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Loughney L, Murphy K, Tully R, Robb WB, McCaffrey N, Dowd K, Skelly F. The effect of a pre- and post-operative exercise program versus standard care on physical activity and sedentary behavior of patients with esophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (the PERIOP-OG Trial): a randomized controlled trial†. Dis Esophagus 2024:doae044. [PMID: 38769843 DOI: 10.1093/dote/doae044] [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: 12/19/2023] [Revised: 04/18/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged ≥18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey.
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Affiliation(s)
- Lisa Loughney
- ExWell Medical, Dublin, Ireland
- School of Health & Human Performance, Dublin City University, Dublin, Ireland
- The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kate Murphy
- School of Health & Human Performance, Dublin City University, Dublin, Ireland
| | - Roisin Tully
- The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland
| | - William B Robb
- The Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Kieran Dowd
- SHE Research Group, Department of Sports & Health Science, Technological University of the Shannon, Athlone Westmeath, Ireland
| | - Fiona Skelly
- ExWell Medical, Dublin, Ireland
- SHE Research Group, Department of Sports & Health Science, Technological University of the Shannon, Athlone Westmeath, Ireland
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Veziant J, Bouché O, Aparicio T, Barret M, El Hajbi F, Lepilliez V, Lesueur P, Maingon P, Pannier D, Quero L, Raoul JL, Renaud F, Seitz JF, Serre AA, Vaillant E, Vermersch M, Voron T, Tougeron D, Piessen G. Esophageal cancer - French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR). Dig Liver Dis 2023; 55:1583-1601. [PMID: 37635055 DOI: 10.1016/j.dld.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION This document is a summary of the French intergroup guidelines regarding the management of esophageal cancer (EC) published in July 2022, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org). METHODS This collaborative work was conducted under the auspices of several French medical and surgical societies involved in the management of EC. Recommendations were graded in three categories (A, B and C), according to the level of evidence found in the literature until April 2022. RESULTS EC diagnosis and staging evaluation are mainly based on patient's general condition assessment, endoscopy plus biopsies, TAP CT-scan and 18F FDG-PET. Surgery alone is recommended for early-stage EC, while locally advanced disease (N+ and/or T3-4) is treated with perioperative chemotherapy (FLOT) or preoperative chemoradiation (CROSS regimen) followed by immunotherapy for adenocarcinoma. Preoperative chemoradiation (CROSS regimen) followed by immunotherapy or definitive chemoradiation with the possibility of organ preservation are the two options for squamous cell carcinoma. Salvage surgery is recommended for incomplete response or recurrence after definitive chemoradiation and should be performed in an expert center. Treatment for metastatic disease is based on systemic therapy including chemotherapy, immunotherapy or combined targeted therapy according to biomarkers testing such as HER2 status, MMR status and PD-L1 expression. CONCLUSION These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice and are subject to ongoing optimization. Each individual case should be discussed by a multidisciplinary team.
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Affiliation(s)
- Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, University of Lille, Lille F-59000, France.
