, F-59037, Lille, France
| | - Osama Abou Arab
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Rond-point du Professeur Christian Cabrol, F-80000, Amiens, France
| | - Marc-Olivier Fischer
- Anesthesiology and Critical Care Department, Normandie University Medical Center, UNICAEN, F-14000, Caen, France
| | - Hervé Dupont
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Rond-point du Professeur Christian Cabrol, F-80000, Amiens, France
| | - Emmanuel Lorne
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Rond-point du Professeur Christian Cabrol, F-80000, Amiens, France
| | - Pierre-Grégoire Guinot
- Anesthesiology and Critical Care Department, Dijon University Medical Center, 2 Bd Maréchal de Lattre de Tassigny, F-21000, Dijon, France
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Knight KA, Fei CH, Boland KF, Dolan DR, Golder AM, McMillan DC, Horgan PG, Black DH, Park JH, Roxburgh CSD. Aortic calcification is associated with non-infective rather than infective postoperative complications following colorectal cancer resection: an observational cohort study. Eur Radiol 2020; 31:4319-4329. [PMID: 33201280 DOI: 10.1007/s00330-020-07189-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/29/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Complications following colorectal cancer resection are common. The degree of aortic calcification (AC) on CT has been proposed as a predictor of complications, particularly anastomotic leak. This study assessed the relationship between AC and complications in patients undergoing colorectal cancer resection. METHODS Patients from 2008 to 2016 were retrospectively identified from a prospectively maintained database. Complications were classified using the Clavien-Dindo (CD) scale. Calcification was quantified on preoperative CT by visual assessment of the number of calcified quadrants in the proximal and distal aorta. Scores were grouped into categories: none, minor (< median AC score) and major (> median AC score). The relationship between clinicopathological characteristics and complications was assessed using logistic regression. RESULTS Of 657 patients, 52% had proximal AC (> median score (1)) and 75% had distal AC (> median score (4)). AC was more common in older patients and smokers. Higher burden of AC was associated with non-infective complications (proximal AC 28% vs 16%, p = 0.004, distal AC 26% vs 14% p = 0.001) but not infective complications (proximal AC 28% vs 29%, p = 0.821, distal AC 29% vs 23%, p = 0.240) or anastomotic leak (proximal AC 6% vs 4%, p = 0.334, distal AC 7% vs 3%, p = 0.077). Independent predictors of complications included open surgery (OR 1.99, 95%CI 1.43-2.79, p = 0.001), rectal resection (OR 1.51, 95%CI 1.07-2.12, p = 0.018) and smoking (OR 2.56, 95%CI 1.42-4.64, p = 0.002). CONCLUSIONS These data suggest that high levels of AC are associated with non-infective complications after colorectal cancer surgery and not anastomotic leak. KEY POINTS • Aortic calcification measured by visual quantification of the number of calcified quadrants at two aortic levels on preoperative CT is associated with clinical outcome following colorectal cancer surgery. • An increased burden of aortic calcification was associated with non-infective complications but not anastomotic leak. • Assessment of the degree of aortic calcification may help identify patients at risk of cardiorespiratory complications, improve preoperative risk stratification and assign preoperative strategies to improve fitness for surgery.
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Affiliation(s)
- Katrina A Knight
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK.
| | - Chui Hon Fei
- School of Medicine, Wolfson Medical School Building, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Kate F Boland
- School of Medicine, Wolfson Medical School Building, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Daniel R Dolan
- School of Medicine, Wolfson Medical School Building, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Allan M Golder
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
| | - Donald C McMillan
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
| | - Paul G Horgan
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
| | - Douglas H Black
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
| | - James H Park
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
| | - Campbell S D Roxburgh
- Academic Unit of Colorectal Surgery, University of Glasgow, Level 2, New Lister Building, Glasgow Royal Infirmary, 10 - 16 Alexandra Parade, Glasgow, G31 2ER, UK
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Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, Brown SR, Wyld L. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open 2020; 4:1022-1041. [PMID: 32959532 PMCID: PMC7709363 DOI: 10.1002/bjs5.50347] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Prehabilitation has emerged as a strategy to prepare patients for elective abdominal cancer surgery with documented improvements in postoperative outcomes. The aim of this study was to assess the evidence for prehabilitation interventions of relevance to the older adult. METHODS Systematic searches were conducted using MEDLINE, Web of Science, Scopus, CINAHL and PsychINFO. Studies of preoperative intervention (prehabilitation) in patients undergoing abdominal cancer surgery reporting postoperative outcomes were included. Age limits were not set as preliminary searches revealed this would be too restrictive. Articles were screened and selected based on PRISMA guidelines, and assessment of bias was performed. Qualitative, quantitative and meta-analyses of data were conducted as appropriate. RESULTS Thirty-three studies (3962 patients) were included. Interventions included exercise, nutrition, psychological input, comprehensive geriatric assessment and optimization, smoking cessation and multimodal (two or more interventions). Nine studies purposely selected high-risk, frail or older patients. Thirty studies were at moderate or high risk of bias. Ten studies individually reported benefits in complication rates, with meta-analyses for overall complications demonstrating significant benefit: multimodal (risk difference -0·1 (95 per cent c.i. -0·18 to -0·02); P = 0·01, I2 = 18 per cent) and nutrition (risk difference -0·18 (-0·26 to -0·10); P < 0·001, I2 = 0 per cent). Seven studies reported reductions in length of hospital stay, with no differences on meta-analysis. CONCLUSION The conclusions of this review are limited by the quality of the included studies, and the heterogeneity of interventions and outcome measures reported. Exercise, nutritional and multimodal prehabilitation may reduce morbidity after abdominal surgery, but data specific to older patients are sparse.
