Development of a reconditioning program for elderly abdominal surgery patients: the Elder-friendly Approaches to the Surgical Environment-BEdside reconditioning for Functional ImprovemenTs (EASE-BE FIT) pilot study

Comprehensive Peri-Operative Risk Assessment and Management of Geriatric Patients

Background: As the population ages, the prevalence of surgical interventions in individuals aged 65+ continues to increase. This poses unique challenges due to the higher incidence of comorbidities, polypharmacy, and frailty in the elderly population, which result in high peri-operative risks. Traditional preoperative risk assessment tools often fail to accurately predict post-operative outcomes in the elderly, overlooking the complex interplay of factors that contribute to risk in the elderly. Methods: A literature review was conducted, focusing on the predictive value of CGA for postoperative prognosis and the implementation of perioperative interventions. Results: Evidence shows that CGA is a superior predictive tool compared to traditional models, as it more accurately identifies elderly patients at higher risk of complications such as postoperative delirium, infections, and prolonged hospital stays. CGA includes assessments of frailty, sarcopenia, nutritional status, cognitive function, mental health, and functional status, which are crucial in predicting post-operative outcomes. Studies demonstrate that CGA can also guide personalized perioperative care, including nutritional support, physical training, and mental health interventions, leading to improved surgical outcomes and reduced functional decline. Conclusions: The CGA provides a more holistic approach to perioperative risk assessment in elderly patients, addressing the limitations of traditional tools. CGA can help guide surgical decisions (e.g., curative or palliative) and select the profiles of patients that will benefit from perioperative interventions to improve their prognosis and prevent functional decline.

Accuracy Validation of a Sensor-Based Inertial Measurement Unit and Motion Capture System for Assessment of Lower Limb Muscle Strength in Older Adults-A Novel and Convenient Measurement Approach

(1) Background: The aim of this study was to assess lower limb muscle strength in older adults during the transfer from sitting to standing (STS) using an inertial measurement unit (IMU). Muscle weakness in this population can severely impact function and independence in daily living and increase the risk of falls. By using an IMU, we quantified lower limb joint moments in the STS test to support health management and individualized rehabilitation program development for older adults. (2) Methods: This study involved 28 healthy older adults (13 males and 15 females) aged 60-70 years. The lower limb joint angles and moments estimated using the IMU were compared with a motion capture system (Mocap) (pair t-test, ICC, Spearman correlations, Bland-Altman plots) to verify the accuracy of the IMU in estimating lower limb muscle strength in the elderly. (3) Results: There was no significant difference in the lower limb joint angles and moments calculated by the two systems. Joint angles and moments were not significantly different (p > 0.05), and the accuracy and consistency of the IMU system was comparable to that of the Mocap system. For the hip, knee, and ankle joints, the ICCs for joint angles were 0.990, 0.989, and 0.885, and the ICCs for joint moments were 0.94, 0.92, and 0.89, respectively. In addition, the results of the two systems were highly correlated with each other: the r-values for hip, knee, and ankle joint angles were 0.99, 0.99, and 0.96, and the r-values for joint moments were 0.92, 0.96, and 0.85. In the present study, there was no significant difference (p > 0.05) between the IMU system and the Mocap system in calculating lower limb joint angles and moments. (4) Conclusions: This study confirms the accuracy of the IMU in assessing lower limb muscle strength in the elderly. It provides a portable and accurate alternative for the assessment of lower limb muscle strength in the elderly.

Phase 1 randomized trial of inpatient high-intensity interval training after major surgery

BACKGROUND

High-intensity interval training (HIT) can provide physiologic benefits and may improve postoperative recovery but has not been evaluated in inpatients. This study aimed to evaluate the safety and tolerability of HIT after major surgery.

METHODS

We performed a phase I randomized study comparing HIT with low-intensity continuous ambulation (40 m) during the initial inpatient stay after major surgery at a large academic center. Clinicopathologic and pre- and post-exercise physiologic data were captured. Perceived exertion was measured throughout the intervention.

RESULTS

Twenty-two subjects were enrolled and randomized with 90% (20 subjects, 10 per arm) completing all aspects of the study. One patient declined participation in the exercise intervention. The HIT and continuous ambulation groups were relatively similar in terms of median age (65.5 vs 63.5), female sex (20% vs 40%), White race (90% vs 90%), having a cancer diagnosis (100% vs 80%), undergoing gastrointestinal surgery (60% vs 80%), median Karnofsky score (60 vs 60), and ability to independently ambulate preoperatively (100% vs 90%). All subjects completed the exercise without protocol deviation, cohort crossover, or safety events. Compared with the continuous ambulation group, the HIT group had higher end median perceived exertion (5.0 [IQR, 5.5] vs 3.0 [IQR, 1.8]), shorter overall time to complete assigned exercise (56.6 seconds vs 91.8 seconds), and a trend toward higher median gait speed over 40 m (0.71 m/s vs 0.44 m/s, P = .126).

CONCLUSION

HIT in the hospitalized postoperative patient is safe and may be implemented to help promote positive physiologic outcomes and recovery.

