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Su J, Huang W, Yu P. Effect of inspiratory muscle training in esophageal cancer patients receiving esophagectomy: A meta-analysis of randomized controlled trials. PLoS One 2024; 19:e0307069. [PMID: 39012869 PMCID: PMC11251638 DOI: 10.1371/journal.pone.0307069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 06/30/2024] [Indexed: 07/18/2024] Open
Abstract
PURPOSE To identify the clinical effect of inspiratory muscle training (IMT) among esophageal cancer patients undergoing esophagectomy based on randomized controlled trials (RCTs). METHODS Several databases were searched for relevant RCTs up to August 23, 2023. Primary outcomes were respiratory muscle function, including the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), and pulmonary function, including the forced expiratory volume in one second % (FEV1%), forced vital capacity% (FVC%), maximal ventilator volume (MVV), FEV1/FVC% and FVC. The secondary outcomes were exercise performance, including the six-minute walk distance test (6MWT) and Borg index; mental function and quality of life, as evaluated by the Hospital Anxiety Depression Scale (HADS) and Nottingham Health Profile (NHP) score; and postoperative complications. All the statistical analyses were performed with REVMAN 5.3 software. RESULTS Eight RCTs were included in this meta-analysis, with 368 patients receiving IMT and 371 control subjects. The pooled results demonstrated that IMT could significantly enhance respiratory muscle function (MIP: MD = 7.14 cmH2O, P = 0.006; MEP: MD = 8.15 cmH2O, P<0.001) and pulmonary function (FEV1%: MD = 6.15%, P<0.001; FVC%: MD = 4.65%, P<0.001; MVV: MD = 8.66 L, P<0.001; FEV1/FVC%: MD = 5.27%, P = 0.03; FVC: MD = 0.50 L, P<0.001). Furthermore, IMT improved exercise performance (6MWT: MD = 66.99 m, P = 0.02; Borg index: MD = -1.09, P<0.001), mental function and quality of life (HADS anxiety score: MD = -2.26, P<0.001; HADS depression score: MD = -1.34, P<0.001; NHP total score: MD = -48.76, P<0.001). However, IMT did not significantly decrease the incidence of postoperative complications. CONCLUSION IMT improves clinical outcomes, such as respiratory muscle function and pulmonary function, in esophageal cancer patients receiving esophagectomy and has potential for broad applications in the clinic.
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Affiliation(s)
- Jianhua Su
- Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wei Huang
- Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Pengming Yu
- Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Loughney L, Bolger J, Tully R, Sorensen J, Bambrick M, Carroll PA, Arumugasamy M, Murphy TJ, McCaffrey N, Robb WB. The effect of a pre- and post- operative exercise program versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): a randomized controlled trial. Int J Surg 2024; 110:01279778-990000000-01730. [PMID: 38935085 PMCID: PMC11487022 DOI: 10.1097/js9.0000000000001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/09/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window. METHODS A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery. RESULTS Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures. CONCLUSIONS This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT.
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Affiliation(s)
- Lisa Loughney
- ExWell Medical, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland
| | - Jarlath Bolger
- Department of Surgery, Royal College of Surgeons in Ireland
- Department of Upper GI Surgery, Beaumont Hospital
| | - Roisin Tully
- Department of Surgery, Royal College of Surgeons in Ireland
- Department of Upper GI Surgery, Beaumont Hospital
| | - Jan Sorensen
- Department of Surgery, Royal College of Surgeons in Ireland
| | - Marie Bambrick
- Department of Surgery, Royal College of Surgeons in Ireland
- Department of Radiology, Beaumont Hospital, Dublin
| | | | - Mayilone Arumugasamy
- Department of Surgery, Royal College of Surgeons in Ireland
- Department of Upper GI Surgery, Beaumont Hospital
| | - Thomas J. Murphy
- Department of Upper GI Surgery, Mercy University Hospital, Cork, Ireland
| | | | - William B. Robb
- Department of Surgery, Royal College of Surgeons in Ireland
- Department of Upper GI Surgery, Beaumont Hospital
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Steffens D, Solomon M, Young J, Beckenkamp PR, Bartyn J, Koh C, Hancock M. A review of patient recruitment in randomised controlled trials of preoperative exercise. Clin Trials 2024; 21:371-380. [PMID: 38149306 DOI: 10.1177/17407745231219270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Randomised controlled trials (RCTs) are considered the gold standard design to determine the effectiveness of an intervention, as the only method of decreasing section bias and minimising random error. However, participant recruitment to randomised controlled trials is a major challenge, with many trials failing to recruit the targeted sample size accordingly to the planned protocol. Thus, the aim of this review is to detail the recruitment challenges of preoperative exercise clinical trials. METHODS A comprehensive search was performed on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED and PsycINFO from inception to July 2021. Randomised controlled trials investigating the effectiveness of preoperative exercise on postoperative complication and/or length of hospital stay in adult cancer patients were included. Main outcomes included recruitment rate, retention rate, number of days needed to screen and recruit one patient and trial recruitment duration. Descriptive statistics were used to summarise outcomes of interest. RESULTS A total of 27 trials were identified, including 3656 patients screened (N = 21) and 1414 randomised (median recruitment rate (interquartile range) = 53.6% (25.2%-67.6%), N = 21). The sample size of the included trials ranged from 19 to 270 (median = 48.0; interquartile range = 40.0-85.0) and the duration of trial recruitment ranged from 3 to 50 months (median = 19.0 months; interquartile range = 10.5-34.0). Overall, a median of 3.6 days was needed to screen one patient, whereas 13.7 days were needed to randomise one participant. Over the trials duration, the median dropout rate was 7.9%. Variations in recruitment outcomes were observed across trials of different cancer types but were not statistically significant. CONCLUSION The recruitment of participants to preoperative exercise randomised controlled trials is challenging, but patient retention appears to be less of a problem. Future trials investigating the effectiveness of a preoperative exercise programme following cancer surgery should consider the time taken to recruit patients. Strategies associated with improved recruitment should be investigated in future studies.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, Sydney, NSW, Australia
| | - Paula R Beckenkamp
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Mark Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Jiang W, Brown KGM, Koh C, Karunaratne S, Solomon M, Beckenkamp PR, Cole R, Steffens D. Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges? J Surg Res 2024; 296:366-375. [PMID: 38306943 DOI: 10.1016/j.jss.2023.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/11/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery. METHODS A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality). RESULTS A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]). CONCLUSIONS Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.
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Affiliation(s)
- Wilson Jiang
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Paula R Beckenkamp
- Faculty of Medicine and Health, Discipline of Physiotherapy, The University of Sydney, Camperdown, NSW, Australia
| | - Ruby Cole
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia.