| | - Olivier Bouché
- Department of Digestive Oncology, CHU Reims, Reims, France
| | - T Aparicio
- Department of Gastroenterology and Digestive Oncology, AP-HP, Saint-Louis Hospital, Paris, France
| | - M Barret
- Gastroenterology Department, Cochin Hospital, APHP, Paris, France
| | - F El Hajbi
- Department of Oncology, Centre Oscar Lambret, Lille, France
| | - V Lepilliez
- Gastroenterology Department, Jean Mermoz Private Hospital, Ramsay Santé, Lyon, France
| | - P Lesueur
- Department of Radiation Oncology, Centre Guillaume le Conquérant, Le Havre, France
| | - P Maingon
- Department of Radiation Oncology, La Pitié-Salpêtrière, APHP, Sorbonne University, Paris, France
| | - D Pannier
- Department of Oncology, Centre Oscar Lambret, Lille, France
| | - L Quero
- Department of Radiation Oncology, Saint-Louis Hospital, APHP, Paris, France
| | - J L Raoul
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - F Renaud
- Department of Pathology, La Pitié-Salpêtrière, APHP, Sorbonne University, Paris, France
| | - J F Seitz
- Department of Digestive Oncology, La Timone, Aix Marseille Université, Marseille, France
| | - A A Serre
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | | | - M Vermersch
- Medical Imaging Department, Valencienne Hospital Centre, Valencienne 59300, France
| | - T Voron
- Department of General and Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, 184 rue du faubourg Saint-Antoine, Paris 75012, France
| | - D Tougeron
- Department of Gastro-Enterology and Hepatology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, University of Lille, Lille F-59000, France
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George J, White D, Fielding B, Scott M, Rockall T, Whyte MB. Systematic review of preoperative n-3 fatty acids in major gastrointestinal surgery. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000172. [PMID: 37397953 PMCID: PMC10314636 DOI: 10.1136/bmjsit-2022-000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/17/2023] [Indexed: 07/04/2023] Open
Abstract
Objectives Perioperative nutrition aims to replenish nutritional stores before surgery and reduce postoperative complications. 'Immunonutrition' (including omega-3 fatty acids) may modulate the immune system and attenuate the postoperative inflammatory response. Hitherto, immunonutrition has overwhelmingly been administered in the postoperative period-however, this may be too late to provide benefit. Design A systematic literature search using MEDLINE and EMBASE for randomized controlled trials (RCTs). Setting Perioperative major gastrointestinal surgery. Participants Patients undergoing major gastrointestinal surgery. Interventions Omega-3 fatty acid supplementation commenced in the preoperative period, with or without continuation into postoperative period. Main outcome measures The effect of preoperative omega-3 fatty acids on inflammatory response and clinical outcomes. Results 833 studies were identified. After applying inclusion and exclusion criteria, 12 RCTs, involving 1456 randomized patients, were included. Ten articles exclusively enrolled patients with cancer. Seven studies used a combination of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) as the intervention and five studies used EPA alone. Eight out of 12 studies continued preoperative nutritional support into the postoperative period.Of the nine studies reporting mortality, no difference was seen. Duration of hospitalisation ranged from 4.5 to 18 days with intervention and 3.5 to 23.5 days with control. Omega-3 fatty acids had no effect on postoperative C-reactive protein and the effect on cytokines (including tumor necrosis factor-α, interleukin (IL)-6 and IL-10) was inconsistent. Ten of the 12 studies had low risk of bias, with one study having moderate bias from allocation and blinding. Conclusions There is insufficient evidence to support routine preoperative omega-3 fatty acid supplementation for major gastrointestinal surgery, even when this is continued after surgery. PROSPERO registration number CRD42018108333.