Frailty, Illness Perception and Lung Functional Exercise Adherence in Lung Cancer Patients After Thoracoscopic Surgery

Background

Lung cancer patients will have lung damage after surgery, need rehabilitation exercise. Common-sense model has shown the impact of patients' perception of illness on health behaviors. However, for patients with lung cancer after thoracoscopic surgery, there has been no relevant exploration of disease perception.

Objective

The purpose of this study was to investigate the clinical status of patients with lung cancer patients who have undergone thoracoscopic surgery, and to explore the correlation between frailty, disease perception, and lung functional exercise compliance.

Methods

The cross-sectional study included 218 patients with lung cancer after thoracoscopic surgery. We collected participants' frailty, disease perception, exercise adherence, and relevant clinical information. T-test, Chi-square, Linear regression, Pearson's correlation, and mediation analysis were used for statistical analysis of patient data.

Results

We analyzed the data by disease perception with high and low median scores and found significant differences in lymphatic dissection, stool within three days, pain, thoracic drainage tube placement time. Linear regression results show that, after controlling for confounding factors, frailty and disease perception were significantly associated with pulmonary function exercise compliance. The higher the frailty score, the worse the compliance, and the higher the disease perception negative score, the less exercise. Illness perception played a partially mediating role in the association between frailty and lung functional exercise adherence.

Conclusion

Frailty and disease perception have an impact on exercise adherence, therefore, we need to consider these factors in the intervention to improve exercise compliance after thoracoscopic surgery for lung cancer.

Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia

BACKGROUND

Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning.

METHODS

A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses.

RESULTS

One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each.

CONCLUSIONS

Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.

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.

Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial

BACKGROUND

Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population.

METHODS

The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days.

RESULTS

Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care.

CONCLUSION

Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Age-related differences in morbidity and mortality after surgery for primary clinical T4 and locally recurrent rectal cancer

AIM

Outcomes in elderly patients (≥75 years) with non-advanced colorectal cancer have improved. It is unclear whether this is also true for elderly patients with clinical T4 rectal cancer (cT4RC) or locally recurrent rectal cancer (LRRC). We aimed to compare age-related differences in morbidity and mortality after curative treatment for cT4RC and LRRC.

METHODS

All cT4RC and LRRC patients without distant metastasis who underwent curative surgery between 2005 and 2017 in the Catharina Hospital (Eindhoven, The Netherlands) were included. Morbidity and mortality were evaluated based on age (<75 and ≥75 years) and date of surgery (2005-2011 and 2012-2017).

RESULTS

Overall, 72 of 474 (15.2%) cT4RC and 53 of 293 (18.1%) LRRC patients were ≥75 years. No significant differences in the incidence of Clavien-Dindo I-IV complications were observed between age groups. However, in elderly cT4RC patients, cerebrovascular accidents occurred more frequently (4.2% vs. 0.5%, P = 0.03). Between 2005-2011 and 2012-2017, 30-day mortality improved from 7.5% to 3.1% and from 10.0% to 0.0% in elderly cT4RC and LRRC patients, respectively. The 1-year mortality during 2012-2017 was worse in elderly than in younger patients (28.1% vs. 6.2%, P = 0.001 for cT4RC and 27.3% vs. 13.8%, P = 0.06 for LRRC). In elderly cT4RC and LRRC patients, 44.4% and 46.2% died due to non-cancer-related causes, while only 27.8% and 23.1% died due to disease recurrence, respectively.

CONCLUSION

Although the 30-day mortality in elderly cT4RC and LRRC patients improved after curative treatment, the 1-year mortality in elderly patients continued to be high, which requires more awareness for the elderly after hospitalization.

The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial

Background

Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer.

Methods

In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme.

Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used.

Discussion

This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients.

Trial registration

ClinicalTrials.gov. Clinical trial registration number NCT03998579. First posted June 26, 2019.

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.

Clinical Effectiveness of the Elder-Friendly Approaches to the Surgical Environment Initiative in Emergency General Surgery

Importance

Older adults, especially those with frailty, have a higher risk for complications and death after emergency surgery. Acute Care for the Elderly models have been successful in medical wards, but little evidence is available for patients in surgical wards.

Objectives

To develop and assess the effect of an Elder-Friendly Approaches to the Surgical Environment (EASE) model in an emergency surgical setting.

Design, Setting, and Participants

This prospective, nonrandomized, controlled before-and-after study included patients 65 years or older who presented to the emergency general surgery service of 2 tertiary care hospitals in Alberta, Canada. Transfers from other medical services, patients undergoing elective surgery or with trauma, and nursing home residents were excluded. Of 6795 patients screened, a total of 684 (544 in the nonintervention group and 140 in the intervention group) were included. Data were collected from April 14, 2014, to March 28, 2017, and analyzed from November 16, 2018, through May 30, 2019.

Interventions

Integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning.

Main Outcomes and Measures

Proportion of participants experiencing a major complication or death (composite) in the hospital, Comprehensive Complication Index, length of hospital stay, and proportion of participants who required an alternative level of care on discharge. Covariate-adjusted, within-site change scores were computed, and the overall between-site, preintervention-postintervention difference-in-differences (DID) were analyzed.

