Postoperative changes in fatigue, physical function and body composition: an analysis of the amalgamated data from five randomized trials on patients undergoing colorectal surgery

The association analysis between fatigue and body composition loss in patients with nasopharyngeal carcinoma during radiotherapy: An observational longitudinal study

PURPOSE

This study aimed to reveal the association of fatigue with weekly changes in the body composition in patients with nasopharyngeal carcinoma (NPC) and identified the independent strength.

METHODS

Four body composition indexes and fatigue were assessed before treatment (T0, baseline) and once a week throughout radiotherapy (T1-T7). Generalized additive mixed models (GAMMs) were used to explore the trajectories and longitudinal relationships of fatigue and weekly changes in body composition. The marginal structural model (MSM) was used to control the effect of depression and anxiety.

RESULTS

The trajectories of fatigue in 105 participants reached a peak in the fifth week, and changes in body composition started appearing from the second week. Four body composition indexes, weight, body mass index (BMI), body fat rate, and lean body weight loss weekly were positively associated with fatigue. High magnitude of effects was revealed when anxiety and depression were controlled as time-dependent confounders. The positive associations with fatigue were manifested in patients aged >53 years, those with senior high and above education, no drinking, >5000 Y/month of family inflow, ≥ stage III, or those receiving a dose of ≥70 Gy, ≥3 cycles of induced chemotherapy, and ≤1 cycle of concurrent chemotherapy.

CONCLUSIONS

Loss of weight, BMI, body fat rate, and lean body weight could be used to independently evaluate the development of fatigue in patients with NPC during radiotherapy. Positive associations between fatigue and weekly body composition loss were found in patients with certain characteristics.

A Novel Use for Pelvic MRI Scans to Estimate Lean Body Mass and Screen for Sarcopenia in Patients With Rectal Cancer

BACKGROUND

Sarcopenia, the combination of low lean body mass and decreased muscle strength, is associated with significant morbidity and mortality among patients with colorectal cancer. Standard methods for assessing lean body mass and muscle strength, such as bioelectric impedance analysis and handgrip dynamometry, are rarely obtained clinically. Per National Cancer Center Network recommendations, pelvic MRI is routinely collected for staging and surveillance among patients with rectal cancer. However, there are no data assessing the relationship of pelvic MRI lean body mass measurements at the fifth lumbar vertebrae with bioelectric impedance analysis, handgrip strength, or abdominal CT in patients with rectal cancer. Therefore, we aimed to assess whether pelvic MRI lean body mass correlates with a standard for lean body mass measurement (bioelectric impedance analysis), muscle function (handgrip strength), and an imaging modality frequently used in the literature to identify sarcopenia (abdominal CT at the third lumbar vertebrae).

IMPACT OF INNOVATION

Lean body mass measurements from routinely collected pelvic MRI at the fifth lumbar vertebrae accurately and reproducibly estimate lean body mass and modestly correlate with handgrip strength. Rectal cancer pelvic MRI may be repurposed for identifying sarcopenia without increasing inconvenience, ionizing radiation exposure, or expenditure to patients with rectal cancer.

TECHNOLOGY, MATERIALS, AND METHODS

Patients with locally advanced rectal cancer with pretreatment bioelectric impedance analysis and handgrip strength measurements within 3 months of their staging pelvic MRI were eligible. Axial skeletal muscle areas were segmented using T1-weighted series pelvic MRI at the fifth lumbar vertebrae and abdominal CT at the third lumbar vertebrae using Slice-O-Matic (Tomovision, Montreal, Canada). Lean body mass (kilograms) was derived from skeletal muscle area with standard equations. Handgrip strength (kilograms) was the maximum of 3 dominant hand attempts in the standing anatomical position. The primary outcome was the agreement between lean body mass measured by pelvic MRI (at the fifth lumbar vertebrae) and bioelectric impedance analysis. Secondary outcomes included the concordance of pelvic MRI lean body mass (at the fifth lumbar vertebrae) with abdominal CT (at the third lumbar vertebrae) and handgrip strength. Additionally, the intra- and interobserver validity, internal consistency, and the mean difference (bias) between lean body mass measurements by pelvic MRI and bioelectric impedance analysis were evaluated.