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Affiliation(s)
- Jason George
- Minimal Access Therapy Training Unit, Guildford, UK
- University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Daniel White
- Minimal Access Therapy Training Unit, Guildford, UK
- University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Barbara Fielding
- University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Michael Scott
- Minimal Access Therapy Training Unit, Guildford, UK
- Anaesthesia and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Brown LR, Kamarajah SK, Madhavan A, Wahed S, Navidi M, Immanuel A, Hayes N, Phillips AW. The impact of age on long-term survival following gastrectomy for gastric cancer. Ann R Coll Surg Engl 2023; 105:269-277. [PMID: 35446718 PMCID: PMC9974338 DOI: 10.1308/rcsann.2021.0355] [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] [Accepted: 12/08/2021] [Indexed: 12/09/2022] Open
Abstract
INTRODUCTION Gastrectomy remains the primary curative treatment modality for patients with gastric cancer. Concerns exist about offering surgery with a high associated morbidity and mortality to elderly patients. The study aimed to evaluate the long-term survival of patients with gastric cancer who underwent gastrectomy comparing patients aged <70 years with patients aged ≥70 years. METHODS Consecutive patients who underwent gastrectomy for adenocarcinoma with curative intent between January 2000 and December 2017 at a single centre were included. Patients were stratified by age with a cut-off of 70 years used to create two cohorts. Log rank test was used to compare overall survival and Cox multivariable regression used to identify predictors of long-term survival. RESULTS During the study period, 959 patients underwent gastrectomy, 520 of whom (54%) were aged ≥70 years. Those aged <70 years had significantly lower American Society of Anesthesiologists grades (p<0.001) and were more likely to receive neoadjuvant chemotherapy (39% vs 21%; p<0.001). Overall complication rate (p=0.001) and 30-day postoperative mortality (p=0.007) were lower in those aged <70 years. Long-term survival (median 54 vs 73 months; p<0.001) was also favourable in the younger cohort. Following adjustment for confounding variables, age ≥70 years remained a predictor of poorer long-term survival following gastrectomy (hazard ratio 1.35, 95% confidence interval 1.09, 1.67; p=0.006). CONCLUSIONS Low postoperative mortality and good long-term survival were demonstrated for both age groups following gastrectomy. Age ≥70 years was, however, associated with poorer outcomes. This should be regarded as important factor when counselling patients regarding treatment options.
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Affiliation(s)
- LR Brown
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - SK Kamarajah
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - A Madhavan
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - S Wahed
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - M Navidi
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - A Immanuel
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - N Hayes
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Kowalchuk RO, Spears GM, Morris LK, Owen D, Yoon HH, Jethwa K, Chuong MD, Ferris MJ, Haddock MG, Hallemeier CL, Wigle D, Lin SH, Merrell KW. Risk stratification of postoperative cardiopulmonary toxicity after trimodality therapy for esophageal cancer. Front Oncol 2023; 13:1081024. [PMID: 36845682 PMCID: PMC9948243 DOI: 10.3389/fonc.2023.1081024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose/objective Postoperative toxicity for esophageal cancer impacts patient quality of life and potentially overall survival (OS). We studied whether patient and toxicity parameters post-chemoradiation therapy predict for post-surgical cardiopulmonary total toxicity burden (CPTTB) and whether CPTTB was associated with short and long-term outcomes. Materials/methods Patients had biopsy-proven esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. CPTTB was derived from total perioperative toxicity burden (Lin et al. JCO 2020). To develop a CPTTB risk score predictive for major CPTTB, recursive partitioning analysis was used. Results From 3 institutions, 571 patients were included. Patients were treated with 3D (37%), IMRT (44%), and proton therapy (19%). 61 patients had major CPTTB (score ≥ 70). Increasing CPTTB was predictive of decreased OS (p<0.001), lengthier post-esophagectomy length of stay (LOS, p<0.001), and death or readmission within 60 days of surgery (DR60, p<0.001). Major CPTTB was also predictive of decreased OS (hazard ratio = 1.70, 95% confidence interval: 1.17-2.47, p=0.005). The RPA-based risk score included: age ≥ 65, grade ≥ 2 nausea or esophagitis attributed to chemoradiation, and grade ≥ 3 hematologic toxicity attributed to chemoradiation. Patients treated with 3D radiotherapy had inferior OS (p=0.010) and increased major CPTTB (18.5% vs. 6.1%, p<0.001). Conclusion CPTTB predicts for OS, LOS, and DR60. Patients with 3D radiotherapy or age ≥ 65 years and chemoradiation toxicity are at highest risk for major CPTTB, predicting for higher short and long-term morbidity and mortality. Strategies to optimize medical management and reduce toxicity from chemoradiation should be strongly considered.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Grant M. Spears