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Affiliation(s)
- S. L. Daniels
- Academic Directorate of General SurgerySheffieldUK
- Department of Oncology and Metabolism, University of SheffieldSheffieldUK
| | - M. J. Lee
- Academic Directorate of General SurgerySheffieldUK
- Department of Oncology and Metabolism, University of SheffieldSheffieldUK
| | - J. George
- Academic Directorate of General SurgerySheffieldUK
- Department of Oncology and Metabolism, University of SheffieldSheffieldUK
| | - K. Kerr
- Directorate of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - S. Moug
- Department of Surgery, Royal Alexandra HospitalPaisleyUK
| | - T. R. Wilson
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDoncasterUK
| | - S. R. Brown
- Academic Directorate of General SurgerySheffieldUK
- Clinical Research Academy, School of Health and Related Research, University of SheffieldSheffieldUK
| | - L. Wyld
- Department of Oncology and Metabolism, University of SheffieldSheffieldUK
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDoncasterUK
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Cardiopulmonary exercise testing and cardiopulmonary morbidity in patients undergoing major head and neck surgery. Br J Oral Maxillofac Surg 2020; 59:297-302. [PMID: 33589309 DOI: 10.1016/j.bjoms.2020.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/10/2020] [Indexed: 11/21/2022]
Abstract
Cardiopulmonary exercise testing (CPET) is used as a risk stratification tool for patients undergoing major surgery. In this study, we investigated the role of CPET in predicting day five cardiopulmonary morbidity in patients undergoing head and neck surgery. This observational cohort study included 230 adults. We recorded preoperative CPET variables and day five postoperative cardiopulmonary morbidity. Full data from 187 patients were analysed; 43 patients either had incomplete data sets or declined surgery/CPET. One hundred and nineteen patients (63.6%) developed cardiopulmonary morbidity at day five. Increased preoperative heart rate and duration of surgery were independently associated with day five cardiopulmonary morbidity. Those with such morbidity also had lower peak V̇O2 11.4 (IQR 8.4-18.0) vs 16.0 (IQR 14.0-19.7) ml.kg-1.min-1, P<0.0001 and V̇O2 at AT 10.6 (IQR 9.1-13.1) vs 11.5 (IQR 10.5-13.0) ml.kg-1.min-1, p=0.03. Logistic regression model containing peak V̇O2 and duration of surgery demonstrated that increased peak V̇O2 was associated with a reduction in the likelihood of cardiopulmonary complications OR 0.92 (95%CI 0.87 to 0.96), p=0.001. The area under the receiver operating characteristic curve for this model was 0.75(95%CI 0.68 to 0.82), p<0.0001, 64% sensitivity, 81% specificity. CPET can help to predict day five cardiopulmonary morbidity in the patients undergoing head and neck surgery. A model containing peak V̇O2 allowed identification of those with such complications.
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A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study. Br J Anaesth 2020; 126:181-190. [PMID: 32690247 DOI: 10.1016/j.bja.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/13/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. METHODS In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg-1 min-1 and peak oxygen consumption (VO2 peak) >16 ml kg-1 min-1, cut-points that represent a reduced risk of postoperative complications. RESULTS Five questions were identified to have dominance in predicting AT>11 ml kg-1 min-1 and VO2 peak>16 ml.kg-1min-1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg-1.min-1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO2 peak>16 ml.kg-1.min-1 and VO2 peak<16 ml.kg-1.min-1. CONCLUSIONS The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management.
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Scott JM, Stene G, Edvardsen E, Jones LW. Performance Status in Cancer: Not Broken, But Time for an Upgrade? J Clin Oncol 2020; 38:2824-2829. [PMID: 32584631 DOI: 10.1200/jco.20.00721] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jessica M Scott
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | - Guro Stene
- Norwegian University of Science and Technology, Trondheim, Norway.,Trondheim University Hospital, Cancer Clinic, Trondheim, Norway
| | | | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
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Thomas G, West MA, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW, Levett DZH. Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing. Perioper Med (Lond) 2020; 9:18. [PMID: 32518637 PMCID: PMC7271469 DOI: 10.1186/s13741-020-00148-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET. Aim We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice. Methods We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET. Results Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male. Conclusion To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.