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Furon Y, Dang Van S, Blanchard S, Saulnier P, Baufreton C. Effects of high-intensity inspiratory muscle training on systemic inflammatory response in cardiac surgery - A randomized clinical trial. Physiother Theory Pract 2024; 40:778-788. [PMID: 36637368 DOI: 10.1080/09593985.2022.2163212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Preoperative inspiratory muscle training reduces the incidence of postoperative pulmonary complications after cardiac surgery, but training protocols vary widely in terms of intensity. Currently, the mechanisms underlying the effectiveness of this practice are not known. The purpose of the present study is to determine whether preoperative high-intensity inspiratory muscle training (HI-IMT) modulates the perioperative systemic inflammatory response in cardiac surgery patients. METHODS Participants awaiting surgical aortic valve replacement were randomized to 3 to 6 weeks preoperative home-based HI-IMT or same duration low-intensity inspiratory muscle training (LI-IMT). The primary outcome was the preoperative value of the soluble tumor necrosis factor receptor 1 (sTNFR1). Secondary outcomes assessed perioperative evolution of the cytokines: sTNFR1, Tumor necrosis factor-α, Interleukin (IL)-6, IL-8, IL10, IL1β, and their combined z-score; reflecting post-training and postoperative inflammatory response. Perioperative pulmonary function and postoperative clinical outcomes were collected. RESULTS Between February 2018 and March 30, 2019 patients were randomized, to HI-IMT or LI-IMT. There were no differences between the groups in terms of baseline characteristics. The median (IQR) training duration was 34 (28-44) days. After training, the median (IQR) predicted maximal inspiratory pressure was higher in the HI-IMT vs LI-IMT group (119 (96-142%) vs 97 (81-107%); p = .04) Levels of the sTNFR1 cytokine increased during training in the HI-IMT group, pre vs post training (Median (IQR) 1073 (920; 1219) vs 1172 (965; 1368) ng/L; p = .03). The 24-h postoperative global inflammatory score was lower in the HI-IMT than in the LI-IMT group (Median (IQR), -0.37 (-0.62, 0.03) vs -0.10 (-0.17, 0.49), p = .04). Global inflammatory scores were not different at other time points. There were no significant differences between the groups in post-operative pulmonary function and postoperative clinical outcome. CONCLUSION High intensity inspiratory muscle training shows immunomodulatory properties. These properties could explain why preoperative inspiratory muscle training can lead to lung protection after cardiac surgery.
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Affiliation(s)
- Yoakim Furon
- Department of Physical and Rehabilitation Medicine, University Hospital of Angers, Angers, France
| | - Simon Dang Van
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Simon Blanchard
- Laboratory of Immunology and Allergology, University Hospital of Angers, Angers, France
| | - Patrick Saulnier
- Research Department Unit, University Hospital of Angers, Angers, France
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Elliott JA, Guinan E, Reynolds JV. Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer. Dis Esophagus 2024; 37:doad062. [PMID: 37899136 PMCID: PMC10906714 DOI: 10.1093/dote/doad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/28/2023] [Indexed: 10/31/2023]
Abstract
Esophagectomy is an exemplar of complex oncological surgery and is associated with a relatively high risk of major morbidity and mortality. In the modern era, where specific complications are targeted in prevention and treatment pathways, and where the principles of enhanced recovery after surgery are espoused, optimum outcomes are targeted via a number of approaches. These include comprehensive clinical and physiological risk assessment, specialist perioperative care by a high-volume team, and multimodal inputs throughout the patient journey that aim to preserve or restore nutritional deficits, muscle mass and function.
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Affiliation(s)
- Jessie A Elliott
- Trinity St. James’s Cancer Institute, Trinity College Dublin and St. James’s Hospital, Dublin, Ireland
| | - Emer Guinan
- Trinity St. James’s Cancer Institute, Trinity College Dublin and St. James’s Hospital, Dublin, Ireland
| | - John V Reynolds
- Trinity St. James’s Cancer Institute, Trinity College Dublin and St. James’s Hospital, Dublin, Ireland
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Stiger RJ, Williams MA, Gustafson OD, Woods A, Collett J. The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review. Disabil Rehabil 2024:1-24. [PMID: 38323587 DOI: 10.1080/09638288.2024.2310765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/19/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes. MATERIALS AND METHODS A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance). RESULTS 6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising. CONCLUSION Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.
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Affiliation(s)
- Robyn J Stiger
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
| | - Mark A Williams
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
- Oxford Allied Health Professions Research and innovations Unit (AHPRU), Oxford University Hospitals NHS Foundation Trust, UK
| | - Owen D Gustafson
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
- Oxford Allied Health Professions Research and innovations Unit (AHPRU), Oxford University Hospitals NHS Foundation Trust, UK
| | | | - Johnny Collett
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Brookes University, Oxford, UK
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Veziant J, Bouché O, Aparicio T, Barret M, El Hajbi F, Lepilliez V, Lesueur P, Maingon P, Pannier D, Quero L, Raoul JL, Renaud F, Seitz JF, Serre AA, Vaillant E, Vermersch M, Voron T, Tougeron D, Piessen G. Esophageal cancer - French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR). Dig Liver Dis 2023; 55:1583-1601. [PMID: 37635055 DOI: 10.1016/j.dld.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION This document is a summary of the French intergroup guidelines regarding the management of esophageal cancer (EC) published in July 2022, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org). METHODS This collaborative work was conducted under the auspices of several French medical and surgical societies involved in the management of EC. Recommendations were graded in three categories (A, B and C), according to the level of evidence found in the literature until April 2022. RESULTS EC diagnosis and staging evaluation are mainly based on patient's general condition assessment, endoscopy plus biopsies, TAP CT-scan and 18F FDG-PET. Surgery alone is recommended for early-stage EC, while locally advanced disease (N+ and/or T3-4) is treated with perioperative chemotherapy (FLOT) or preoperative chemoradiation (CROSS regimen) followed by immunotherapy for adenocarcinoma. Preoperative chemoradiation (CROSS regimen) followed by immunotherapy or definitive chemoradiation with the possibility of organ preservation are the two options for squamous cell carcinoma. Salvage surgery is recommended for incomplete response or recurrence after definitive chemoradiation and should be performed in an expert center. Treatment for metastatic disease is based on systemic therapy including chemotherapy, immunotherapy or combined targeted therapy according to biomarkers testing such as HER2 status, MMR status and PD-L1 expression. CONCLUSION These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice and are subject to ongoing optimization. Each individual case should be discussed by a multidisciplinary team.
