Value of preoperative 6-minute walk test for predicting postoperative pulmonary complications

Association between the 6MWT and other measurements of physical functioning in patients with cancer awaiting major surgery

BACKGROUND

The Six Minute Walk Test (6MWT) is a widely used measure of functional capacity in (p)rehabilitation of cancer patients, but it is time-consuming and requires specific space conditions. In this study we explore the association between the 6MWT with other measurements of physical functioning and their predictive value in classifying patients according to their estimated functional capacity.

DESIGN

This prospective study included cancer patients referred to a prehabilitation programme prior to major surgery. For each patient, data on different measurements of physical functioning including the Duke Activity Status Index (DASI), the handgrip strength, the 30" Sit-to-Stand Test and self-reported physical activity levels were collected. Bivariate associations were performed to determine the association between the 6MWT and other variables. Multivariate analyses were performed to identify potential predictive factors of 6MWT in this population. A subsequent algorithm was developed to classify patients based on their functional capacity (good performance - 6MWT>400 m or poor performance 6MWT<400 m) RESULTS: Between mid-2018 to mid 2022, 692 patients were assessed of whom the 6MWT was performed in 524 (75.7 %) (mean age 72.5 ± 11.8 years; 57.1 % men). Moderate-to-strong correlations were found between 6MWT and 30" Sit-To-Stand Test (r = 0.54, p < 0.001), DASI (r = 0.68; p < 0.001) and handgrip strength (r = 0.5; p < 0.001). Multivariate analyses confirmed that a combination of six variables were able to classify 80 % of patients in good (>400 m) or poor (<400 m) performance in the 6MWT.

CONCLUSION

The 6MWT was moderately associated with several variables of physical functioning, a combination of which can be used to predict performance in the 6MWT.

Exercise capacity prior to major cancer surgery: A cross-sectional observational study of the validity of the 6-minute walk and 30-second sit-to-stand tests

INTRODUCTION

Cardiopulmonary exercise testing (CPET) is the gold standard for measuring exercise capacity, however, it is resource intensive and has limited availability. This study aimed to determine: 1) the association between the 6-min walk test (6MWT) and the 30-s sit-to-stand test (30STS) with CPET peak oxygen uptake (VO2peak) and anaerobic threshold (AT) and 2) 6MWT and 30STS cut points associated with a higher risk of postoperative complications.

METHODS

A cross-sectional study, retrospectively analyzing data collected from a tertiary cancer center over a 23-month period. Measures included CPET VO2peak and AT, 6MWT and 30STS test. Correlations were used to characterize relationships between variables. Receiver operating characteristic curve analyses determined 6MWT and 30STS cut points that aligned with CPET variable cut points.

RESULTS

Note that, 156 participants were included. The 6MWT and 30STS displayed moderate correlations with VO2peak, rho = 0.65, p = 0.01 and rho = 0.52, p < 0.005 respectively. Fair correlations were observed between AT and 6MWT (rho = 0.36, p = 0.01) and 30STS (rho = 0.41, p < 0.005). The optimal cut points to identify VO2peak < 15 mL/kg/min were 493.5 m on the 6MWT and 12.5 stands on the 30STS test and for AT < 11 mL/kg/min were 506.5 m on the 6MWT and 12.5 stands on the 30STS test.

CONCLUSION

Both the 6MWT and 30STS test could be used as alternative tools for measuring exercise capacity preoperatively in the cancer setting where CPET is not available. A range of 6MWT and 30STS cut points, according to sensitivity and specificity levels, may be used to evaluate risk of postoperative outcomes.

Preoperative 6-minute walk distance is associated with postoperative complications in patients undergoing laparoscopic gastrointestinal cancer surgery

OBJECTIVE

The 6-min walk test (6MWT) is a simple and valid method to evaluate cardiopulmonary function. We performed this prospective study in patients undergoing laparoscopic gastrointestinal cancer surgery to explore the association between preoperative 6MWT performance and overall postoperative complications.

METHODS

This study was registered at clinicaltrials.gov (NCT03711526). The study consecutively enrolled patients receiving laparoscopic gastrointestinal cancer surgery in our institution. All patients performed the 6MWT upon recruitment and received 30 days of postoperative follow-up. The primary outcome was overall complications, defined by ≥ grade I Clavien-Dindo (CD) classification (2004) complications. Multivariable logistic regression was used to test the association of 6-min walk distance (6MWD) with the outcome.

RESULTS

A total of 184 patients were included in the final analyses. In the 37 (20.1 %) patients with overall complications, the mean (standard deviation) preoperative 6MWD was 469.1 (86.8) m. In patients with no complications, the 6MWD was 502.6 (90.2) m. The mean difference was 33.5 m (95 % confidence interval, 1.3, 65.7; P = 0.042). A longer preoperative 6MWD was associated with a lower odds of developing postoperative complications (odds ratio, 0.994 per meter increase; 95 % confidence interval, 0.989, 0.999; p = 0.023).

CONCLUSION

This study indicated an association between the preoperative 6MWD and postoperative complications in patients undergoing laparoscopic gastrointestinal cancer surgery.

Surgical Considerations for Neoadjuvant Therapy for Pancreatic Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a challenging disease process with a 5-year survival rate of only 11%. Neoadjuvant therapy in patients with localized pancreatic cancer has multiple theoretical benefits, including improved patient selection for surgery, early delivery of systemic therapy, and assessment of response to therapy. Herein, we review key surgical considerations when selecting patients for neoadjuvant therapy and curative-intent resection. Accurate determination of resectability at diagnosis is critical and should be based on not only anatomic criteria but also biologic and clinical criteria to determine optimal treatment sequencing. Borderline resectable or locally advanced pancreatic cancer is best treated with neoadjuvant therapy and resection, including vascular resection and reconstruction when appropriate. Lastly, providing nutritional, prehabilitation, and supportive care interventions to improve patient fitness prior to surgical intervention and adequately address the adverse effects of therapy is critical.