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Affiliation(s)
- G Thomas
- Department of Intensive Care, Spaarne Hospital, Haarlem, The Netherlands
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone, Kent, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, 9th Floor Terence Lewis Building, Plymouth, UK.,Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- STRAPH Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, East Ayrshire, Scotland, UK
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - M P W Grocott
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - D Z H Levett
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
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Association of a Preoperative Leisure-Time Physical Activity With Short- and Long-term Outcomes of Patients Undergoing Curative Resection for Stage I to III Colorectal Cancer: A Propensity Score Matching Analysis. Dis Colon Rectum 2020; 63:796-806. [PMID: 32118625 DOI: 10.1097/dcr.0000000000001651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Physical activity might be directly or indirectly linked to the risk of colorectal cancer and the prognosis of patients with colorectal cancer. OBJECTIVE This study aimed to elucidate whether preoperative physical activity plays a role in reducing short-term postoperative complications and improving long-term survival of patients with colorectal cancer. DESIGN This was a retrospective analysis of prospectively collected data. SETTINGS This study was conducted at a department of colorectal surgery in a tertiary teaching hospital between January 1995 and December 2016. PATIENTS Patients who underwent curative resection for stage I to III primary colorectal cancer were enrolled. According to the preoperative leisure-time weekly metabolic equivalent of task values, patients were divided into 2 groups: the metabolic equivalent of task <12 group and the metabolic equivalent of task ≥12 group. A 1:1 propensity score matching was used to reduce imbalance and selection biases based on 6 covariates, namely, age, sex, BMI, tumor location, tumor stage, and adjuvant chemotherapy administration. MAIN OUTCOME MEASURES χ tests were used to analyze short-term postoperative complications. Kaplan-Meier analyses were used to evaluate disease-free survival and overall survival. RESULTS In the matched cohort patients, significant differences in overall postoperative complications and mortality were observed in favor of the metabolic equivalent of task ≥12 group, although there was no difference in any single item of postoperative morbidity. The results of the Kaplan-Meier analysis and log-rank test demonstrated a significant survival benefit in the metabolic equivalent of task ≥12 group compared with the metabolic equivalent of task <12 group both for disease-free and overall survival. LIMITATIONS This study is limited by its retrospective nature. CONCLUSIONS This single-institute study provides evidence of the association of preoperative leisure-time physical activity with short-term postoperative morbidity and mortality, as well as long-term survival. See Video Abstract at http://links.lww.com/DCR/B189. ASOCIACIÓN DE ACTIVIDAD FÍSICA DE TIEMPO LIBRE PREOPERATORIA CON RESULTADOS A CORTO Y LARGO PLAZO DE PACIENTES SOMETIDOS A RESECCIÓN CURATIVA POR CÁNCER COLORRECTAL EN ESTADIO I-III: UN ANÁLISIS DE COINCIDENCIA DE PUNTAJE DE PROPENSIÓN ANTECEDENTES: LA ACTIVIDAD FíSICA PUEDE ESTAR DIRECTA O INDIRECTAMENTE RELACIONADA CON EL RIESGO DE CÁNCER COLORRECTAL Y EL PRONÓSTICO DE LOS PACIENTES CON CÁNCER COLORRECTAL.: Este estudio tuvo como objetivo dilucidar si la actividad física preoperatoria desempeña un papel en la reducción de las complicaciones postoperatorias a corto plazo y en mejorar la supervivencia a largo plazo de los pacientes con cáncer colorrectal.Este fue un análisis retrospectivo de datos recolectados prospectivamente.Este estudio se realizó en un departamento de cirugía colorrectal en un hospital universitario terciario entre Enero de 1995 y Diciembre de 2016.Se incluyeron pacientes sometidos a resección curativa por cáncer colorrectal primario en estadio I-III. De acuerdo con el equivalente metabólico semanal en el tiempo libre de los valores de la tarea preoperatorio, los pacientes se dividieron en dos grupos: el equivalente metabólico del grupo de tarea <12 y el equivalente metabólico del grupo de tarea ≥ 12. Se utilizó una coincidencia de puntaje de propensión 1: 1 para reducir los desequilibrios y los sesgos de selección basados en seis covariables, principalmente, edad, sexo, índice de masa corporal, ubicación del tumor, estadio del tumor y administración de quimioterapia adyuvante.Las pruebas de Chi-cuadrado se utilizaron para analizar las complicaciones postoperatorias a corto plazo. Los análisis de Kaplan-Meier se utilizaron para evaluar la supervivencia libre de enfermedad y la supervivencia general.en los pacientes de la cohorte emparejada, se observaron diferencias significativas en las complicaciones postoperatorias generales y la mortalidad a favor del equivalente metabólico del grupo de tareas ≥ 12, aunque no hubo diferencias en ningún elemento único de morbilidad postoperatoria. Los resultados del análisis de Kaplan-Meier y la prueba de log-rank demostraron un beneficio de supervivencia significativo en el equivalente metabólico del grupo tarea ≥ 12 en comparación con el equivalente metabólico del grupo tarea <12 tanto para la supervivencia libre de enfermedad como para la supervivencia general.Este estudio está limitado por su naturaleza retrospectiva.Este estudio de instituto único proporciona evidencia de la asociación de la actividad física preoperatoria en el tiempo libre con la morbilidad y mortalidad postoperatorias a corto plazo, así como la supervivencia a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B189. (Traducción-Dr. Yesenia Rojas-Kahlil).
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