- Department of Statistics, Mayo Clinic, Rochester, MN, United States
| | - Lindsay K. Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Harry H. Yoon
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Krishan Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | - Matthew J. Ferris
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, MD, United States
| | - Michael G. Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Dennis Wigle
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Steven H. Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States,*Correspondence: Kenneth W. Merrell,
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Schmid S, Minnella EM, Pilon Y, Rokah M, Rayes R, Najmeh S, Cools-Lartigue J, Ferri L, Mulder D, Sirois C, Owen S, Shieh B, Ofiara L, Wong A, Sud S, Baldini G, Carli F, Spicer J. Neoadjuvant Prehabilitation Therapy for Locally Advanced Non-Small-Cell Lung Cancer: Optimizing Outcomes Throughout the Trajectory of Care. Clin Lung Cancer 2022; 23:593-599. [PMID: 35705449 DOI: 10.1016/j.cllc.2022.05.004] [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: 02/03/2022] [Revised: 04/20/2022] [Accepted: 05/08/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Prehabilitation is well established for improving outcomes in cancer surgery. Combining prehabilitation with neoadjuvant treatments may provide an opportunity to rapidly initiate cancer-directed therapy while improving functional status in preparation for local consolidation. In this proof-of-concept study, we analyzed non-small-cell lung cancer patients who underwent simultaneous prehabilitation and neoadjuvant therapy. PATIENTS AND METHODS We retrospectively analyzed all patients who underwent neoadjuvant treatment for non-small-cell lung cancer followed by curative intent surgery between 2015 and 2021. Patients who were screened for the prehabilitation program were identified. The screening included assessment of physical performance, nutritional status, and signs of anxiety and depression. RESULTS We identified a total of 141 patients who underwent neoadjuvant therapy. Twenty patients were screened to undergo a prehabilitation program. Four patients did not complete the exercise program (1 surgical intervention too soon, 1 drop-out after the first session, and 2 patients were deemed fit without intervention). The postoperative median length of stay was 2 days (range 1-18). Patients improved their 6-minute-walk test despite undergoing neoadjuvant treatment by a mean of 33 meters (± 50, P = .1). Self-reported functional status (DASI) showed significant improvement by a mean of 10 points (± 11, P = .03), and HADS-anxiety-score was significantly reduced after the prehabilitation program by a mean of 1.5 points (± 1, P = .005). CONCLUSION Neoadjuvant prehabilitation therapy is feasible and associated with encouraging results. The performance of all measures remains a logistic challenge. With multimodal strategies for lung cancer treatment becoming key to optimal outcomes, neoadjuvant prehabilitation therapy is a concept worthy of prospective multi-center evaluation.
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Affiliation(s)
- Severin Schmid
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg, Germany
| | | | - Yohann Pilon
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Merav Rokah
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Roni Rayes
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Sara Najmeh
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - David Mulder
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Christian Sirois
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Scott Owen
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada
| | - Benjamin Shieh
- Division of Respiratory Medicine, McGill University, Montreal, QC, Canada
| | - Linda Ofiara
- Division of Respiratory Medicine, McGill University, Montreal, QC, Canada
| | - Annick Wong
- Department of Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Shelly Sud
- Department of Medical Oncology, Centre Intégré de Santé et des Services Sociaux de l'Outaouais, Gatineau, QC, Canada
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Spicer
- Division of Thoracic Surgery, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.