Comparison of 6-min walk test distance vs. estimated maximum oxygen consumption for predicting postoperative pulmonary complications in patients undergoing upper abdominal surgery: a prospective cohort study

OBJECTIVE

The present study aims to evaluate the predictive ability of estimated maximum oxygen consumption (e[Formula: see text]O_2max) and 6-min walk distance (6MWD) for postoperative pulmonary complications (PPCs) in adult surgical patients undergoing major upper abdominal surgery.

METHOD

This study was conducted by collecting data prospectively from a single center. The two predictive variables in the study were defined as 6MWD and e[Formula: see text]O_2max. Patients scheduled for elective major upper abdominal surgery from March 2019 to May 2021 were included. The 6MWD was measured for all patients before surgery. e[Formula: see text]O_2max was calculated using the regression model of Burr, which uses 6MWD, age, gender, weight, and resting heart rate (HR) to predict aerobic fitness. The patients were categorized into PPC and non-PPC group. The sensitivity, specificity, and optimum cutoff values for 6MWD and e[Formula: see text]O_2max were calculated to predict PPCs. The area under the receiver operating characteristic curve (AUC) of 6MWD or e[Formula: see text]O_2max was constructed and compared using the Z test. The primary outcome measure was the AUC of 6MWD and e[Formula: see text]O_2max in predicting PPCs. In addition, the net reclassification index (NRI) was calculated to assess ability of e[Formula: see text]O_2max compared with 6MWT in predicting PPCs.

RESULTS

A total of 308 patients were included 71/308 developed PPCs. Patients unable to complete the 6-min walk test (6MWT) due to contraindications or restrictions, or those taking beta-blockers, were excluded. The optimum cutoff point for 6MWD in predicting PPCs was 372.5 m with a sensitivity of 63.4% and specificity of 79.3%. The optimum cutoff point for e[Formula: see text]O_2max was 30.8 ml/kg/min with a sensitivity of 91.6% and specificity of 79.3%. The AUC for 6MWD in predicting PPCs was 0.758 (95% confidence interval (CI): 0.694-0.822), and the AUC for e[Formula: see text]O_2max was 0.912 (95%CI: 0.875-0.949). A significantly increased AUC was observed in e[Formula: see text]O_2max compared to 6MWD in predicting PPCs (P < 0.001, Z = 4.713). And compared with 6MWT, the NRI of e[Formula: see text]O_2max was 0.272 (95%CI: 0.130, 0.406).

CONCLUSION

The results suggested that e[Formula: see text]O_2max calculated from the 6MWT is a better predictor of PPCs than 6MWD in patients undergoing upper abdominal surgery and can be used as a tool to screen patients at risk of PPCs.

Utilization of Wearable Pedometer Devices in the Perioperative Period: A Qualitative Systematic Review

Functional capacity assessment is important for perioperative risk stratification; however, there are currently limited options for objective and economical functional capacity evaluation. Pedometer functions are now widely available in mobile devices and offer a nonintrusive and objective approach to measuring patient activity level over time. Therefore, we conducted this systematic review to assess the value of pedometer readings in predicting perioperative outcomes. We systematically searched PubMed, EMBASE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science Citation Index for studies, which assessed the correlation between perioperative (30 days before to 30 days after surgery) pedometer data and perioperative outcomes. We identified a total of 18 studies for inclusion. Seven of the studies recorded preoperative pedometer data, and 13 studies recorded postoperative pedometer data. Notably, 10 of the studies covered oncologic surgery patients. The included studies consistently reported that preoperative pedometer readings correlated with postoperative complication rates. In addition, in-hospital postoperative pedometer readings correlated with postdischarge complications and readmissions. Perioperative pedometer data demonstrated consistent and biologically plausible association with perioperative outcomes. Further studies are needed to validate the use of pedometer in the perioperative period and to identify the optimal approach for its use to potentially improve patient outcomes.

Functional Outcomes Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Prospective Cohort Study

BACKGROUND

Pre-operative physical status and its association with post-operative surgical outcomes is poorly understood in patients with peritoneal malignancy who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). The aims of this study were to determine the pre-operative physical function in patients having CRS-HIPEC and investigate the association between physical function and post-operative outcomes.

PATIENTS AND METHODS

Patients undergoing CRS-HIPEC between 2017 and 2021 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary physical function measures were the 6-min walk test (6MWT) and the five-times sit to stand test (5STS). Data were collected pre-operatively and at post-operative day 10, and were analysed according to pre-operative patient characteristics and post-operative outcomes such as length of hospital stay (LOS) and complications.

RESULTS

The cohort of patients that participated in functional assessments consisted of 234 patients, with a median age of 56 years. Patients having CRS-HIPEC performed worse on the 6MWT pre-operatively compared with the general Australian population (p < 0.001). Post-operatively, these patients experienced a further deterioration in 6MWT and 5STS performance and the degree of the post-operative decline in function was associated with post-operative morbidity. A higher level of pre-operative physical function was associated with shorter LOS and minor post-operative complications.

CONCLUSIONS

Patients who have undergone CRS-HIPEC were functionally impaired pre-operatively compared with the general population and experience a further deterioration of physical function post-operatively. A higher level of pre-operative physical function is associated with minor post-operative morbidity, which is highly relevant for pre-operative optimisation of patients with cancer.

Examining the impact of physical function performance in predicting patient outcomes after lung-sparing surgery for malignant pleural mesothelioma

PURPOSE

The purpose of this study was to examine the impact of physical function performance and pulmonary function on patient outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).

MATERIALS AND METHODS

A retrospective review of 54 patients with MPM from 2015 to 2020 was performed. The primary objective was to assess whether physical function, as measured by the Eastern Cooperative Oncology Group Performance Status (ECOG), and pulmonary function tests were predictive of postoperative patient outcomes (ventilator days, chest tube days, hospital length of stay). A secondary objective was to explore demographic and preoperative variables that best predict postoperative physical function and patient outcomes.