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Affiliation(s)
- Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, University of Lille, Lille F-59000, France.
| | - Olivier Bouché
- Department of Digestive Oncology, CHU Reims, Reims, France
| | - T Aparicio
- Department of Gastroenterology and Digestive Oncology, AP-HP, Saint-Louis Hospital, Paris, France
| | - M Barret
- Gastroenterology Department, Cochin Hospital, APHP, Paris, France
| | - F El Hajbi
- Department of Oncology, Centre Oscar Lambret, Lille, France
| | - V Lepilliez
- Gastroenterology Department, Jean Mermoz Private Hospital, Ramsay Santé, Lyon, France
| | - P Lesueur
- Department of Radiation Oncology, Centre Guillaume le Conquérant, Le Havre, France
| | - P Maingon
- Department of Radiation Oncology, La Pitié-Salpêtrière, APHP, Sorbonne University, Paris, France
| | - D Pannier
- Department of Oncology, Centre Oscar Lambret, Lille, France
| | - L Quero
- Department of Radiation Oncology, Saint-Louis Hospital, APHP, Paris, France
| | - J L Raoul
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - F Renaud
- Department of Pathology, La Pitié-Salpêtrière, APHP, Sorbonne University, Paris, France
| | - J F Seitz
- Department of Digestive Oncology, La Timone, Aix Marseille Université, Marseille, France
| | - A A Serre
- Department of Radiotherapy, Centre Léon Bérard, Lyon, France
| | | | - M Vermersch
- Medical Imaging Department, Valencienne Hospital Centre, Valencienne 59300, France
| | - T Voron
- Department of General and Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, 184 rue du faubourg Saint-Antoine, Paris 75012, France
| | - D Tougeron
- Department of Gastro-Enterology and Hepatology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, University of Lille, Lille F-59000, France
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Okura K, Suto A, Sato Y, Takahashi Y, Hatakeyama K, Nagaki Y, Wakita A, Kasukawa Y, Miyakoshi N, Minamiya Y. Preoperative inspiratory muscle weakness as a risk factor of postoperative pulmonary complications in patients with esophageal cancer. J Surg Oncol 2023; 128:1259-1267. [PMID: 37671598 DOI: 10.1002/jso.27436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/25/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE We examined whether preoperative inspiratory muscle weakness (IMW) is a risk factor for postoperative pulmonary complications (PPCs) in patients with esophageal cancer who underwent subtotal esophagectomy. METHODS This single-center retrospective cohort study enrolled patients with esophageal cancer who underwent a scheduled subtotal esophagectomy between June 2020 and May 2022. Maximal inspiratory pressure (MIP) was measured as inspiratory muscle strength using a respiratory dynamometer, and we defined IMW as MIP < 80% of the predicted value. Our primary outcome comprised overall PPCs. We investigated the relationship between IMW and PPCs using the Bayesian logistic regression model. RESULTS After exclusion, 72 patients were included in this study. IMW was identified in 26 patients (36%), and PPCs developed in 28 patients (39%). Among patients with IMW, 15 (58%) developed PPCs. Preoperative IMW was associated with PPCs (mean odds ratio [OR]: 3.58; 95% credible interval [95% CrI]: 1.29, 9.73) in the unweighted model. A similar association was observed in the weighted model adjusted for preoperative and intraoperative contributing factors (mean OR: 4.15; 95% CrI: 2.04, 8.45). CONCLUSIONS Preoperative IMW was associated with PPCs in patients with esophageal cancer who underwent subtotal esophagectomy. This association remained after adjusting for preoperative and intraoperative contributing factors.
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Affiliation(s)
- Kazuki Okura
- Division of Rehabilitation, Akita University Hospital, Akita City, Japan
| | - Akiyoshi Suto
- Department of Data Science, Yokohama City University Graduate School of Data Science, Yokohama City, Japan
| | - Yusuke Sato
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Yusuke Takahashi
- Division of Rehabilitation, Akita University Hospital, Akita City, Japan
| | | | - Yushi Nagaki
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Akiyuki Wakita
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Yuji Kasukawa
- Department of Rehabilitation Medicine, Akita University Hospital, Akita City, Japan
| | - Naohisa Miyakoshi
- Department of Rehabilitation Medicine, Akita University Hospital, Akita City, Japan
| | - Yoshihiro Minamiya
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
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Kumar S, Parshad S, Bijyal S, Mittal G, Sikka G. A Comparison of Two Methods of Pre-operative Inspiratory Muscle Training on Post-operative Outcome Following Esophagectomy. Indian J Surg Oncol 2023; 14:956-962. [PMID: 38187852 PMCID: PMC10766938 DOI: 10.1007/s13193-023-01812-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/25/2023] [Indexed: 01/09/2024] Open
Abstract
Esophageal carcinoma is a multifaceted and complex disease of rapidly rising incidence that exerts an increasing social and financial burden on global healthcare systems. Esophagectomy is associated with high rates of peri- and post-operative morbidity and mortality because of complex anatomy, frail health of patients, and late diagnosis of the disease. The most common complication seen is post-operative pulmonary complication (PPC). This study was planned to compare and analyze the outcome of two different protocols of preoperative IMT program on the rate of PPCs in patients undergoing esophagectomy. Twenty patients who underwent esophagectomy for carcinoma esophagus were included in the study and were randomly divided into 2 groups of 10 each. Group A received IMT-HI training for 4 weeks, whereas the group B received IMT-E training for 4 weeks pre-operatively. All the patients included in the study underwent a baseline pulmonary assessment which included pulmonary function test (FVC, FEV1, and FEV1/FVC), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). Four-week preoperative IMT-HI lead to better outcome following esophagectomy as compared to IMT-E. Relative risk of PPC was 4:1 (IMT-E:IMT-HI). However, there was no statistically significant improvement in PFTs, MEP, and MIP from baseline or between two groups. The difference in PPC in two groups did not reach statistical significance despite the fact that relative risk of PPC was 4:1 (IMT-E:IMT-HI).