PRELIMINARY RESULTS

Sixteen patients were eligible. The average lean body mass was similar and consistent across 2 observers between bioelectric impedance analysis and pelvic MRI. There was a strong correlation between lean body mass measured on pelvic MRI, bioelectric impedance analysis, and abdominal CT. The reliability of 2 pelvic MRI lean body mass measurements (2 weeks apart by blinded observers) and the correlation of lean body mass between pelvic MRI and bioelectric impedance analysis was strong. Inter- and intraobserver correlation, reliability, and internal consistency were strong for the entire cohort. There was a moderate correlation between pelvic MRI lean body mass and handgrip strength.

CONCLUSIONS

Lean body mass measured at the fifth lumbar vertebrae on pelvic MRI is reproducible and correlates strongly with measurements from bioelectric impedance analysis (standard) and abdominal CT at the third lumbar vertebrae and modestly with handgrip strength. These data suggest that MRI lean body mass measurements may be a method to screen patients with rectal cancer for sarcopenia.

FUTURE DIRECTIONS

Future studies may evaluate changes in lean body mass on serial pelvic MRI studies among patients with rectal cancer.

Association of health literacy with short-term postoperative outcomes in older adult patients with abdominal tumors undergoing surgery and perioperative rehabilitation program: A prospective cohort study

INTRODUCTION

Low health literacy (HL) is associated with poor surgical outcomes in patients with abdominal tumors, despite enhanced recovery programs. However, the relationship between HL and postoperative outcomes, including health-related quality of life (HRQOL) and physical functions, has been unclear in patients with abdominal tumors receiving perioperative rehabilitation programs (PRPs). Our objective was to identify associations of HL with postoperative functional and general outcomes in patients with abdominal tumors undergoing surgery and PRPs, controlling for critical covariates.

MATERIALS AND METHODS

The prospective cohort study was conducted from April 2020 to December 2021 in a single acute care hospital in Akita City, Japan. Out of 112 consecutive older adults with abdominal tumors referred to PRPs before surgery for tumors, 101 participated. Three patients declined undergoing follow-up assessment, and thus 97 were analyzed. Demographic data, comorbidities, education, surgical procedure, frailty status, cognitive functions, physical activity, nutritional status, tumor sites, types, and stages were collected as covariates at baseline. All participants underwent PRPs. HL was measured using the Japanese version of the European Health Literacy Survey Questionnaire, a comprehensive HL measurement. Primary endpoints were changes in HRQOL, measured using the EuroQol 5-dimension 5-level (EQ-5D-5L) index and EuroQol-visual analog scale (EQ-VAS), and physical functions (chair-stand ability, usual gait speed, and grip strength) from before surgery to discharge. Secondary endpoints were 90-day readmissions, postoperative complications, and length of hospital stay. Multivariate regression with inverse probability weighting, using propensity scores, estimeted associations of HL with the outcomes.

RESULTS

Of the 97 patients (36 [37.1%] women, mean [standard deviation] age 74.4 [6.3] years), 42 (43.3%) reported low HL. At baseline, patients with low HL exhibited worse EQ-5D-5L scores (P = .001), EQ-VAS values (P = .03), chair-stand ability (P = .001), and gait speed (P = .03) than controls. Low HL was associated with a low risk of grip strength declines (risk ratio, 0.13; 95% confidence interval, 0.12-0.99) but not with any other outcome.

DISCUSSION

There appeared to be no apparent associations of HL with surgical outcomes in patients with abdominal tumors receiving PRPs. Thus, HL might not be a crucial predictor of surgical outcomes when combined with PRPs.