RESULTS

Data include 54 patients who underwent extended pleurectomy-decortication. Preoperative ECOG was a significant predictor of postoperative patient outcomes while preoperative lung function lacked predictive ability. Preoperative ECOG was also predictive of preoperative lung function. Age on the day of surgery was the best predictor of postoperative physical function, which was significantly reduced postoperatively.

CONCLUSIONS

Preoperative physical function performance was a significant predictor of postoperative outcomes. The results of our study highlight the importance of physical function in patients with MPM and support the need for early rehabilitation and further research to determine optimal rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONPreoperative physical function can predict outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).Physical function in patients with MPM should be carefully examined.To accurately reflect patients' abilities, patient assessment should include both patient-reported outcomes and performance-based measures.Patients with MPM should receive rehabilitation early after diagnosis and throughout the continuum of care.

Pre-operative physiotherapy for elderly patients undergoing abdominal surgery

Background

Elderly patients report a decrease in function and activities of daily living following abdominal surgery. The objectives of our pilot study were to determine the effects of a single pre-operative physiotherapy session consisting of education and exercise on clinical and physical function outcomes in elderly patients.

Methods/design

A single-blind pilot randomised controlled trial evaluated clinical and functional outcomes of elderly patients following surgery in a private hospital in Pretoria, South Africa. The outcomes included length of hospital stay (LOS), postoperative pulmonary complications (PPC), first mobilisation uptime, DeMorton Mobility Index (DEMMI), 6-minute walk test (6MWT), Lawton-Brody's instrumental activities of daily living (IADL) and the Functional Comorbidity Index (FCI). Descriptive and inferential statistics were undertaken, and statistical significance was set at p ≤ 0.05.

Discussion

Twelve participants (n = 11 female [91.67%] and n = 1 [8.33%] male) with a mean age of 65.75 (±4.47) years were included. Most participants (n = 10, 83.33%) underwent lower abdominal laparotomy (n = 10, 83.33%). The median hospital LOS was n = 4 (IQR 3.25-4) days; walking distance at first mobilisation was 130 m (IQR (85-225), with intervention participants walking further (intervention: 177 m, IQR 100-242.50; control: 90, IQR 60 m - 245 m; p = 0.59). Recruitment was low, with only 10.95% referrals and 47.82% nonconsents.

Conclusion

A single physiotherapy session prior to surgery demonstrated a potential favourable change in elderly patients' mobility postoperatively; however, further research is necessary.

Clinical implication

A once-off pre-operative physiotherapy session could enhance recovery in elderly patients.

Trial registration

Pan African Clinical Trial Registry, PACTR201809874713904, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3593.

Surgical outcomes and quality of life following exercise-based prehabilitation for hepato-pancreatico-biliary surgery: A systematic review and meta-analysis

BACKGROUND

Hepato-pancreatico-biliary (HPB) patients experience significant risk of preoperative frailty. Studies assessing preventative prehabilitation in HPB populations are limited. This systematic review and meta-analysis evaluates outcomes for HPB patients treated with exercise prehabilitation.

DATA SOURCES

A comprehensive search of MEDLINE (via Ovid), Embase (Ovid), Scopus, Web of Science Core Collection, Cochrane Library (Wiley), ProQuest Dissertations, Theses Global, and Google Scholar was conducted with review and extraction following PRISMA guidelines. Included studies evaluated more than 5 adult HPB patients undergoing ≥ 7-day exercise prehabilitation. The primary outcome was postoperative length of stay (LOS); secondary outcomes included complications, mortality, physical performance, and quality of life.

RESULTS

We evaluated 1778 titles and abstracts and selected 6 (randomized controlled trial, n = 3; prospective cohort, n = 1; retrospective cohort, n = 2) that included 957 patients. Of those, 536 patients (56.0%) underwent exercise prehabilitation and 421 (44.0%) received standard care. Patients in both groups were similar with regards to important demographic factors. Prehabilitation was associated with a 5.20-day LOS reduction (P = 0.03); when outliers were removed, LOS reduction decreased to 1.85 days and was non-statistically significant (P = 0.34). Postoperative complications (OR = 0.70; 95% CI: 0.39 to 1.26; P = 0.23), major complications (OR = 0.83; 95% CI: 0.60 to 1.14; P = 0.24), and mortality (OR = 0.67; 95% CI: 0.17 to 2.70; P = 0.57) were similar. Prehabilitation was associated with improved strength, cardiopulmonary function, quality of life, and alleviated sarcopenia.

CONCLUSIONS

Exercise prehabilitation may reduce LOS and morbidity following HPB surgery. Studies with well-defined exercise regimens are needed to optimize exercise prehabilitation outcomes.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation—Implications for Physiotherapists

Objectives

To investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI).

Methods

A total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op.

Results

The mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as “high risk” prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ.

Conclusion

This is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Preoperative functional capacity and postoperative outcomes following abdominal and pelvic cancer surgery: a systematic review and meta-analysis

BACKGROUND

There is clinical uncertainty regarding an association between preoperative functional capacity of cancer patients, and postoperative outcomes. The aim of this systematic review and meta-analysis is to investigate whether poor performance on preoperative six-minute walk test (6MWT) or five-times sit to stand test (5STS) is associated with worse postoperative complication rates and prolonged length of hospital stay (LOS) in cancer patients.

METHODS

An electronic search was performed from earliest available record to 26th February 2021 in MEDLINE, Embase and AMED. Studies investigating the association between preoperative physical function (measured using either 6MWT or 5STS) and postoperative outcomes (complications and LOS) in patients with gastrointestinal, abdominal and pelvic cancers were included. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Where possible, summary odds ratios (OR) or mean differences (MD), and 95% confidence intervals (CI) were calculated using random-effect models.