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Affiliation(s)
- Sushil Kumar
- Department of Surgical Oncology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana India
| | - Sanjeev Parshad
- Department of Surgical Oncology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana India
| | - Sajan Bijyal
- Department of Surgical Oncology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana India
| | - Gourav Mittal
- Department of General Surgery, Post Graduate Institute of Medical Sciences, Rohtak, Haryana India
| | - Gitanjali Sikka
- Department of Physiotherapy, Post Graduate Institute of Medical Sciences, Rohtak, Haryana India
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11
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Knight W, Moore JL, Whyte GP, Zylstra J, Lane AM, Pate J, Gervais-Andre L, Maisey N, Hill M, Tham G, Lagergren J, Kelly M, Baker C, Van Hemelrijck M, Goh V, Gossage J, Browning M, Davies AR. Prehabilitation exercise before oesophagectomy: long-term follow-up of patients declining/withdrawing from the program. Br J Surg 2023; 110:1668-1672. [PMID: 37611139 DOI: 10.1093/bjs/znad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/29/2023] [Accepted: 07/21/2023] [Indexed: 08/25/2023]
Affiliation(s)
- William Knight
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | | | - Greg P Whyte
- School of Sports and Exercise Sciences, Liverpool John Moore's University, Liverpool, UK
- Centre for Health and Human Performance, London, UK
| | - Janine Zylstra
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Sports and Exercise Sciences, Liverpool John Moore's University, Liverpool, UK
| | - Andrew M Lane
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - James Pate
- Centre for Health and Human Performance, London, UK
| | | | - Nick Maisey
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - Mark Hill
- Department of Oncology, Maidstone and Tunbridge Wells NHS Trust Hospitals, Maidstone, UK
| | - Gemma Tham
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
| | - Jesper Lagergren
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mark Kelly
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | - Cara Baker
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | | | - Vicky Goh
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
| | - James Gossage
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mike Browning
- Department of Oncology, Maidstone and Tunbridge Wells NHS Trust Hospitals, Maidstone, UK
| | - Andrew R Davies
- Guy's and St Thomas' Oesophago-gastric Centre, London, UK
- School of Cancer and Pharmaceutical, King's College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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12
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Bingül ES, Şentürk NM, Kaynar AM. Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection. Front Med (Lausanne) 2023; 10:1196981. [PMID: 37849492 PMCID: PMC10577193 DOI: 10.3389/fmed.2023.1196981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.
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Affiliation(s)
- Emre Sertaç Bingül
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Nüzhet Mert Şentürk
- Department of Anesthesiology, Acibadem University School of Medicine, Istanbul, Türkiye
| | - Ata Murat Kaynar
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- The Center for Innovation in Pain Care (CIPC), University of Pittsburgh, Pittsburgh, PA, United States
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA, United States
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13
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Harrison SL, Loughran KJ, Trevis J, Witharana P, Maier R, Hancock H, Bardgett M, Mathias A, Akowuah EF. Experiences of patients enrolled and staff involved in the prehabilitation of elective patients undergoing cardiac surgery trial: a nested qualitative study. Anaesthesia 2023; 78:1215-1224. [PMID: 37402349 DOI: 10.1111/anae.16082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
The purpose of this study was to understand the views and experiences of patients enrolled and staff involved in the prehabilitation of elective patients undergoing cardiac surgery trial. This sub-study was informed by normalisation process theory, a framework for evaluating complex interventions, and used consecutive sampling to recruit patients assigned to both the intervention and control groups. Patients and all staff involved in delivering the trial were invited to participate in focus groups, which were recorded, transcribed verbatim and subjected to reflexive thematic analysis. Five focus groups were held comprising 24 participants in total (nine patients assigned to the prehabilitation; seven assigned to control; and eight staff). Five themes were identified. First, preparedness for surgery reduced fear, where participants described that knowing what to expect from surgery and preparing the body physically increased feelings of control and subsequently reduced apprehension regarding surgery. Second, staff were concerned but trusted in a safe environment, describing how, despite staff's concerns regarding the risks of exercise in this population, the patients felt safe in their care whilst participating in an exercise programme in hospital. Third, rushing for recovery and the curious carer, where patients from both groups wanted to mobilise quickly postoperatively whilst staff visited patients on the ward to observe their recovery progress. Fourth, to survive and thrive postoperatively, reflecting staff and patients' expectations from the trial and what motivated them to participate. Fifth, benefits are diluted by lengthy waiting periods, reflecting the frustration felt by patients waiting for their surgery after completing the intervention and the fear about continuing exercise at home before they had been 'fixed'. To conclude, functional exercise capacity may not have improved following prehabilitation in people before elective cardiac surgery due to concerns regarding the safety of exercise that may have hindered delivery and receipt of the intervention. Instead, numerous non-physical benefits were elicited. The information from this qualitative study offers valuable recommendations regarding refining a prehabilitation intervention and conducting a subsequent trial.
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Affiliation(s)
- S L Harrison
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - K J Loughran
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - J Trevis
- Academic Cardiovascular Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - P Witharana
- Academic Cardiovascular Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - R Maier
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - H Hancock
- Newcastle University, Newcastle Upon Tyne, UK
| | - M Bardgett
- Newcastle University, Newcastle Upon Tyne, UK
| | - A Mathias
- Newcastle University, Newcastle Upon Tyne, UK
| | - E F Akowuah
- Cardiac Surgery, Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
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14
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Meißner C, Meyer F, Ridwelski K. Prehabilitation in elective surgical interventions - what must the general and abdominal surgeon know. Innov Surg Sci 2023; 8:93-101. [PMID: 38058772 PMCID: PMC10696941 DOI: 10.1515/iss-2023-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/02/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives For years, many efforts have been invested to prepare patients, in particular, those with reduced physical and psychic status, much better to provide and finally achieve better outocme if there is time available to provide several beneficial measures. Methods Therefore, the objective was to illustrate the concept and various single elements of a complex prehabilitation concept based on (i) selective references from the medical literature and (ii) own clinical experiences from clinical practice in general and abdominal surgery. Results Prehabiliation can be considered the solution of the efforts to improve preoperative status for patients in a disadvantageous status for almost all types of surgery and all other operative and/or interventional procedures. It is the targeted process to improve individual functionality and organ function before a planned (elective) surgical intervention; P. comprises basically nutritional, physical and psychological measures; P. focusses especially onto the elderly, frail and malnourished patients before a planned surgical intervention; the overall aim is to significantly improve final outcome characterized by shorter length of stay, lower complication rate and mortality as well as cost efficiency; P. is especially important in cancer surgery, in which the beneficial effects can be particularly implemented; P. programs and/or "Standard Operating Protocols" (SOP) may help to establish and materialize its single aspects and enhanced recovery after surgery (ERAS). There is still further potential to reliably establish and to utilize the options of prehabilitation measures as listed above. Conclusions Prehabiliation is an indispensable aspect in today's preparation for elective surgery, which needs to become obligatory part of the preparation measures to planned surgical interventions, which can further contribute to a better final outcome and ERAS as well as, in addtion, needs to be further developed and accomplished.