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The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review. Cancers (Basel) 2022; 14:cancers14092096. [PMID: 35565226 PMCID: PMC9102916 DOI: 10.3390/cancers14092096] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Surgery is the only potentially curative treatment option for esophagogastric cancer. Although esophagectomy/gastrectomy remains associated with major surgical trauma and significant morbidity. Prehabilitation has emerged as a novel strategy to improve postoperative outcomes by preparing patients for a surgery-associated physiological challenge. We discuss current knowledge and the results of studies on the role of prehabilitation in esophagogastric cancer surgery. Abstract Esophagogastric cancer is among the most common malignancies worldwide. Surgery with or without neoadjuvant therapy is the only potentially curative treatment option. Although esophagogastric resections remain associated with major surgical trauma and significant postoperative morbidity. Prehabilitation has emerged as a novel strategy to improve clinical outcomes by optimizing physical and psychological status before major surgery through exercise and nutritional and psychological interventions. Current prehabilitation programs may be unimodal, including only one intervention, or multimodal, combining the benefits of different types of interventions. However, it still is an investigational treatment option mostly limited to clinical trials. In this comprehensive review, we summarize the current evidence for the role of prehabilitation in modern esophagogastric cancer surgery. The available studies are very heterogeneous in design, type of interventions, and measured outcomes. Yet, all of them confirm at least some positive effects of prehabilitation in terms of improved physical performance, nutritional status, quality of life, or even reduced postoperative morbidity. However, the optimal interventions for prehabilitation remain unclear; thus, they cannot be standardized and widely adopted. Future studies on multimodal prehabilitation are necessary to develop optimal programs for patients with esophagogastric cancer.
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Deana C, Vetrugno L, Bignami E, Bassi F. Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint. J Thorac Dis 2021; 13:6037-6051. [PMID: 34795950 PMCID: PMC8575828 DOI: 10.21037/jtd-21-940] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
Objective This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint. Background Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients. Methods We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports. Conclusions Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy.,Department of Medical Area, University of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
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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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10
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Anastomotic leak following oesophagectomy: research priorities from an international Delphi consensus study. Br J Surg 2021; 108:66-73. [PMID: 33640931 DOI: 10.1093/bjs/znaa034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/23/2020] [Accepted: 09/18/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks. METHODS A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income. RESULTS In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis. CONCLUSION Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.
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11
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Gillis C, Davies SJ, Carli F, Wischmeyer PE, Wootton SA, Jackson AA, Riedel B, Marino LV, Levett DZH, West MA. Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review. Front Nutr 2021; 8:644723. [PMID: 33898499 PMCID: PMC8062858 DOI: 10.3389/fnut.2021.644723] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Sarah J. Davies
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Paul E. Wischmeyer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Stephen A. Wootton
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Alan A. Jackson
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Anaethesia, Pain and Perioperative Medicine Unit, The University of Melbourne, Melbourne, VIC, Australia
- Centre for Integrated Critical Care Medicine and The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Luise V. Marino
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- National Institute of Health Research Cancer and Nutrition Collaboration, Southampton, United Kingdom
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Nutrition and Dietetics, Faculty of Health and Well Being, University of Winchester, Winchester, United Kingdom
| | - Denny Z. H. Levett
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Anaesthesia, Perioperative and Critical Care Research Group, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, University of Southampton, Southampton, United Kingdom
| | - Malcolm A. West
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
- Anaesthesia, Perioperative and Critical Care Research Group, National Institute for Health Research Biomedical Research Centre, University Hospital Southampton National Health Service Foundation Trust, University of Southampton, Southampton, United Kingdom
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, United Kingdom
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12
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Davies SJ, West MA, Rahman SA, Underwood TJ, Marino LV. Oesophageal cancer: The effect of early nutrition support on clinical outcomes. Clin Nutr ESPEN 2021; 42:117-123. [PMID: 33745564 DOI: 10.1016/j.clnesp.2021.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is prevalent in oesophageal cancer. Evidence for the use of nutrition support and prehabilitation in this cohort is variable. The aim of this study was to examine the effect of early nutrition support and functional measures of nutritional status on post-operative outcomes in adult patients with oesophageal cancer. METHODS Retrospective review of adults with oesophageal cancer undergoing oesophagectomy (n = 151). Early nutrition support was defined as: oral or enteral nutrition supplementation during neoadjuvant treatment. Late nutrition support defined as: oral or enteral nutrition supplementation prescribed post-operatively. Nutrition outcome measures were; percentage weight loss from 3 to 6 months prior to diagnosis, peri- and post-operatively, and pre-operative assessment of handgrip-strength (HGS). RESULTS Pre-operative weight loss ≥10% was a significant predictor of mortality at 1 year (OR 2.84, 95%CI 1.03-7.83, p = 0.04) independent of tumour stage, adjuvant treatment, age and gender. Adults prescribed early nutrition support during neoadjuvant treatment experienced less weight loss at 12-months post-oesophagectomy compared to adults prescribed late oral nutrition support (p=<0.05). Pre-operative HGS measurements were not a useful predictor of postoperative complications (p = 0.2), length of stay (p = 0.9) or 90-day mortality (p = 0.6). CONCLUSIONS Pre-operative weight loss ≥10% was associated with mortality. Early nutrition support was associated with less weight loss at 12-months post-operatively. Pre-operative HGS measures did not have prognostic value as a stand-alone measure. Future work should investigate the efficacy of early nutrition support in reducing both pre- and post-operative weight loss to improve nutritional status and surgical outcomes as part of a multimodal prehabilitation programme in adults with oesophageal cancer.