Results

A total of 684 patients were included in the analysis (mean [SD] age, 76.0 [7.6] years; 327 women [47.8%] and 357 men [52.2%]), of whom 139 (20.3%) were frail. At the intervention site, in-hospital major complications or death decreased by 19% (51 of 153 [33.3%] vs 19 of 140 [13.6%]; P < .001; DID P = .06), and mean (SE) Comprehensive Complication Index decreased by 12.2 (2.5) points (P < .001; DID P < .001). Median length of stay decreased by 3 days (10 [interquartile range (IQR), 6-17] days to 7 [IQR, 5-14] days; P = .001; DID P = .61), and fewer patients required an alternative level of care at discharge (61 of 153 [39.9%] vs 29 of 140 [20.7%]; P < .001; DID P = .11).

Conclusions and Relevance

To our knowledge, this is the first study to examine clinical outcomes associated with a novel elder-friendly surgical care delivery redesign. The findings suggest the clinical effectiveness of such an approach by reducing major complications or death, decreasing hospital stays, and returning patients to their home residence.

Trial Registration

ClinicalTrials.gov Identifier: NCT02233153.

How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer

Almost one third of colorectal cancer (CRC) cases are diagnosed in an emergency setting, mostly among geriatric patients. Clinical scenarios are often complex and decision making delicate. Besides the obvious need to consider the patient's and/or family and care givers' desires, the surgeon should be able to make the best educated guess on future outcomes in three areas: oncological prognosis, morbidity and mortality risk, and long-term functional loss. Using simple and brief tools for frailty screening reasonable treatment goals with curative or palliative intent can be planned. The most frequent clinical scenarios of CRC in emergency are bowel obstruction and perforation. We propose treatment algorithms based on assessment of the patient's overall reserve and discuss the indications, techniques and impact of a stoma in the geriatric patient. Bridge to surgery strategies may be best adapted to help the frail geriatric patient overcome the acute disease and maybe return to previous state of function. Post-operative morbidity and mortality rates are high in emergency surgery for CRC, but if the geriatric patient survives the post-operative period, oncological prognosis seems to be similar to younger patients. Because the occurrence of complications is the strongest predictor of functional decline and death, post-operative care plays a major role to optimize outcomes. Future studies should further investigate emergency surgery of CRC in the older adults focusing in particular on functional outcomes in order to help physicians counsel patients and families for a tailored treatment.

Emergency General Surgery in Older Adults: A Review

Older people are the fastest growing segment of the population and over-represented among people requiring emergency general surgery. Independent of comorbid and procedural factors, perioperative risk increases with increasing age. This effect is amplified with frailty or sarcopenia. Multidisciplinary perioperative care aligned with goals of care is most likely to achieve optimal patient and health system outcomes; however, substantial knowledge gaps exist in emergency general surgery for older people. Anesthesiologists are uniquely positioned to address these knowledge gaps, including optimizing goal-directed intraoperative care, appropriate provision of acute postoperative monitoring, and integration of principles of geriatric medicine in perioperative care.

Frailty predicts increased costs in emergent general surgery patients: A prospective cohort cost analysis

BACKGROUND

Aging populations have led to increasing numbers of seniors presenting for emergency surgery. Older patients are at a higher risk of postoperative complications, prolonged hospitalization, and increased institutionalization. We hypothesized that increased frailty would be a risk factor for increased health care costs in elderly surgical patients who have undergone emergency abdominal surgery.

METHODS

A prospective cost analysis of emergency general surgery patients 65 years of age and older was conducted. Demographic and clinical characteristics were obtained. Preadmission Clinical Frailty Scale score and Clavien-Dindo postoperative complications were collected. Patients were followed for 6 months after discharge. Hospitalization costs were calculated using the Alberta Health Services (AHS) microcosting database; other costs were obtained from Alberta Health Services and Alberta Health databases. The primary outcome was total insured cost (2016 Can$). Multivariate generalized linear regression of log-transformed costs was conducted.

RESULTS

Overall, 321 patients were enrolled. Mean age was 76.1 years (standard deviation 7.8), median Clinical Frailty Scale was 3, mean length of stay was 15.9 days (standard deviation 23.4), and 48% suffered a complication. Median total insured cost was Can$18,021 and median total cost was Can$26,739. Multivariate analysis found American Society of Anesthesiologists score (adjusted ratio [AR] = 1.24, P = .001), CFS (AR = 1.27, P < .001), major complications (AR = 2.11, P < .001), and minor complications (AR = 1.48, P < .001) lead to increased total insured costs.

CONCLUSION

Costs increased-after adjusting for age, comorbidities, and preadmission function as frailty-and American Society of Anesthesiologists score increased if minor or major complications occurred. The detection of frailty represents an opportunity to target risk-reduction strategies and interventions to improve outcomes and decrease cost.

The significant impact of age on the clinical outcomes of laparoscopic appendectomy: Results from the Polish Laparoscopic Appendectomy multicenter large cohort study

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

Background

Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone.

Methods

The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery.

Discussion

The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial.

Trial registration

ACTRN 12615000318583. Registered 8 April 2015

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0189-y) contains supplementary material, which is available to authorized users.