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Affiliation(s)
- Carl Meißner
- MVZ “Im Altstadtquartier”, General Surgery, Magdeburg, Germany
- Otto-von-Guericke University at Magdeburg, Institute for Quality Assurance in Operative Medicine, Magdeburg, Germany
| | - Frank Meyer
- Department of General, Abdominal, Vascular and Transplant Surgery, Otto-von-Guericke University at Magdeburg with University Hospital, Magdeburg, Germany
| | - Karsten Ridwelski
- Department of General and Abdominal Surgery, Municipal Hospital (“Klinikum Magdeburg gGmbH”), Magdeburg, Germany
- Otto-von-Guericke University at Magdeburg, Institute for Quality Assurance in Operative Medicine, Magdeburg, Germany
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15
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Lee Y, Samarasinghe Y, Javidan A, Tahir U, Samarasinghe N, Shargall Y, Finley C, Hanna W, Agzarian J. The fragility of significant results from randomized controlled trials in esophageal surgeries. Esophagus 2023; 20:195-204. [PMID: 36689016 DOI: 10.1007/s10388-023-00985-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023]
Abstract
While randomized controlled trials (RCTs) are regarded as one of the highest forms of clinical research, the robustness of their P values can be difficult to ascertain. Defined as the minimum number of patients in a study arm that would need to be changed from a non-event to event for the findings to lose significance, the Fragility Index is a method for evaluating results from these trials. This study aims to calculate the Fragility Index for trials evaluating perioperative esophagectomy-related interventions to determine the strength of RCTs in this field. MEDLINE and EMBASE were searched for RCTs related to esophagectomy that reported a significant dichotomous outcome. Two reviewers independently screened articles and performed the data extractions with risk of bias assessment. The Fragility Index was calculated using a two-tailed Fisher's exact test. Bivariate correlation was conducted to evaluate associations between the Fragility Index and study characteristics. 41 RCTs were included, and the median sample size was 80 patients [Interquartile range (IQR) 60-161]. Of the included outcomes, 29 (71%) were primary, and 12 (29%) were secondary. The median Fragility Index was 1 (IQR 1-3), meaning that by changing one patient from a non-event to event, the results would become non-significant. Fragility Index was correlated with P value, number of events, and journal impact factor. The RCTs related to esophagectomy did not prove to be robust, as the significance of their results could be changed by altering the outcome status of a handful of patients in one study arm.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Yasith Samarasinghe
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, University of Toronto, Toronto, ON, Canada
| | - Umair Tahir
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Christian Finley
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Wael Hanna
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - John Agzarian
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada.
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16
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Akdemir E, Sweegers MG, Vrieling A, Rundqvist H, Meijer RP, Leliveld-Kors AM, van der Heijden AG, Rutten VC, Koldewijn EL, Bos SD, Wijburg CJ, Marcelissen TAT, Bongers BC, Retèl VP, van Harten WH, May AM, Groen WG, Stuiver MM. EffectiveNess of a multimodal preHAbilitation program in patieNts with bladder canCEr undergoing radical cystectomy: protocol of the ENHANCE multicentre randomised controlled trial. BMJ Open 2023; 13:e071304. [PMID: 36882246 PMCID: PMC10008243 DOI: 10.1136/bmjopen-2022-071304] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Radical cystectomy (RC) is the standard treatment for patients with non-metastatic muscle-invasive bladder cancer, as well as for patients with therapy refractory high-risk non-muscle invasive bladder cancer. However, 50-65% of patients undergoing RC experience perioperative complications. The risk, severity and impact of these complications is associated with a patient's preoperative cardiorespiratory fitness, nutritional and smoking status and presence of anxiety and depression. There is emerging evidence supporting multimodal prehabilitation as a strategy to reduce the risk of complications and improve functional recovery after major cancer surgery. However, for bladder cancer the evidence is still limited. The aim of this study is to investigate the superiority of a multimodal prehabilitation programme versus standard-of-care in terms of reducing perioperative complications in patients with bladder cancer undergoing RC. METHODS AND ANALYSIS This multicentre, open label, prospective, randomised controlled trial, will include 154 patients with bladder cancer undergoing RC. Patients are recruited from eight hospitals in The Netherlands and will be randomly (1:1) allocated to the intervention group receiving a structured multimodal prehabilitation programme of approximately 3-6 weeks, or to the control group receiving standard-of-care. The primary outcome is the proportion of patients who develop one or more grade ≥2 complications (according to the Clavien-Dindo classification) within 90 days of surgery. Secondary outcomes include cardiorespiratory fitness, length of hospital stay, health-related quality of life, tumour tissue biomarkers of hypoxia, immune cell infiltration and cost-effectiveness. Data collection will take place at baseline, before surgery and 4 and 12 weeks after surgery. ETHICS AND DISSEMINATION Ethical approval for this study was granted by the Medical Ethics Committee NedMec (Amsterdam, The Netherlands) under reference number 22-595/NL78792.031.22. Results of the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05480735.
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Affiliation(s)
- Emine Akdemir
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Center for Quality of Life, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maike G Sweegers
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Center for Quality of Life, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alina Vrieling
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helene Rundqvist
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annemarie M Leliveld-Kors
- Department of Urology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Vera C Rutten
- Department of Urology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Evert L Koldewijn
- Department of Urology, Catharina Hospital, Eindhoven, The Netherlands
| | - Siebe D Bos
- Department of Urology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - Carl J Wijburg
- Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Tom A T Marcelissen
- Department of Urology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam University Medical Center Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands
| | - Martijn M Stuiver
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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17
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Waterland JL, Ismail H, Granger CL, Patrick C, Denehy L, Riedel B. Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study. Perioper Med (Lond) 2022; 11:32. [PMID: 35996196 PMCID: PMC9396890 DOI: 10.1186/s13741-022-00263-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery. Methods Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications. Results Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63–77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low—with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions. Conclusion Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12620000073909) retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-022-00263-2.
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Affiliation(s)
- Jamie L Waterland
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia. .,Department of Physiotherapy, The University of Melbourne, Melbourne, Australia. .,Peter MacCallum Cancer Centre, Division of Allied Health, Melbourne, Australia.
| | - Hilmy Ismail
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia.,The University of Melbourne, Centre for Integrated Critical Care, Melbourne, Australia
| | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.,Physiotherapy Department, The Royal Melbourne Hospital, Melbourne, Australia
| | - Cameron Patrick
- The University of Melbourne, Statistical Consulting Centre, School of Mathematics and Statistics, Melbourne, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Division of Allied Health, Melbourne, Australia
| | - Bernhard Riedel
- Peter MacCallum Cancer Centre, Department of Anaesthesia, Perioperative and Pain Medicine, Melbourne, Australia.,The University of Melbourne, Centre for Integrated Critical Care, Melbourne, Australia.,The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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18
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Janssen THJB, Fransen LFC, Heesakkers FFBM, Dolmans-Zwartjes ACP, Moorthy K, Nieuwenhuijzen GAP, Luyer MDP. Effect of a multimodal prehabilitation program on postoperative recovery and morbidity in patients undergoing a totally minimally invasive esophagectomy. Dis Esophagus 2022; 35:6455658. [PMID: 34875680 DOI: 10.1093/dote/doab082] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/15/2021] [Indexed: 12/11/2022]
Abstract
Postoperative morbidity following esophagectomy remains substantial. Studies in major abdominal surgery have shown that prehabilitation can improve postoperative outcomes. This single-center study investigated the influence of prehabilitation on postoperative outcomes in patients undergoing minimally invasive Ivor-Lewis esophagectomy (MIE-IL). Data were collected on patients that underwent a MIE-IL and received a fully standardized enhanced recovery after surgery (ERAS) program, between October 2015 and February 2020. The intervention group comprised patients enrolled in the PREPARE prehabilitation program. The control group comprised a retrospective cohort with similar ERAS care, prior to implementation of PREPARE. Postoperative outcomes included (functional) recovery, length of hospital stay (LOHS), cardiopulmonary complications (CPC) and other predefined outcomes. The PREPARE group comprised 52 and control group 43 patients. Median time to functional recovery was 6 vs. 7 days (P = 0.074) and LOHS 7 vs. 8 days (P = 0.039) in PREPARE and control patients, respectively. Hospital readmission rate was 9.6 vs. 14.3% (P = 0.484). A 17% reduction in thirty-day overall postoperative complication rate was observed in PREPARE patients, but this was not statistically significant (P = 0.106). Similarly, a clinically relevant reduction of 14% in CPC rate was observed (P = 0.190). Anastomotic leakage rate was similar (9.6 vs 14.0%; P = 0.511). Despite no difference in severity (Clavien-Dindo) of complications (P = 0.311), ICU readmission rate was lower in PREPARE patients (3.8 vs. 16.3%, P = 0.039). Prehabilitation prior to MIE-IL led to a shorter LOHS and reduced ICU readmission rate. Additionally, a clinically relevant improvement in postoperative recovery and reduced morbidity rate was observed in prehabilitated patient.