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Affiliation(s)
- S J Davies
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK.
| | - M A West
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - S A Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - T J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - L V Marino
- Department of Dietetics/ Speech and Language Therapy, University Hospital NHS Foundation Trust Southampton, Tremona Road, Southampton, SO16 6YD, UK; NIHR Biomedical Research Centre Southampton, University Hospital NHS Foundation Trust Southampton, UK; Nutrition and Dietetics, Faculty of Health and Well Being, University of Winchester, UK
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13
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Hajjar LA, Costa IBSDSD, Lopes MACQ, Hoff PMG, Diz MDPE, Fonseca SMR, Bittar CS, Rehder MHHDS, Rizk SI, Almeida DR, Fernandes GDS, Beck-da-Silva L, Campos CAHDM, Montera MW, Alves SMM, Fukushima JT, Santos MVCD, Negrão CE, Silva TLFD, Ferreira SMA, Malachias MVB, Moreira MDCV, Valente Neto MMR, Fonseca VCQ, Soeiro MCFDA, Alves JBS, Silva CMPDC, Sbano J, Pavanello R, Pinto IMF, Simão AF, Dracoulakis MDA, Hoff AO, Assunção BMBL, Novis Y, Testa L, Alencar Filho ACD, Cruz CBBV, Pereira J, Garcia DR, Nomura CH, Rochitte CE, Macedo AVS, Marcatti PTF, Mathias Junior W, Wiermann EG, Val RD, Freitas H, Coutinho A, Mathias CMDC, Vieira FMDAC, Sasse AD, Rocha V, Ramires JAF, Kalil Filho R. Brazilian Cardio-oncology Guideline - 2020. Arq Bras Cardiol 2020; 115:1006-1043. [PMID: 33295473 PMCID: PMC8452206 DOI: 10.36660/abc.20201006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | | | - Paulo Marcelo Gehm Hoff
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Instituto D'or Pesquisa e Ensino, Rio de Janeiro, RJ - Brasil
| | - Maria Del Pilar Estevez Diz
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Silvia Moulin Ribeiro Fonseca
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Cristina Salvadori Bittar
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Marília Harumi Higuchi Dos Santos Rehder
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Stephanie Itala Rizk
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | | | - Luís Beck-da-Silva
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil.,Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | - Júlia Tizue Fukushima
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Maria Verônica Câmara Dos Santos
- Sociedade Brasileira de Oncologia Pediátrica (SOBOPE), São Paulo, SP - Brasil.,Departamento de Cardiopatias Congênitas e Cardiologia Pediátrica (DCC/CP) da Sociedade Brasileira de Cardiologia (SBC), Rio de Janeiro, RJ - Brasil
| | - Carlos Eduardo Negrão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Silvia Moreira Ayub Ferreira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | | | | | | | | | - Juliana Barbosa Sobral Alves
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - João Sbano
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Ricardo Pavanello
- Hospital do Coração da Associação do Sanatório Sírio - HCor, São Paulo, SP - Brasil
| | | | | | | | - Ana Oliveira Hoff
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Yana Novis
- Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Laura Testa
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Cecília Beatriz Bittencourt Viana Cruz
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Juliana Pereira
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Diego Ribeiro Garcia
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Cesar Higa Nomura
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Hospital do Coração (HCOR), São Paulo, SP - Brasil
| | | | | | - Wilson Mathias Junior
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Renata do Val
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | | | | | | | - André Deeke Sasse
- Grupo SOnhe, Campinas, SP - Brasil.,Universidade Estadual de Campinas (Unicamp), Campinas, SP - Brasil
| | - Vanderson Rocha
- Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - José Antônio Franchini Ramires
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Roberto Kalil Filho
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.,Instituto do Câncer Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
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14
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Sheill G, Reynolds S, O'Neill L, Mockler D, Reynolds JV, Hussey J, Guinan E. Cardiopulmonary Exercise Testing in Oesophagogastric Surgery: a Systematic Review. J Gastrointest Surg 2020; 24:2667-2678. [PMID: 32632727 DOI: 10.1007/s11605-020-04696-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/07/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery. METHODS Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool. RESULTS Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay. CONCLUSION Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity.