Objective Activity Parameters Track Patient-specific Physical Recovery Trajectories After Surgery and Link With Individual Preoperative Immune States

OBJECTIVE

The longitudinal assessment of physical function with high temporal resolution at a scalable and objective level in patients recovering from surgery is highly desirable to understand the biological and clinical factors that drive the clinical outcome. However, physical recovery from surgery itself remains poorly defined and the utility of wearable technologies to study recovery after surgery has not been established.

BACKGROUND

Prolonged postoperative recovery is often associated with long-lasting impairment of physical, mental, and social functions. Although phenotypical and clinical patient characteristics account for some variation of individual recovery trajectories, biological differences likely play a major role. Specifically, patient-specific immune states have been linked to prolonged physical impairment after surgery. However, current methods of quantifying physical recovery lack patient specificity and objectivity.

METHODS

Here, a combined high-fidelity accelerometry and state-of-the-art deep immune profiling approach was studied in patients undergoing major joint replacement surgery. The aim was to determine whether objective physical parameters derived from accelerometry data can accurately track patient-specific physical recovery profiles (suggestive of a 'clock of postoperative recovery'), compare the performance of derived parameters with benchmark metrics including step count, and link individual recovery profiles with patients' preoperative immune state.

RESULTS

The results of our models indicate that patient-specific temporal patterns of physical function can be derived with a precision superior to benchmark metrics. Notably, 6 distinct domains of physical function and sleep are identified to represent the objective temporal patterns: ''activity capacity'' and ''moderate and overall activity (declined immediately after surgery); ''sleep disruption and sedentary activity (increased after surgery); ''overall sleep'', ''sleep onset'', and ''light activity'' (no clear changes were observed after surgery). These patterns can be linked to individual patients preopera-tive immune state using cross-validated canonical-correlation analysis. Importantly, the pSTAT3 signal activity in monocytic myeloid-derived suppressor cells predicted a slower recovery.

CONCLUSIONS

Accelerometry-based recovery trajectories are scalable and objective outcomes to study patient-specific factors that drive physical recovery.

'Fit for surgery': The relationship between cardiorespiratory fitness and postoperative outcomes

New Findings

What is the topic of this review?

The relationships and physiological mechanisms underlying the clinical benefits of cardiorespiratory fitness (CRF) in patients undergoing major intra‐abdominal surgery.

What advances does it highlight?

Elevated CRF reduces postoperative morbidity/mortality, thus highlighting the importance of CRF as an independent risk factor. The vascular protection afforded by exercise prehabilitation can further improve surgical risk stratification and postoperative outcomes.

Abstract

Surgery accounts for 7.7% of all deaths globally and the number of procedures is increasing annually. A patient's ‘fitness for surgery’ describes the ability to tolerate a physiological insult, fundamental to risk assessment and care planning. We have evolved as obligate aerobes that rely on oxygen (O₂). Systemic O₂ consumption can be measured via cardiopulmonary exercise testing (CPET) providing objective metrics of cardiorespiratory fitness (CRF). Impaired CRF is an independent risk factor for mortality and morbidity. The perioperative period is associated with increased O₂ demand, which if not met leads to O₂ deficit, the magnitude and duration of which dictates organ failure and ultimately death. CRF is by far the greatest modifiable risk factor, and optimal exercise interventions are currently under investigation in patient prehabilitation programmes. However, current practice demonstrates potential for up to 60% of patients, who undergo preoperative CPET, to have their fitness incorrectly stratified. To optimise this work we must improve the detection of CRF and reduce potential for interpretive error that may misinform risk classification and subsequent patient care, better quantify risk by expressing the power of CRF to predict mortality and morbidity compared to traditional cardiovascular risk factors, and improve patient interventions with the capacity to further enhance vascular adaptation. Thus, a better understanding of CRF, used to determine fitness for surgery, will enable both clinicians and exercise physiologists to further refine patient care and management to improve survival.