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Affiliation(s)
| | - Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | - Krishna Moorthy
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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19
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The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review. Cancers (Basel) 2022; 14:cancers14092096. [PMID: 35565226 PMCID: PMC9102916 DOI: 10.3390/cancers14092096] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Surgery is the only potentially curative treatment option for esophagogastric cancer. Although esophagectomy/gastrectomy remains associated with major surgical trauma and significant morbidity. Prehabilitation has emerged as a novel strategy to improve postoperative outcomes by preparing patients for a surgery-associated physiological challenge. We discuss current knowledge and the results of studies on the role of prehabilitation in esophagogastric cancer surgery. Abstract Esophagogastric cancer is among the most common malignancies worldwide. Surgery with or without neoadjuvant therapy is the only potentially curative treatment option. Although esophagogastric resections remain associated with major surgical trauma and significant postoperative morbidity. Prehabilitation has emerged as a novel strategy to improve clinical outcomes by optimizing physical and psychological status before major surgery through exercise and nutritional and psychological interventions. Current prehabilitation programs may be unimodal, including only one intervention, or multimodal, combining the benefits of different types of interventions. However, it still is an investigational treatment option mostly limited to clinical trials. In this comprehensive review, we summarize the current evidence for the role of prehabilitation in modern esophagogastric cancer surgery. The available studies are very heterogeneous in design, type of interventions, and measured outcomes. Yet, all of them confirm at least some positive effects of prehabilitation in terms of improved physical performance, nutritional status, quality of life, or even reduced postoperative morbidity. However, the optimal interventions for prehabilitation remain unclear; thus, they cannot be standardized and widely adopted. Future studies on multimodal prehabilitation are necessary to develop optimal programs for patients with esophagogastric cancer.
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Ikeda T, Noma K, Maeda N, Tanabe S, Sakamoto Y, Katayama Y, Shirakawa Y, Fujiwara T, Senda M. Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer. Surg Today 2022; 52:1143-1152. [PMID: 34988678 DOI: 10.1007/s00595-021-02449-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/08/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate if early exercise can help prevent skeletal muscle loss and improve the clinical outcomes of esophageal cancer patients receiving preoperative neoadjuvant chemotherapy (NAC). METHODS This was a single-center, retrospective observational cohort study of 110 patients with advanced esophageal cancer. We analyzed the effect of early exercise on the risk of skeletal muscle loss (defined as > 2.98%) during NAC and the subsequent clinical outcomes. Patients in the early exercise group (n = 71) started exercise therapy 8 days earlier than those the late exercise group (n = 39). RESULTS The median age of the patients was 65.4 years, the mean BMI was 21.1 kg/m2, and 92 (84%) of the 110 patients were men. Skeletal muscle loss occurred in 34% and 67% of the early and late exercise groups, respectively (p < 0.001). There was a lower risk of surgical site infection in the early exercise group (1% vs 16%, p = 0.021). Multivariate analysis revealed that early exercise reduced the risk of skeletal muscle loss (OR = 0.25, 95% CI 0.09-0.65, p = 0.006). CONCLUSIONS Our results suggest that early exercise reduces the risk of both skeletal muscle loss during NAC and subsequent surgical site infection in patients with esophageal cancer.
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Affiliation(s)
- Tomohiro Ikeda
- Department of Rehabilitation Medicine, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan.
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Shunsuke Tanabe
- Department of Gastroenterological Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Yoko Sakamoto
- Center for Innovative Clinical Medicine, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Yoshimi Katayama
- Department of Rehabilitation Medicine, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Yasuhiro Shirakawa
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima, 730-8518, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
| | - Masuo Senda
- Department of Rehabilitation Medicine, Okayama University, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan
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Tukanova KH, Chidambaram S, Guidozzi N, Hanna GB, McGregor AH, Markar SR. Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 29:3148-3167. [PMID: 34961901 PMCID: PMC8990957 DOI: 10.1245/s10434-021-11122-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/11/2021] [Indexed: 12/30/2022]
Abstract
Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. Objective The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. Methods An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). Results Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. Conclusion This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-11122-7.
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Affiliation(s)
- Karina H Tukanova
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Nadia Guidozzi
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alison H McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK. .,Nuffield Department of Surgery, University of Oxford, Oxford, UK. .,Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden. .,Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, London, UK.
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Respiratory Prehabilitation for the Prevention of Postoperative Pulmonary Complications after Major Surgery. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00495-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Carter J, Chang J, Birriel TJ, Moustarah F, Sogg S, Goodpaster K, Benson-Davies S, Chapmon K, Eisenberg D. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery. Surg Obes Relat Dis 2021; 17:1956-1976. [PMID: 34629296 DOI: 10.1016/j.soard.2021.08.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/11/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Jonathan Carter
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California.