RESULTS

Five studies (379 patients) were included, of which none utilized the 5STS. Overall, studies were rated as having low to moderate risk of bias. Higher preoperative performance on the 6MWT (≥400 m) was associated with low grade postoperative complications (OR = 0.38; 95% CI = 0.15-0.95) but was not associated with a shorter LOS (MD = 3.29; 95%CI = -1.07-7.66).

CONCLUSION

The available evidence suggests that in cancer patients, a higher preoperative functional capacity may be associated with reduced postoperative complications. Conversely, there is no significant association between preoperative function and LOS. Further high-quality studies are needed in this area, including studies involving 5STS.

Predicting recovery and disability after surgery in patients with severe obesity: The role of the six-minute walk test

The most appropriate method to predict postoperative outcomes in patients with severe obesity undergoing elective non-bariatric surgery is not known. We conducted a single-centre prospective cohort study in patients with a body mass index of at least 35 kg/m² undergoing non-bariatric, non-cardiac surgery. Patients completed the six-minute walk test prior to surgery. Disability was measured before and six months after surgery using the World Health Organization disability assessment schedule. Primary outcome measures included quality of recovery at one month and significantly increased disability at six months after surgery. A total of 293 patients participated. The median body mass index was 41 kg/m². Patients generally recovered well. Following surgery, 9% of patients experienced a poor quality of recovery and 7% developed a significant increase in disability. The proportion of patients free from clinically significant disability increased from 66% prior to surgery to 90% at six months after surgery. The distance walked in six minutes was weakly predictive of poor recovery at one month and significantly increased disability at six months; weight and body mass index were not. The area under the receiver operating characteristic curve was 0.65 (95% confidence intervals 0.51 to 0.78) for poor recovery and 0.64 (95% confidence intervals 0.51 to 0.77) for increased disability. A preoperative six-minute walk test distance of 308 m was the best cut-off value for predicting increased postoperative disability (sensitivity 0.68, specificity 0.63). The six-minute walk test was most discriminatory at shorter distances. This population of patients with severe obesity appeared to recover well and had few adverse outcomes. The degree of functional capacity was more important than the degree of obesity in predicting postoperative outcomes.

Evaluation of the Post-COVID Patient Prior to Elective Plastic Surgery: Developing an Evidence-Based Framework

Preoperative assessment of a potential surgical patient has long been a cornerstone of patient safety. As more patients get, and recover from, COVID-19, plastic surgeons will be faced with the challenge of evaluating the health status and operative risk of convalescent COVID patients who now desire elective surgery. A significant fraction of these patients, however, can have new or persistent health issues as a result of COVID-19, which can affect surgical safety. This paper briefly examines the current relevant literature regarding the post-COVID patient, reviews the waiting period for adequate recovery, and suggests an evidence-based framework for preoperative assessment, based on the severity of the prior COVID-19 episode, ongoing symptoms, and basic screening tests.

Impact of preoperative 6-minute walk distance on long-term prognosis after esophagectomy in patients with esophageal cancer

BACKGROUND

The 6-minute walk distance (6MWD) is a simple way of assessing exercise capacity. The purpose of this study was to investigate the relationship between preoperative 6MWD and long-term prognosis after esophagectomy.

METHODS

This retrospective cohort study involved 108 patients who underwent radical esophagectomy for esophageal cancer between 2013 and 2020. The patients were classified into the short group (SG: 6MWD < 480 m) or the long group (LG: 6MWD  ≥  480 m). To adjust for the background characteristics of both groups, propensity score matching (PSM) analysis was performed and 32 patients were matched from each group. Five-year overall survival (OS) and relapse-free survival (RFS) were analyzed by the Kaplan-Meier method. The log-rank test was used to evaluate differences in survival between the groups. After adjusting for other prognostic factors, the Cox proportional hazards model was used to investigate the impact of preoperative 6MWD on long-term prognosis.

RESULTS

The median follow-up period was 923 days. Thirty-three deaths were recorded during the study period. After PSM, 5-year OS following surgery was 29.2 and 66.1% (p = 0.003) and 5-year RFS was 27.9 and 58.6% (p  =  0.021) in the SG and LG, respectively. In Cox proportional hazards analysis, the SG was a significant independent risk factor for OS (hazard ratio 3.33; 95% confidence interval 1.37-8.11, p = 0.008) and RFS (hazard ratio 2.30; 95% confidence interval 1.08-4.88, p = 0.030).

CONCLUSION

The preoperative 6MWD is useful for evaluating exercise capacity and predicting the long-term outcome in patients undergoing esophagectomy.

Risk assessment and risk stratification for perioperative complications and mitigation: Where should the focus be? How are we doing?

Various risk stratification tools are used to predict patients' risk of adverse outcomes. Most of these tools are based on type of surgery and patient comorbidities. Accuracy of risk prediction is improved when additional factors such as functional capacity are included. However, these tools are limited because data are obtained from specific patient populations, are simplified to aid ease of use, and do not account for improved treatment modalities that occur over time. Risk estimation allows for shared decision-making among the perioperative care team and the patient, for perioperative planning, and for opportunity for risk mitigation. Technological advancement in data collection will likely improve existing risk assessment and allow development of new options. Future research should focus on establishing and standardizing perioperative outcomes that include meaningful patient-centric considerations such as quality of life. We review available stratification tools and important risk assessment biomarkers that address the most common causes of adverse outcomes.

Functional outcomes following pelvic exenteration: results from a prospective cohort study

AIM

Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this study was to determine the short-term functional outcomes following pelvic exenteration surgery using objective measures of physical function.

METHOD

Patients undergoing pelvic exenteration surgery between January 2017 and May 2020 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary measures were the 6-min walk test (6MWT) and the five times sit to stand (5STS) test. Data were collected at baseline (preoperatively), 10 days postoperatively and at discharge from hospital, and were analysed according to tumour type, extent of exenteration, sacrectomy, length of hospital stay, major nerve resection and postoperative complications.