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Affiliation(s)
- G Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - S Reynolds
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - L O'Neill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - D Mockler
- Medical Library, Trinity College Dublin, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, Trinity College Dublin and St. James's Hospital, Dublin, Ireland
| | - J Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - E Guinan
- School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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15
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Vetter D, Gutschow CA. Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction. Langenbecks Arch Surg 2020; 405:1069-1077. [PMID: 32651652 PMCID: PMC7686179 DOI: 10.1007/s00423-020-01926-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/18/2022]
Abstract
Background Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research. Purpose The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery. Conclusions There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.
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Affiliation(s)
- Diana Vetter
- Division Head Upper Gastrointestinal Surgery, Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christian A Gutschow
- Division Head Upper Gastrointestinal Surgery, Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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16
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Gritsenko K, Helander E, Webb MPK, Okeagu CN, Hyatali F, Renschler JS, Anzalone F, Cornett EM, Urman RD, Kaye AD. Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:199-212. [PMID: 32711829 DOI: 10.1016/j.bpa.2020.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.
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Affiliation(s)
- Karina Gritsenko
- Family & Social Medicine, and Physical Medicine & Rehabilitation. Program Director, Regional Anesthesia and Acute Pain Medicine Fellowship, Montefiore Medical Center, Montefiore Multidisciplinary Pain Program. Department of Anesthesiology. 1250 Waters Place, Tower II, 8th Floor, Bronx, NY 10461, USA.
| | - Erik Helander
- Department of Anesthesiology, LSU Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Michael P K Webb
- Department of Anaesthesia and Pain Medicine, Counties Manukau Health, Hospital Road, Otahuhu, Auckland 1640, New Zealand.
| | - Chikezie N Okeagu
- Department of Anesthesiology, LSU Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Farees Hyatali
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Jordan S Renschler
- Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
| | | | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences; Provost, Chief Academic Officer, and Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport LA 71103, USA.