| | - Julietta Chang
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - T Javier Birriel
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Fady Moustarah
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Stephanie Sogg
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Kasey Goodpaster
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Sue Benson-Davies
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Katie Chapmon
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
| | - Dan Eisenberg
- Clinical Issues Committee, American Society of Metabolic and Bariatric Surgeons; Department of Clinical Surgery, University of California-San Francisco, San Francisco, California
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Higaki E, Abe T, Fujieda H, Hosoi T, Nagao T, Komori K, Ito S, Itoh N, Matsuo K, Shimizu Y. Significance of Antimicrobial Prophylaxis for the Prevention of Early-Onset Pneumonia After Radical Esophageal Cancer Resection: A Retrospective Analysis of 356 Patients Undergoing Thoracoscopic Esophagectomy. Ann Surg Oncol 2021; 29:1374-1387. [PMID: 34591223 DOI: 10.1245/s10434-021-10867-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postoperative pneumonia is a common complication after esophagectomy and is associated with a high mortality rate. Although many randomized, controlled trials have been conducted on the prevention of postoperative pneumonia, little attention has been paid to the efficacy of antimicrobial prophylaxis. The purpose of this study was to investigate the impact of antimicrobial prophylaxis on the prevention of postoperative pneumonia. METHODS Data of patients with esophageal cancer who underwent thoracoscopic esophagectomy between 2016 and 2020 were collected. Early-period patients received cefazolin (CEZ) per protocol as antimicrobial prophylaxis (n = 250), and later-period patients received ampicillin/sulbactam (ABPC/SBT) (n = 106) because of the unavailability of CEZ in Japan. The incidence of pneumonia was compared between treatments in this quasi-experimental setting. Pneumonia detected by routine computed tomography (CT) on postoperative Days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later was defined as late-onset pneumonia. RESULTS The incidence of early-onset pneumonia was significantly lower (3.8% vs. 13.6%, P = 0.006), and the median length of postoperative hospital stay was significantly shorter (17 vs. 20 days, P < 0.001) in the ABPC/SBT group than in the CEZ group. The incidence of late-onset pneumonia was similar between groups (9.4% vs. 10.0%, P = 0.870). The incidence of Clostridioides difficile infections and the incidence of multidrug-resistant organisms were similar between groups. Multivariate analyses consistently showed the superiority of ABPC/SBT to CEZ in preventing early-onset pneumonia (odds ratio: 0.20, P = 0.006). CONCLUSIONS ABPC/SBT after esophagectomy was better at preventing early-onset pneumonia compared with CEZ and was feasible regarding the development of antimicrobial resistance.
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Affiliation(s)
- Eiji Higaki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan.
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Hironori Fujieda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Takuya Nagao
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan.,Division of Cancer Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
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Bona D, Lombardo F, Matsushima K, Cavalli M, Lastraioli C, Bonitta G, Cirri S, Danelli P, Aiolfi A. Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis. Surgery 2021; 171:940-947. [PMID: 34544603 DOI: 10.1016/j.surg.2021.08.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/01/2021] [Accepted: 08/18/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival. METHODS Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures. RESULTS Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy. CONCLUSION For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.
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Affiliation(s)
- Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy
| | - Francesca Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| | - Marta Cavalli
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Caterina Lastraioli
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy
| | - Silvia Cirri
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy
| | - Piergiorgio Danelli
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Italy.
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Dewulf M, Verrips M, Coolsen MME, Olde Damink SWM, Den Dulk M, Bongers BC, Dejong K, Bouwense SAW. The effect of prehabilitation on postoperative complications and postoperative hospital stay in hepatopancreatobiliary surgery a systematic review. HPB (Oxford) 2021; 23:1299-1310. [PMID: 34039535 DOI: 10.1016/j.hpb.2021.04.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Increasing numbers of high-risk (older and/or frail) patients are undergoing hepatopancreatobiliary (HPB) surgery. Therefore, optimization of the patient's psychophysiological capacity by prehabilitation is rapidly gaining importance. The aim of this study was to collect all available evidence on prehabilitation in HPB surgery and determine its effects on postoperative complications and length of hospital stay. METHODS A systematic review was performed according to PRISMA guidelines. The electronic databases MEDLINE, Web of Science, Embase, CENTRAL, clinicaltrials.gov, and the international clinical trials registry platform (ICTRP) were searched from inception to April 2020. Methodological quality of included studies was assessed using the Cochrane Collaboration's tool for assessing risk of bias and the ROBINS-I tool. RESULTS Seven articles including a total of 1377 patients were included in the quality analysis. A trend towards less complications and a shorter hospital stay was seen in the prehabilitation group, but current evidence fails to demonstrate a statistically significant difference between groups. Risk of bias in included studies was variable, and was generally scored as moderate. CONCLUSION Strong evidence for the beneficial effect of prehabilitation on clinical outcomes in HPB surgery is lacking. A trend towards less complications and shorter hospital stay was seen in the prehabilitation group.
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Affiliation(s)
- Maxime Dewulf
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Mared Verrips
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marielle M E Coolsen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kees Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
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Bolourani S, Tayebi MA, Diao L, Wang P, Patel V, Manetta F, Lee PC. Using machine learning to predict early readmission following esophagectomy. J Thorac Cardiovasc Surg 2021; 161:1926-1939.e8. [DOI: 10.1016/j.jtcvs.2020.04.172] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/17/2020] [Accepted: 04/30/2020] [Indexed: 02/07/2023]
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Hoeppner J, Plum PS, Buhr H, Gockel I, Lorenz D, Ghadimi M, Bruns C. [Surgical treatment of esophageal cancer-Indicators for quality in diagnostics and treatment]. Chirurg 2021; 92:350-360. [PMID: 32876700 PMCID: PMC8016790 DOI: 10.1007/s00104-020-01267-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Within the framework of the quality initiative of the German Society for General and Visceral Surgery (DGAV) a review article was compiled based on a systematic literature search. Recommendations for the current diagnostics and treatment of esophageal cancer were also elaborated. METHODS The systematic literature search was carried out in March 2019 according to the PRISMA criteria using the MEDLINE databank. The recommendations were formulated based on a consensus in the DGAV. RESULTS AND CONCLUSION Operations below the currently valid minimum quantity threshold should no longer be carried out. There are many indications that the minimum quantity in Germany should be raised to ≥20 resections/year/hospital in order to comprehensively improve the quality. Prehabilitation programs with endurance, strength and intensive breathing training as well as nutritional therapy improve patient outcome. The current treatment of esophageal cancer is stage-dependent and incorporates endoscopic resection of (sub)mucosal low-risk tumors (T1m1-3 or T1sm1 low risk), primary esophagectomy of submucosal high-risk tumors (T1a), submucosal cancer (T1sm2-3) and T2N0 tumors, multimodal treatment with neoadjuvant chemoradiotherapy or perioperative chemotherapy and operations for advanced stages. Esophagectomy is nowadays carried out in one stage as a so-called hybrid procedure (laparoscopy and muscle-preserving thoracotomy) or as a total minimally invasive operation (laparoscopy and thoracoscopy).