RESULTS

The cohort of patients that participated in functional assessments consisted of 135 patients, with a median age of 61 years. Pelvic exenteration patients had a reduced 6MWT distance preoperatively compared to the general population (P < 0.001). Following surgery, we observed a further decrease in 6MWT distance (P < 0.001) and an increase in time to complete 5STS (P < 0.001) at postoperative day 10 compared to baseline, with a slight improvement at discharge. There were no differences in 6MWT and 5STS outcomes between patients based on comparisons of surgical and oncological factors.

CONCLUSION

Pelvic exenteration patients are functionally impaired in the preoperative period compared to the general population. Surgery causes a further reduction in physical function in the short term; however, functional outcomes are not impacted by tumour type, extent of exenteration, sacrectomy or nerve resection.

Analysis of exercise tolerance on the basis of six-minute walk test - 6MWT and Borg RPE scale in men with inguinal hernia before and after Lichtenstein repair

&lt;b&gt;Introduction:&lt;/b&gt; Assessment of exercise tolerance (ET) plays an important role in qualifications for treatment and rehabilitation. &lt;br&gt;&lt;b&gt;Aim: &lt;/b&gt;The aim of the study was to assess ET in patients before and after inguinal hernia operations with Lichtenstein method. &lt;br&gt;&lt;b&gt;Material and methods:&lt;/b&gt; The cohort study included men with inguinal hernia divided into the study group (SG) (n = 50) and control (CG) (n = 50) undergone the Lichtenstein surgery. Patients from the SG met the criterion of coexistence of cardiovascular and respiratory diseases. Day before and on the second day after surgery, patients performed 6MWT and subjectively rate the exertion according to Borg- RPE- Scale (before, immediately after and 10 minutes after the test). 6MWT distance, Borg scale ratings were analysed. On the second day after surgery 66% of patients from the SG and 58% from the CG did not complete the test. Patients from the SG before (500,07 ± 40,38 m) and on the second day after surgery (243,46 ± 18,18 m) achieved shorter distances compared to the CG (565,93 ± 20,41 m; 249,47 ± 26,66 m), p &lt; 0,001 i p = 0,481. A statistically significant negative correlation between 6MWT distance before surgery and age of the patients was confirmed. Patients who did not develop complications achieved significantly longer distances on admission (p = 0,003 for SG, p = 0,004 for CG). For 6MWT before surgery and 2 days after surgery, patients from the SG showed a significantly higher level of fatigue compared to the CG after the test (before: p = 0,001, after: p = 0,001). Patients form the SG often discontinued 6MWT and less tolerated effort compared to the CG. Hence, 6MWT is useful tool for ascertaining physical capacity and ET.

Frequency of Sarcopenia, Sarcopenic Obesity, and Changes in Physical Function in Surgical Oncology Patients Referred for Prehabilitation

Purpose:

Sarcopenia and suboptimal performance status are associated with postoperative complications and morbidity in cancer patients. Prehabilitation has emerged as an approach to improve fitness and muscle strength in patients preoperatively. We sought to describe the frequency of sarcopenia and sarcopenic obesity (SO) in a cohort of cancer patients referred for prehabilitation and the association between body composition and physical function.

Methods:

In this retrospective review of 99 consecutive cancer patients referred for prehabilitation prior to intended oncologic surgery, prehabilitation included physical medicine and rehabilitation (PM&R) physician evaluation of function and physical therapy for individualized home-based exercise. Sarcopenic A was defined using sex-adjusted norms of skeletal muscle (SKM), measured using the sliceOmatic software (TomoVision, 2012) on computed tomography images at baseline. Sarcopenic B was defined by abnormal SKM and physical function. SO was defined as sarcopenia with BMI ≥ 25. Six-minute walk test (6MWT), 5 times sit-to-stand (5×STS), and grip strength were obtained at consultation (baseline) and at preoperative follow-up (if available).

Results:

Forty-nine patients (49%) were Sarcopenic A, 28 (28%) SO, and 38 (38%) Sarcopenic B. Age was negatively correlated with SKM (P = .0436). There were no significant associations between Sarcopenic A/B or SO with baseline or changes in physical function. Assessed by sex, Sarcopenic A females had low 5×STS (P = .04) and Sarcopenic B females had low GS (P = .037). Sarcopenic B males had low preoperative GS (P = .026). 6MWT and grip strength at baseline were lower than age- and sex-related norms (both P < .001). Preoperatively, 6MWT distance and 5×STS time improved (both P < .001). Functional improvement in the sarcopenic and nonsarcopenic patients did not differ according to sex.

Conclusions:

In this cohort of prehabilitation surgical oncology patients, frequencies of sarcopenia and SO were high, and baseline physical function was abnormal but improved significantly regardless of body composition. These findings suggest that patients have considerable prehabilitation needs and are capable of improving with comprehensive care.

Association of six-minute walk test distance with postoperative complications in non-cardiac surgery: a secondary analysis of a multicentre prospective cohort study

PURPOSE

The six-minute walk test (6MWT) is a simple and valid test for assessing cardiopulmonary fitness. Nevertheless, the relationship between preoperative 6MWT distance and postoperative complications is uncertain. We conducted a secondary analysis of the 6MWT nested cohort substudy of the Measurement of Exercise Tolerance before Surgery study to determine if 6MWT distance predicts postoperative complications or death.

METHODS

This analysis included 545 adults (≥ 40 yr) who were at elevated cardiac risk and had elective inpatient non-cardiac surgery at 15 hospitals in Canada, Australia, and New Zealand. Each participant performed a preoperative 6MWT and was followed for 30 days after surgery. The primary outcome was moderate or severe in-hospital complications. The secondary outcome was 30-day death or myocardial injury. Multivariable logistic regression modelling was used to characterize the adjusted association of 6MWT distance with these outcomes.

