Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing open cardiothoracic or upper abdominal surgery: protocol for a systematic review

Comparison of an expiratory flow accelerator device versus positive expiratory pressure for tracheobronchial airway clearance after lung cancer lobectomy: a preliminary study

OBJECTIVE

A new type of device has recently been introduced in chest physiotherapy as an aid to tracheo-bronchial airway clearance: expiratory flow accelerator (EFA). It promotes mucus clearance without generating any pressure gradient, allowing patients to breathe at tidal volume against no resistance.

DESIGN

Pilot randomized controlled study.

SETTING

Tertiary hospital.

PARTICIPANTS

Fifty adult patients who underwent lung cancer lobectomy were randomized to undergo chest physiotherapy with EFA (n=26) or PEP (n=24).

INTERVENTIONS

EFA; PEP bottle.

MAIN OUTCOMES

Incidence of postoperative pulmonary complications (PPC) and length of stay.

SECONDARY OUTCOMES

trends in inspiratory capacity, respiratory rate, oxygen saturation, and dyspnoea. Patients rated user-friendliness of the two devices on a 5-point Likert scale.

RESULTS

A slightly different incidence of PPCs was observed between the EFA and PEP group. Nevertheless, the length of stay was similar in the two groups. No substantial differences were seen in trends of inspiratory capacity, respiratory rate, oxygen saturation, dyspnoea between the two groups. Patient-reported user-friendliness of the two devices did not differ significantly, although the use of the EFA device appeared less strenuous.

CONCLUSIONS

Results of this pilot study point to the use of EFA as an alternative treatment option rather than as a replacement for the PEP bottle in chest physiotherapy following lung cancer lobectomy. EFA may be preferable for weaker patients and/or with airway leakages in whom PEP has limited indications. Further investigation in a larger sample is required to statistically confirm the findings. Clinical Trial Registration Number ChiCTR-ONC-17013255.

The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review

AIM

Prehabilitation, defined as enhancement of the preoperative condition of a patient, is a possible strategy for improving postoperative outcome. Lack of muscle strength and poor physical condition, increasingly prevalent in older patients, are risk factors for postoperative complications. Eighty-five per cent of patients with colorectal cancer are aged over 60 years. Since surgery is the cornerstone of their treatment, this review systemically examined the literature on the effect of physical prehabilitation in older patients undergoing colorectal surgery.

METHOD

Trials and case-control studies investigating the effect of physical prehabilitation in patients over 60 years undergoing colorectal surgery were retrieved from MEDLINE, EMBASE, CINAHL and the Cochrane library. Patient characteristics, the type of intervention and outcome measurements were recorded. The risk of bias and heterogeneity was assessed.

RESULTS

Five studies including 353 patients were identified. They were small, containing an average of 77 patients and were of moderate methodological quality. Compliance rates of the prehabilitation programme varied from 16 to 97%. None of the studies could identify a significant reduction of postoperative complications or length of hospital stay. Four studies showed physical improvement (walking distance, respiratory endurance) in the prehabilitation group. Clinical heterogeneity precluded a meta-analysis.

CONCLUSION

Prehabilitation is a possible means of enhancing the physical condition of patients preoperatively. The quality of studies in older patients undergoing colorectal surgery is poor, despite the increase in elderly people with colorectal cancer. Defining specific patient groups at risk and standardizing the outcome are essential for improving the results of treatment.

Open abdominal surgery: a risk factor for future laparoscopic surgery?

BACKGROUND

This study seeks to investigate the outcomes of laparoscopic procedures in patients with previous open abdominal surgery.

METHODS

Using data from the National Surgical Quality Improvement Program (2005 to 2009), we identified patients who had undergone laparoscopic cholecystectomy, Nissen fundoplication, Heller myotomy, splenectomy, Roux-en-Y, sleeve gastrectomy, gastric band, appendectomy, or colectomy. Patients were then classified as to whether adhesiolysis (AD) was also carried out. Bivariate and multivariate analysis was used to compare groups.

RESULTS

A total of 162,415 patients met our inclusion criteria, comprising 4,501 (3%) in the AD group and 157,913 (97%) in the nonadhesiolysis (NAD) group. Patient who had received lysis of adhesion were older, had 41% higher odds of overall complications, 17% higher adjusted mean lysis of adhesion (P < .001), and 26% higher adjusted mean operation duration (P < .001).

CONCLUSIONS

A history of previous open abdominal surgery increases the potential complication rate and hospital length of stay during subsequent laparoscopic surgery. The extent of this relationship deserves further investigation.

Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis

Objective:

To evaluate whether preoperative inspiratory muscle training is effective in preventing postoperative pulmonary complications and reducing length of hospital stay in people undergoing cardiothoracic or upper abdominal surgery.

Data sources:

Medline, CINAHL, AMED, PsychINFO, Scopus, PEDro, and the Cochrane Library.

Review methods:

A systematic review and meta analysis of randomized controlled trials (or quasi-randomized controlled trials) investigating a form of preoperative inspiratory muscle training, compared with sham or no inspiratory muscle training. Participants were adults (16 years and over) awaiting elective open cardiac, thoracic, or upper abdominal surgery. Methodological quality was assessed using the PEDro scale.

Results:

Eight studies involving 295 participants were eligible for inclusion. The trained group had significantly higher maximal inspiratory pressure at the end of the preoperative training period (mean difference: 15 cm H2O, 95% confidence interval (CI): 9 to 21). This benefit was maintained through the early postoperative period, when lung function also recovered significantly more quickly in the trained group. Inspiratory muscle training also substantially reduced postoperative pulmonary complications (relative risk 0.48, 95% CI 0.26 to 0.89). Although not statistically significant, length of hospital stay also tended to favour the trained group. There were no statistically significant differences between the groups for the remaining outcomes. Participant satisfaction with inspiratory muscle training was high.

Conclusion:

Preoperative inspiratory muscle training significantly improves respiratory (muscle) function in the early postoperative period, halving the risk of pulmonary complications. The training does not increase length of stay, but more data are required to confirm whether it reduces length of stay.