Changes in motor function and quality of life after surgery in patients with pancreatic cancer

OBJECTIVE

To determine the changes in motor function and health-related quality of life after pancreatectomy and identify factors influencing postoperative physical functioning in health-related quality of life.

METHODS

This single-centre, prospective, observational study measured 6-min walking distance, grip strength, knee extension strength and health-related quality of life variables in patients with pancreatic cancer, before and after surgery. Paired t- and Wilcoxon signed-rank tests were used to compare pre- and postoperative motor function and health-related quality-of-life variables. Factors associated with postoperative physical functioning scores of health-related quality of life were assessed using multiple regression analysis.

RESULTS

Fifty-nine individuals were enrolled. Motor function values decreased significantly postoperatively, including 6-min walking distance (mean ± standard deviation: 402.5 ± 95.4 vs. 497.7 ± 80.4 m, p < 0.001), knee extensor strength (0.42 ± 0.10 vs. 0.47 ± 0.10 kgf/kg, p < 0.001) and grip strength (22.0 ± 8.9 vs. 24.5 ± 9.2 kg, p = 0.001). Multiple regression analysis showed significant association between 6-min walking distance change and postoperative physical functioning scores of health-related quality of life (p = 0.036).

CONCLUSION

The results suggest that motor function decreases postoperatively, and a decrease in 6-min walking distance after surgery is associated with postoperative physical functioning in patients with pancreatic cancer.

Perioperative physical and nutritional therapy for tongue cancer-induced malnutrition and muscle atrophy: A case report

Malnutrition is a common complication in patients with tongue cancer who experience dysphagia and can steadily lead to skeletal muscle atrophy. Additionally, skeletal muscle loss commonly occurs in patients after invasive surgery. Therefore, patients with tongue cancer are at high risk of skeletal muscle atrophy during the perioperative phase of treatment. Over time, physical and nutritional therapy are expected to increase skeletal muscle mass and improve nutritional status. However, immediate benefits for patients in the perioperative phase of treatment are largely unknown. This case report aimed to evaluate the combined effects of physical and nutritional therapy for a patient in the perioperative phase of treatment for tongue cancer. We describe a 48-year-old woman diagnosed with tongue cancer. Her increasing difficulty with eating and swallowing led to malnutrition. After hospital admission for oral surgery, physical and nutritional therapy were initiated. Skeletal muscle mass measured by body composition analyzer and ultrasound apparatus showed increases, whereas blood tests to indicate nutritional status showed no improvement. This case suggests that physical and nutritional therapy are effective for increasing skeletal muscle during perioperative phase treatment in malnourished patients with tongue cancer and assessment of skeletal muscle mass is a reliable method for clinical evaluation.

Factors associated with fatigue one month after surgery in patients with gastrointestinal cancer

OBJECTIVE

The purpose of this study was to examine the factors associated with the occurrence of cancer-related fatigue (CRF) one month after surgery in patients with gastrointestinal cancer.

METHOD

The study included 96 patients with gastrointestinal cancer (50 males and 46 females, mean age 62.7 ± 11.4 years). Data of the Cancer Fatigue Scale (CFS), 6-minute walk distance (6MWD), and hospital anxiety and depression scale (HADS) were obtained before surgery and one month after surgery. The subjects were divided into the following two groups: severe CRF group (CFS score of ≥19 points) and mild CRF group (CFS score of <19 points). Each parameter was compared between the severe and mild CRF groups. The factors associated with CRF were identified by logistic regression analysis involving factors with significant differences between the groups.

RESULT

The CFS score showed a significant interaction, and the CFS score, 6MWD, and HADS score showed significant differences both before and one month after surgery between the two groups. The CFS score was significantly higher in the severe CRF group than in the mild CRF group both before and one month after surgery. Additionally, the 6MWD was significantly lower in the severe CRF group than in the mild CRF group both before and one month after surgery. The factors identified on logistic regression analysis were the preoperative CFS score and preoperative 6MWD.