RESULTS

Seven participants (1%) terminated their 6MWT sessions early because of lower limb pain, dyspnea, or dizziness. Eighty-one (15%) participants experienced moderate or severe complications and 69 (13%) experienced 30-day myocardial injury or death. Decreased 6MWT distance was associated with increased odds of moderate or severe complications (adjusted odds ratio, 1.32 per 100 m decrease; 95% confidence interval, 1.01 to 1.73; P = 0.045). There was no association of 6MWT distance with myocardial injury or 30-day death (non-linear association; P = 0.49).

CONCLUSION

Preoperative 6MWT distance had a modest association with moderate or severe complications after inpatient non-cardiac surgery. Further studies are needed to determine the optimal role of the 6MWT as an objective exercise test for informing preoperative risk stratification.

A randomized clinical trial in improving pulmonary function and functional capacity in pediatric open abdominal surgery

PURPOSE

Pulmonary function and functional capacity gets compromised and reduced after open abdominal surgery. We assessed whether Preoperative physiotherapy education (POPE) along with postoperative physiotherapy (POP) preserve pulmonary function and functional capacity after open abdominal surgery among Pediatric population. Hence, the goal of this study was to determine the effectiveness of POPE combined with POP against the standard treatment care of, Postoperative physiotherapy (POP) only in improving pulmonary function and functional capacity in pediatric open abdominal surgery.

METHODS

Twenty one children aged, 5-17 years old undergoing the open abdominal surgery were randomized to POPE and POP group (Intervention arm 1) and Postoperative physiotherapy group (POP) only group (Intervention arm 2). Primary outcome measure was pulmonary function measured by computerized spirometry. Six minute walk test (6MWT), Ten meter walk test (10mWT), Timed up and go test (TUGT) and Nine stair climbing test (9SCT) were used as secondary outcome measures to measure functional capacity along with chest expansion. Pulmonary function measured by spirometery, 10mWT, TUG and chest expansion were measured 1 day before undergoing abdominal surgery (Pre-OP), post-operative day 1 (POD1) and post-operative day 5 (POD5) while 6MWT and 9SCT were measured only at POD1 and POD5.

RESULTS

Eighteen children who were undergoing open abdominal surgery completed this trial. No statistical difference were noted in Spirometric parameters from Pre-OP to POD5 in both the groups, they are almost approximate to preoperative values, but from POD1 to POD5, statistical difference were noted in all the Spirometric parameters in Intervention arm 1 as compared to Intervention arm 2. Statistical significant improvement (p < 0.05) were noted in TUGT, 10mWT, 9SCT from Pre-OP to POD5 and from POD1 to POD5 also in Intervention arm 1 as compared to Intervention arm 2.

CONCLUSION

There is sufficient evidence to confirm that POPE combined with POP might improve pulmonary function and functional capacity in children undergoing open abdominal surgery.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level I.

Thoracic Surgeon Impressions of the Impact of the COVID-19 Pandemic on Lung Cancer Care-Lessons from the First Wave in Canada

BACKGROUND

COVID-19 has invariably changed the way lung cancer surgical care is provided in Canada. Despite relevant management guidelines, the way in which cancer care has been affected has yet to be described for thoracic surgical populations. Routine lung cancer physiologic and staging assessments are unique in that they are droplet producing and aerosolizing procedures. Our objective was to quantify the effect of the COVID-19 pandemic on surgical lung cancer care as perceived by practicing thoracic surgeons during the first wave of the pandemic in Canada.

METHODS

An electronic survey was distributed to members of the Canadian Association of Thoracic Surgeons. The survey was designed to determine surgeon perception of lung cancer preoperative care during the Canadian pandemic-instilled period of resource reallocation compared to standard care. Planned analyses were exploratory in nature; with count and frequency distributions of responses quantified.

RESULTS

Fifty-three thoracic surgeons completed the survey. Responses were collected from all Canadian provinces. Little change in access to preoperative imaging was noted. However, a significant decrease in access to lung function and bronchoscopy testing occurred. Pulmonary surgery was perceived to be lengthier with reduced operating theater availability. Despite decreased OR access, only 40% of surgeons were aware of respective institutional mitigation strategies.

SUMMARY

The COVID-19 pandemic has had an impact on standard lung cancer care preoperative workup. Further inquiry using institutional data is warranted to quantify its impact on cancer patient outcomes. Assessing the extent and effects of newly present barriers to standard lung cancer care is essential in forming appropriate mitigation strategies and planning for future pandemic waves.

Effect of thoracic paravertebral nerve block on the early postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery

Objective

To evaluate the effect of thoracic paravertebral nerve block on early postoperative rehabilitation in patients undergoing radical thoracoscopic surgery for lung cancer.

Methods

Ninety patients scheduled for elective video-assisted thoracoscopic lobectomy of lung cancer were divided into 2 groups: the general anesthesia group (GA group, n = 45) and the TPVB group (TP group, n = 45). The primary outcome was the decline rate of the 6-min walking test (6MWT); the second outcomes were as follows: absolute value and the completion rate of 6MWT, postoperative analgesia deficiency and pain scores, oxycodone consumption, sleep quality, the incidence of postoperative pulmonary complications, and the hospital stay.

Results

Compared with the GA group, the TP group had a lower decline rate of the 6MWT on POD1 and POD2. The walking distance on POD1 and POD2 in the TP group was significantly longer than that in the GA group; the completion rate at POD1 in the TP group was higher than that in the GA group. The pain scores and oxycodone consumption at POD1 in the TP group were lower than the GA group. The sleep quality in the TP group was higher than the GA group.

Conclusions

TPVB can significantly improve postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery, which is helpful for promoting the early recovery of patients.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1900026213. Registered 26 Sept. 2019, http://www.chictr.org.cn/showproj.aspx?proj=43733.