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17
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Papaconstantinou D, Vretakakou K, Paspala A, Misiakos EP, Charalampopoulos A, Nastos C, Patapis P, Pikoulis E. The impact of preoperative sarcopenia on postoperative complications following esophagectomy for esophageal neoplasia: a systematic review and meta-analysis. Dis Esophagus 2020; 33:doaa002. [PMID: 32193528 DOI: 10.1093/dote/doaa002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/15/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022]
Abstract
Esophageal cancer is characterized by profound changes in body composition due to dysphagia and generalized cachexia. Sarcopenia or muscle wasting is a component of cachexia associated with poor postoperative performance status. The skeletal muscle index (SMI) calculated by computed tomography scans at the level of the third lumbar vertebra is an easily quantifiable and reproducible measure of sarcopenia. The aim of this meta-analysis is to investigate the impact of preoperative sarcopenia (low SMI) on postoperative complications after esophagectomy for neoplastic lesions. In this context, a comprehensive literature search was undertaken to identify studies reporting short-term postoperative outcomes in relation to their preoperative SMI values. Cumulative risk ratios (RR) and risk differences (RD) and their respective 95% confidence intervals (CIs) were calculated using a random-effect model. A total of 11 studies incorporating 1,979 total patients (964 patients with sarcopeniaversus 1,015 without sarcopenia) were included in the final analysis. The results demonstrated a significant increase in overall morbidity (RR 1.16, 95% CI 1.01-1.33), respiratory complications (RR 1.64, 95% CI 1.21-2.22) and anastomotic leaks (RR 1.39, 95% CI 1.10-1.76) in patients with sarcopenia. No statistically significant difference was noted in overall mortality (RD 0, 95% CI -0.02-0.02) or Clavien-Dindo grade III or greater complications (RR 1.17, 95% CI 0.96-1.42). The above results demonstrate the validity of the SMI as a predictive factor for post-esophagectomy complications. Although the risk associated with sarcopenia is not prohibitive for surgery, patients with low SMI require closer vigilance during their postoperative course due to the increased propensity for respiratory and anastomotic complications.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Konstantina Vretakakou
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Anna Paspala
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Evangelos P Misiakos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Anestis Charalampopoulos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Constantinos Nastos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Paul Patapis
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Emmanouil Pikoulis
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
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18
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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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19
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Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: A systematic review and meta-analysis. Surgery 2020; 167:540-549. [DOI: 10.1016/j.surg.2019.07.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/15/2019] [Accepted: 07/29/2019] [Indexed: 12/26/2022]
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20
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Brown SA. Preventive Cardio-Oncology: The Time Has Come. Front Cardiovasc Med 2020; 6:187. [PMID: 31998754 PMCID: PMC6965025 DOI: 10.3389/fcvm.2019.00187] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/10/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sherry-Ann Brown
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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21
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Molenaar CJL, Papen-Botterhuis NE, Herrle F, Slooter GD. Prehabilitation, making patients fit for surgery - a new frontier in perioperative care. Innov Surg Sci 2019; 4:132-138. [PMID: 33977122 PMCID: PMC8059351 DOI: 10.1515/iss-2019-0017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023] Open
Abstract
Optimizing a patients’ condition before surgery to improve the postoperative outcome can be achieved by using prehabilitation; preoperative interventions focusing on modifiable risk factors to improve the physical, nutritional, and mental status of the patient. A multimodal, multidisciplinary approach induces a synergistic effect between the various interventions and affects the outcome postoperatively. While awaiting higher-quality evidence, the worldwide implementation of prehabilitation programs has started, resulting in a true revolution in perioperative care.
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Affiliation(s)
| | | | - Florian Herrle
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Gerrit D Slooter
- Department of Surgical Oncology, Máxima MC, 5500MB, Veldhoven, the Netherlands, E-mail:
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22
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Bolger JC, Loughney L, Tully R, Cunningham M, Keogh S, McCaffrey N, Hickey W, Robb WB. Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: a systematic review. Dis Esophagus 2019; 32:5519688. [PMID: 31206582 DOI: 10.1093/dote/doz058] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/30/2019] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
Cancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.
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Affiliation(s)
- Jarlath C Bolger
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
| | - Lisa Loughney
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Roisin Tully
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
| | | | | | - Noel McCaffrey
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | | | - William B Robb
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
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23
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Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review. Arch Gynecol Obstet 2019; 301:315-326. [DOI: 10.1007/s00404-019-05321-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/21/2019] [Indexed: 12/18/2022]
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24
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O. Bechstein W, A. Schnitzbauer A. Operative Procedures: New Ways of Managing Frailty. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:61-62. [PMID: 30950383 PMCID: PMC6444032 DOI: 10.3238/arztebl.2019.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Wolf O. Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt
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