CONCLUSION

CRF occurring one month after surgery might be affected by preoperative fatigue and preoperative exercise tolerance.

Skeletal muscle loss in the postoperative acute phase after esophageal cancer surgery as a new prognostic factor

Background

The postoperative survival rate of patients with esophageal squamous cell carcinoma (ESCC) remains poor compared with other gastrointestinal cancers. We hypothesized that skeletal muscle loss in the postoperative acute phase might be a new predictor for long-term prognosis after highly invasive surgery such as ESCC surgery.

Methods

The following items were retrospectively investigated. First, whether skeletal muscle loss occurred in the postoperative acute phase of ESCC was verified. Second, the preoperative and intraoperative factors involved in skeletal muscle loss in the postoperative acute phase of ESCC were investigated. Then, whether skeletal muscle loss in the postoperative acute phase affected long-term prognosis was examined. The medical records of consecutive patients who underwent radical esophagectomy for ESCC between January 2010 and February 2015 were retrospectively reviewed; 72 cases were eligible for this study. The total psoas major muscle mass index (TPI) at the level of the third lumbar vertebra (L3) was measured using computed tomography (CT) before surgery and 3 days after surgery. The long-term prognosis was estimated by the Kaplan-Meier method and the multivariate logistic regression model.

Results

There was already a significant reduction of TPI in the acute phase up to POD 3 after ESCC surgery in comparison with the preoperative baseline TPI (P < 0.001). The TPI reduction rate was significantly milder in cases with less blood loss during surgery and in cases that underwent thoracoscopic esophagectomy than in cases that underwent open esophagectomy. The 3-year overall survival rate was significantly different between the TPI reduction rate severe group and the TPI reduction rate mild group.

Conclusion

Skeletal muscle loss occurred even in the postoperative acute phase. Furthermore, it is very significant that skeletal muscle loss in the postoperative acute phase of ESCC surgery is involved in the long-term prognosis.

Impact of sequential implementation of multimodal perioperative care pathways on colorectal surgical outcomes

Background

Standardized care protocols offer the potential to reduce postoperative complication rates. The purpose of this study was to determine whether there was an additive benefit associated with the sequential implementation of the evidence-based surgical site infection bundle (SSIB) and enhanced recovery after surgery (ERAS) protocols for patients undergoing colorectal surgery in a community hospital.

Methods

Patients at a single institution who underwent elective colorectal surgery between Apr. 1, 2011, and Dec. 31, 2015, were identified by means of American College of Surgeons National Surgical Quality Improvement Program data. Patients were stratified into 3 groups according to the protocol implementation dates: pre-SSIB/pre-ERAS (control), post-SSIB/pre-ERAS and post-SSIB/post-ERAS. Primary outcomes assessed were length of stay and wound complication rates. We used inverse proportional weighting to control for possible differences between the groups.

Results

There were 368 patients included: 94 in the control group, 95 in the post-SSIB/pre-ERAS group and 179 in the post-SSIB/post-ERAS group. In the adjusted analyses, mean length of stay (control group 7.6 d, post-SSIB/post-ERAS group 5.5 d, p = 0.04) and overall wound complication rates (14.7% and 6.5%, respectively, p = 0.049) were reduced after sequential implementation of the protocols.

Conclusion

Sequential implementation of quality-improvement initiatives yielded additive benefit for patients undergoing colorectal surgery in a community hospital, with a decrease in length of stay and wound complication rates. The amount of improvement attributable to either initiative is difficult to define as they were implemented sequentially. The improved outcomes were realized after the introduction of the ERAS protocol in adjusted analyses.