Preserving pulmonary function and functional capacity in children undergoing open abdominal surgery: A one group pretest-posttest, quasiexperimental pilot trial

PURPOSE

The aim of this trial was to determine the effects of Preoperative physiotherapy education (POPE) and Postoperative physiotherapy (POP) maintaining pulmonary function and functional capacity in children undergoing open abdominal surgery.

METHODS

A total of eight children aged, 5-17 years old posted for open abdominal surgery received POPE and POP. Spirometry, 10 m walk test (10mWT), timed up and go test (TUGT) and chest expansion were taken preoperatively and postoperatively on day one and five. Six minute walk test (6MWT), and Nine stair climbing test (9SCT) were taken preoperatively and postoperatively on day five.

RESULTS

No statistical significant difference were noted in FVC, FEV1, PEFR, FEV1/FVC Ratio, chest expansion levels and Borg scale but in TUGT, 10mWT, 6MWT and 9SCT significant difference was noted. Effect size were calculated and post hoc power analysis revealed that the power of the study is >90%.

CONCLUSION

POPE might have positive effects in preserving pulmonary function and functional capacity.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level II.

Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes

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.

Performance in 6-min walk test in prediction of post-operative pulmonary complication in major oncosurgeries: A prospective observational study

Background and Aims

Post-operative pulmonary complications (PPC) contribute to increased morbidity and mortality, necessitating pre-operative functional assessment. Six-minute walk test (6MWT) is a simple option for functional assessment.

Methods

This is a prospective observational study conducted in 75 patients who underwent elective abdominal or thoracic oncosurgery under general anaesthesia with either age above 60 years or with cardiopulmonary diseases or obstructive sleep apnoea or low serum albumin or smoking. Patients with history of acute coronary syndrome in past 6 months, dyspnoea at rest, severe pain, inability to walk or interpret instructions and haemodynamic instability were excluded. Preoperatively 6MWT was conducted according to the American Thoracic Society guidelines and patients were observed for PPC. Patients were divided into two groups: group 1-no PPC and group 2-developed PPC. Statistical analysis was done using SPSS software (version 11.0.1). Categorical variables were assessed using Chi-square/Fisher's exact test and continuous variables using student's t-test/Mann-Whitney U test. Association was tested using logistic regression.

Results

Out of the 75 patients, 40 patients had no PPC (group 1) and 35 patients had PPC (group 2) including a death. The 6MWD of group with PPCs was significantly less (344 ± 61.927 m) compared to the group without PPCs (442.28 ± 83.194 m, P value = 0.001). The cut-off 6MWD obtained was 390 m, which correlated with longer duration of hospital stay and ICU stay (P = 0.001).

Conclusion

Six-minute walk test is a reliable predictor of post-operative pulmonary complications with a cut-off 6MWD of 390 m in the studied oncosurgery patients.

Interstitial Lung Disease in Systemic Sclerosis: Focus on Early Detection and Intervention

Systemic sclerosis (SSc) is a progressive and often devastating disease characterized by autoimmune dysfunction, vasculopathy, and fibrosis. Interstitial lung disease (ILD) is identified in the majority of patients with SSc and is the leading cause of SSc-related mortality. Although clinical manifestations and ILD severity vary among patients, lung function typically declines to the greatest extent during the first 3-4 years after disease onset. We aim to provide an overview of SSc-associated ILD (SSc-ILD) with a focus on current and emerging tools for early diagnosis of ILD and current and novel treatments under investigation. Early detection of ILD provides the opportunity for early therapeutic intervention, which could improve patient outcomes. Thoracic high-resolution computed tomography is the most effective method of identifying ILD in patients with SSc; it enables detection of mild lung abnormalities and plays an important role in monitoring disease progression. Cyclophosphamide and mycophenolate mofetil are the most commonly prescribed treatments for SSc-ILD. Recently, nintedanib (an antifibrotic) was approved by the Food and Drug Administration for patients with SSc-ILD; it is indicated for slowing the rate of decline in pulmonary function. However, there is a need for additional effective and well-tolerated disease-modifying therapy. Ongoing studies are evaluating other antifibrotics and novel agents. We envision that early detection of lung involvement, combined with the emergence and integration of novel therapies, will lead to improved outcomes in patients with SSc-ILD.

Prehabilitation: how to prepare our patients for elective major abdominal surgeries?

Surgical approach is the main form of treatment for several diseases of the abdominal cavity. However, surgical procedure itself is a stressor that may lead to adverse effects unrelated to the treatment goal. Prehabilitation has emerged as a multifactorial preoperative health conditioning program, which promotes improvement in functional capacity and postoperative evolution. The present study reviews literature using MEDLINE, Ovid, Google Scholar, and Cochrane databases in order to determine the concept of prehabilitation program and the indications and means of patient selection for it, as well as to suggest ways to implement this program in cases of major abdominal surgeries.

Role and impact of multimodal prehabilitation for gynecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) program

Patients undergoing major surgery are predisposed to a decrease in functional capacity as a response to surgical stress that can delay post-operative recovery. A prehabilitation program consists of patient preparation strategies before surgery, and include pre-operative measures to improve functional capacity and enhance post-operative recovery. Multimodal prehabilitation may include exercise, nutritional counseling, psychological support, and optimization of underlying medical conditions, as well as cessation of unfavorable health behaviors such as smoking and drinking. Currently, there are no standardized guidelines for prehabilitation, and the existent studies are heterogeneous; however, multimodal approaches are likely to have a greater impact on functional outcomes than single management programs. We have reviewed the literature on prehabilitation in general, and in gynecologic surgery in particular, to identify tools to establish an optimal prehabilitation program within an Enhanced Recovery After Surgery (ERAS) protocol for gynecologic oncology patients. We suggest a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support. The analysis of the prehabilitation program implementation in an ERAS protocol should undergo further research in order to test the efficacy on surgical outcome and recovery after surgery.

Association between early pulmonary complications after abdominal surgery and preoperative physical capacity

Objective: To investigate whether early postoperative pulmonary complications after abdominal surgery are associated with a lower performance in preoperative six-minute walk test.Methods: A cross-sectional cohort study of 50 participants who underwent elective abdominal surgery and performed the six-minute walk test within 48 hours prior to surgery were conducted. Postoperative pulmonary complications up to the seventh postoperative day were obtained from medical records.Results: Overall, 25 participants developed postoperative pulmonary complications. The mean (standard deviation) preoperative walked distances of the participants with and without postoperative pulmonary complications were, respectively, 444.8 (81.3) meters and 498.3 (63.7) meters (p = .013). The incidence of postoperative pulmonary complications was greater in the participants with walked distance < 400 meters. The multivariable logistic regression model revealed a significant association between postoperative pulmonary complications and preoperative walked distance (Odds ratio = 0.978, p = .010) in participants who underwent intestinal, stomach, or bile tract resection. Conclusions: This study found a high incidence of postoperative pulmonary complications in abdominal surgery participants and an association between lower preoperative physical capacity and the risk of postoperative pulmonary complications in participants who underwent intestinal, stomach, and biliary tract resection.

Home-Based Exercise Prehabilitation During Preoperative Treatment for Pancreatic Cancer Is Associated With Improvement in Physical Function and Quality of Life

Purpose: To investigate relationships among physical activity, changes in physical function, and health-related quality of life (HRQOL) among patients with pancreatic adenocarcinoma enrolled in a home-based exercise prehabilitation program. Methods: Patients with resectable pancreatic adenocarcinoma receiving preoperative chemotherapy and/or chemoradiation were enrolled on this prospective, single-arm trial and were advised to perform ≥60 minutes each of moderate-intensity aerobic exercise and strengthening exercise weekly. Activity was measured via self-report and accelerometers, including moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and sedentary activity (SA). Physical function measures at baseline and restaging follow-up included 6-minute walk test (6MWT), 5 times sit-to-stand (5×STS), handgrip strength (HGS), 3-m walk for gait speed (GS), and the PROMIS Physical Function Short Form. HRQOL was measured via the FACT-Hep questionnaire. Results: Fifty participants with mean age 66 years (standard deviation = 8 years) were enrolled. The 6MWT, 5×STS, and GS significantly improved from baseline to restaging follow-up (P=.001, P=.049, and P=.009, respectively). Increases in self-reported aerobic exercise, weekly MVPA, and LPA were associated with improvement in 6MWT (β=.19, P=.048; β=.18, P=.03; and β=.08, P=.03, respectively) and self-reported physical functioning (β=.02, P=.03; β=.03, P=.005; and β=.01, P=.02, respectively). Increased weekly LPA was associated with increased HRQOL (β=.03, P=.02). Increased SA was associated with decreased HRQOL (β=-.02,P=.01). Conclusions: Patients with potentially resectable pancreatic cancer exhibit meaningful improvement in physical function with prehabilitation; physical activity was associated with improved physical function and HRQOL. These data highlight the importance of physical activity during treatment for pancreatic cancer.

Preoperative 6-minute walk distance accurately predicts postoperative complications after operations for hepato-pancreato-biliary cancer

BACKGROUND

Operation for hepato-pancreato-biliary cancer is among the most invasive open abdominal operations, with a high postoperative morbidity and mortality rate. The purpose of the present study is to investigate whether a preoperative 6-minute walk distance can predict major postoperative complications after operation for hepato-pancreato-biliary diseases.

METHODS

A total of 81 participants who underwent pancreaticoduodenectomy, major hepatectomy with extrahepatic bile duct resection, or hepatopancreatoduodenectomy were included. The 6-minute walk distance was performed within 1 week before operation. Patients were categorized into 2 groups based on surgical complications: Clavien-Dindo grade <3 and Clavien-Dindo grade ≥3. Clinical differences between the 2 groups were analyzed. Multivariate logistic regression analysis was performed to identify risk factors for postoperative complications that were categorized as Clavien-Dindo grade ≥3.

RESULTS

The multiple logistic regression model revealed a significant correlation between major postoperative complications and preoperative low 6-minute walk distance, low body mass index, and major blood loss. In patients with 6-minute walk distance <400 m (1,312 feet), the Clavien-Dindo grade was considerably greater than patients with ≥400 m.

CONCLUSION

The 6-minute walk distance is useful in identifying patients with a greater chance of developing major postoperative complications after surgery for hepato-pancreato-biliary cancer.

Recent trends in surgical research of cancer treatment in the elderly, with a primary focus on lung cancer: Presentation at the 2015 annual meeting of SIOG

Surgical research concentrating on cancer in the elderly has changed from small single institution outcome studies of carefully selected patients to larger studies that test specific aspects of surgical selection, treatment, and outcome. The purpose of this paper is to review major new trends in surgical geriatric oncology research within the last decade. Reviewing PubMed listings of the last 10years reveals several identifiable areas of particular concentration. Although we use specific studies primarily from lung cancer treatment, the generalizations can be seen across the spectrum of geriatric cancers. These trends include screening for disease that can be successfully treated, integration of operative and non-operative therapies that are changing the indications for surgery, the use of prehabilitation to allow more borderline frail patients to be treated surgically, the use of rehabilitation to facilitate rapid and complete recovery, prevention and treatment of common morbidities, with a special recent focus on delirium and cognitive impairment. New areas of surgical research include research on team building in the OR and ICU. Recent surgical research is becoming quantitative and multi-institutionally based. Overall surgical mortality has dropped over the past 25years in both academic and community hospitals. Prevention of morbidity and loss of functional status is a major focus of research. Funding for new Quality Assurance Projects for elderly patients has been awarded to the American College of Surgeons, and should provide multi-institutional quality outcome data within 5years.