Perioperative body composition changes in the multimodal treatment of gastrointestinal cancer

Surgical resection and perioperative adjuvant therapy are widely accepted standard treatments for gastrointestinal cancer. However, body composition changes, such as weight loss and skeletal muscle loss, are unavoidable during these treatments. Several studies have shown that perioperative body composition changes are affected by multimodal treatment for gastrointestinal cancer. This review summarizes the background, current status, and future perspectives of perioperative body composition changes in the multimodal treatment of gastrointestinal cancer. Recent studies have described the body composition changes observed in the early period after surgery and during adjuvant therapy. Changes in the body composition might affect adjuvant chemotherapy toxicity after surgery and postoperative complications after neoadjuvant therapy. The mechanisms underlying body composition changes during multimodal therapy are multifactorial and include systemic inflammation, reduced nutrient intake, and physical inactivity. Several approaches have been tested to maintain the body composition, and especially prevent skeletal muscle wasting, during multimodal therapy. Although the ideal approach for managing body composition changes in gastrointestinal cancer patients remains unclear, recent studies support the combination of multiple approaches rather than a single approach.

Multi-modal prehabilitation: addressing the why, when, what, how, who and where next?

Just as there is growing interest in enhancing recovery after surgery, prehabilitation is becoming a recognised means of preparing the patient physically for their operation and/or subsequent treatment. Exercise training is an important stimulus for improving low cardiovascular fitness and preserving lean muscle mass, which are critical factors in how well the patient recovers from surgery. Despite the usual focus on exercise, it is important to recognise the contribution of nutritional optimisation and psychological wellbeing for both the adherence and the response to the physical training stimulus. This article reviews the importance of a multi-modal approach to prehabilitation in order to maximise its impact in the pre-surgical period, as well as critical future steps in its development and integration in the healthcare system.

Decline in tongue pressure during perioperative period in cancer patients without oral feeding

BACKGROUND AND AIMS

Systemic muscle wasting during perioperative periods has a major impact on postoperative morbidity. However, data on oropharyngeal muscle weakness after surgery are scarce. We examined whether maximum tongue pressure (MTP) and hand grip strength (HGS) diminished during the perioperative period without and with oral feeding in patients receiving cancer surgery.

METHODS

A total of 258 patients undergoing cancer surgery who had visited a hospital dental clinic were prospectively recruited between October 2015 and February 2016. MTP and HGS were measured on the day before and 4 days after surgery. Data on age, sex, tumor location, surgical procedure, and oral feeding status were obtained from patient medical records. We analyzed for differences in the perioperative changes of MTP and HGS according to surgical procedure, oral feeding, and tumor location using ANOVA.

RESULTS

Neither MTP nor HGS differed significantly among tumor locations before surgery. The proportion of patients with an oral diet at 4 days after surgery was 36.7% and 34.5% for upper GI and colorectum groups versus 89.2% and 86.4% for genitourinary and lung groups, respectively. During the perioperative period, MTP decreased more significantly in patients without oral feeding than in those with oral feeding at 4 days after surgery (P < 0.01). HGS was not affected by postoperative oral feeding status. Both MTP and HGS decreased more significantly in the upper gastrointestinal group than in the genitourinary and lung groups (P < 0.05), except for MTP between upper GI and genitourinary groups (P = 0.10).

CONCLUSIONS

MTP, but not HGS, diminishes significantly during the perioperative period without oral feeding. As tongue muscle disuse after surgery may adversely impact postoperative oropharyngeal muscle decline, perioperative tongue muscle strengthening exercises may assist in maintaining muscle strength and good oral feeding.

Changes in fatigue and physical function with age for patients with gastrointestinal cancer in the perioperative period: a comparison between older and young patients

[Purpose] The purpose of this study was to examine changes in fatigue and physical function with age for groups of patients with gastrointestinal cancer in the perioperative period. [Subjects and Methods] The study involved 52 patients with gastrointestinal cancer (28 males and 24 females, aged 62.4 ± 12.0 years). The subjects were divided into two groups: those 65 or over (the so-called elderly group,) and those 64 or under (the so-called young group). The six minute walk distance (6MWD), Cancer Fatigue Scale (CFS), and serum albumin (ALB) were evaluated on three occasions: before surgery, after surgery and after discharge. This study considered change in physical function and fatigue, differences between the two groups and correlations between age and each evaluation on the three occasions. [Results] The 6MWD was the main difference between the elderly and young groups, with the former having significantly reduced 6MWD values as compared to the latter after surgery. Age was positively correlated with 6MWD and ALB after surgery and after discharge. Moreover, age was negatively correlated with CFS after surgery and after discharge. [Conclusion] It is suggested that elderly patients are more likely to experience a decline in exercise tolerance and an increase in fatigue.

Changes in incontinence after hysterectomy

PURPOSE

Information about the perioperative incontinence following hysterectomy is limited. To advance the postoperative rehabilitation further we need more information about qualitative changes in incontinence, fatigue and physical function of patients undergoing hysterectomy.

METHODS

108 patients undergoing planned hysterectomy were compared pre- and postoperatively. In a sub-study of the prospective follow-up study the changes in incontinence, postoperative fatigue, quality of life, physical function, and body composition were evaluated preoperatively, 13 and 30 days postoperatively. Sample size calculation indicated that 102 women had to be included. The incontinence status was estimated by a Danish version of the ICIG questionnaire; further, visual analogue scale, dynamometer for hand grip, knee extension strength and balance were applied. Work capacity was measured ergometer cycle together with lean body mass by impedance. Quality of life was assessed using the SF-36 questionnaire. Patients were examined preoperatively and twice postoperatively.

RESULTS

In total 41 women improved their incontinence after hysterectomy and 10 women reported deterioration. Preoperative stress incontinence correlated with BMI (r = 0.25, p < 0.01) and urge incontinence with age (r = 0.24, p < 0.02). Further, improvement after hysterectomy in stress incontinence was associated with younger age (r = 0.20, p < 0.04). Improvement in urge incontinence was positively associated with BMI (r = 0.22, p = 0.02). A slight but significant loss was seen in lean body mass 13 and 30 days postoperatively.

CONCLUSIONS

Hysterectomy was not significantly associated with the risk of incontinence; in particular, when no further vaginal surgery is performed. Hysterectomy may even have a slightly positive effect on incontinence and de-novo cure.

Quantifying fatigue in (long-term) colorectal cancer survivors: a study from the population-based patient reported outcomes following initial treatment and long term evaluation of survivorship registry

BACKGROUND

Few studies specifically focus on fatigue of (long-term) colorectal cancer (CRC) survivors or compare fatigue levels with a normative population. Association between surviving multiple primary cancers and fatigue is also explored.

METHODS

Survivors diagnosed from 1998 to 2009 were identified from the Eindhoven Cancer Registry. In total, 3739 (79%) respondents and an age- and gender-matched normative population (n=338) completed questionnaires on fatigue and psychological distress.

RESULTS

More survivors reported feeling fatigued than the normative population (39% versus 22%, p<0.0001). Short-term survivors (<5 years post-diagnosis) had the highest mean fatigue scores compared with long-term survivors (≥5 years post-diagnosis) or the normative population (21±7 versus 20±7 versus 18±5, p<0.0001, respectively). Having primary cancers prior to CRC was associated with more fatigue. Surgery+chemoradiation was independently associated with fatigue (odds ratio (OR): 1.63, 95% confidence interval (CI): 1.17-2.29, p=0.004) as were anxiety (OR: 1.16, 95% CI: 1.12-1.19, p<0.0001) and depressive symptoms (OR: 1.38, 95% CI: 1.33-1.43, p<0.0001).

CONCLUSIONS

Fatigue is a significant problem, especially for short-term CRC survivors. The association between chemoradiation and fatigue suggests that patients could benefit from better information on treatment side-effects. When treating fatigue, clinical care should also focus on survivors' psychological needs, especially survivors of multiple primary cancers.

Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol.

METHODS

Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group.

RESULTS

For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system).

CONCLUSIONS

Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.