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Affiliation(s)
- Jens Hoeppner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg im Breisgau, Hugstetter Straße 55, 79106, Freiburg, Deutschland.
| | - Patrick Sven Plum
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - Heinz Buhr
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Berlin, Deutschland
| | - Ines Gockel
- Klinik für Viszeral‑, Thorax‑, Transplantations- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein‑, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt, Deutschland
| | - Michael Ghadimi
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Christiane Bruns
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinikum Köln, Köln, Deutschland
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Piraux E, Reychler G, de Noordhout LM, Forget P, Deswysen Y, Caty G. What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review. BMC Sports Sci Med Rehabil 2021; 13:33. [PMID: 33766107 PMCID: PMC7993458 DOI: 10.1186/s13102-021-00260-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 03/17/2021] [Indexed: 01/10/2023]
Abstract
Background Substantial postoperative complications occur after tumor resection for esophagogastric cancers. Physical prehabilitation programs aim to prepare patients for surgery by improving their functional status with the aim of reducing postoperative complications. This systematic review aims to summarize the effects of physical prehabilitation programs on exercise capacity, muscle strength, respiratory muscle function, postoperative outcomes, and health-related quality of life and to determine the optimal design of such a program to improve these outcomes in esophagogastric cancer patients undergoing tumor resection. Methods A systematic literature review was conducted using PubMed, The Cochrane Library, Scopus, and PEDro databases to identify studies evaluating the effects of physical prehabilitation program on exercise capacity, muscle strength, respiratory muscle function, postoperative complications, length of hospital stay, mortality, and health-related quality of life in patients with esophagogastric cancer awaiting surgery. Data from all studies meeting the inclusion criteria were extracted. The quality of each selected study was determined using the Downs and Black checklist. Results Seven studies with 645 participants were included. The preoperative exercise program consisted of respiratory training alone in three studies, a combination of aerobic and resistance training in two studies, and a combination of respiratory, aerobic, and resistance training in two studies. Training frequency ranged from three times a day to twice a week and each session lasted between 20 and 75 min. Four studies were of fair quality and three of good quality. Some studies reported improvements in maximal inspiratory pressure, inspiratory muscle endurance, postoperative (pulmonary) complications, and length of hospital stay in the preoperative exercise group compared to the control group. Conclusion This systematic review reports the current evidence for physical prehabilitation programs in patients with esophagogastric cancer awaiting surgery. However, due to the limited number of randomized controlled trials, the significant heterogeneity of exercise programs, and the questionable quality of the studies, higher quality randomized controlled trials are needed. Trial registration PROSPERO Registration Number: CRD42020176353. Supplementary Information The online version contains supplementary material available at 10.1186/s13102-021-00260-w.
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Affiliation(s)
- Elise Piraux
- Pôle de Neuro Musculo Skeletal Lab, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab, Université catholique de Louvain, Avenue Mounier 53, bte B1.53.07, 1200, Brussels, Belgium. .,Pôle de Pneumologie, ORL & Dermatologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium. .,Clinical Neuroscience, Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium.
| | - Gregory Reychler
- Pôle de Pneumologie, ORL & Dermatologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Haute Ecole Léonard de Vinci, Parnasse-ISEI, Brussels, Belgium.,Secteur de kinésithérapie, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Service de Pneumologie, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Louise Maertens de Noordhout
- Pôle de Neuro Musculo Skeletal Lab, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab, Université catholique de Louvain, Avenue Mounier 53, bte B1.53.07, 1200, Brussels, Belgium.,Pôle de Pneumologie, ORL & Dermatologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Clinical Neuroscience, Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium
| | - Patrice Forget
- Department of Anaesthetics, Institute of Applied Health Sciences, Epidemiology Group, University of Aberdeen, NHS Grampian, Aberdeen, UK
| | - Yannick Deswysen
- Upper Gastrointestinal Surgery Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gilles Caty
- Pôle de Neuro Musculo Skeletal Lab, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab, Université catholique de Louvain, Avenue Mounier 53, bte B1.53.07, 1200, Brussels, Belgium.,Clinical Neuroscience, Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium.,Service de médecine physique et réadaptation, Cliniques universitaires Saint-Luc, Brussels, Belgium
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Chevallay M, Jung M, Chon SH, Takeda FR, Akiyama J, Mönig S. Esophageal cancer surgery: review of complications and their management. Ann N Y Acad Sci 2020; 1482:146-162. [PMID: 32935342 DOI: 10.1111/nyas.14492] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.
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Affiliation(s)
- Mickael Chevallay
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Minoa Jung
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine (NCGM), Tokyo, Japan
| | - Stefan Mönig
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Tully R, Loughney L, Bolger J, Sorensen J, McAnena O, Collins CG, Carroll PA, Arumugasamy M, Murphy TJ, Robb WB. The effect of a pre- and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): Study protocol for a randomised controlled trial. Trials 2020; 21:638. [PMID: 32660526 PMCID: PMC7359259 DOI: 10.1186/s13063-020-04311-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advances in peri-operative oncological treatment, surgery and peri-operative care have improved survival for patients with oesophagogastric cancers. Neoadjuvant cancer treatment (NCT) reduces physical fitness, which may reduce both compliance and tolerance of NCT as well as compromising post-operative outcomes. This is particularly detrimental in a patient group where malnutrition is common and surgery is demanding. The aim of this trial is to assess the effect on physical fitness and clinical outcomes of a comprehensive exercise training programme in patients undergoing NCT and surgical resection for oesophagogastric malignancies. METHODS The PERIOP-OG trial is a pragmatic, multi-centre, randomised controlled trial comparing a peri-operative exercise programme with standard care in patients with oesophagogastric cancers treated with NCT and surgery. The intervention group undergo a formal exercise training programme and the usual care group receive standard clinical care (no formal exercise advice). The training programme is initiated at cancer diagnosis, continued during NCT, between NCT and surgery, and resumes after surgery. All participants undergo assessments at baseline, post-NCT, pre-surgery and at 4 and 10 weeks after surgery. The primary endpoint is cardiorespiratory fitness measured by demonstration of a 15% difference in the 6-min walk test assessed at the pre-surgery timepoint. Secondary endpoints include measures of physical health (upper and lower body strength tests), body mass index, frailty, activity behaviour, psychological and health-related quality of life outcomes. Exploratory endpoints include a health economics analysis, assessment of clinical health by post-operative morbidity scores, hospital length of stay, nutritional status, immune and inflammatory markers, and response to NCT. Rates of NCT toxicity, tolerance and compliance will also be assessed. DISCUSSION The PERIOP-OG trial will determine whether, when compared to usual care, exercise training initiated at diagnosis and continued during NCT, between NCT and surgery and then during recovery, can maintain or improve cardiorespiratory fitness and other physical, psychological and clinical health outcomes. This trial will inform both the prescription of exercise regimes as well as the design of a larger prehabilitation and rehabilitation trial to investigate whether exercise in combination with nutritional and psychological interventions elicit greater benefits. TRIAL REGISTRATION ClinicalTrials.gov: NCT03807518 . Registered on 1 January 2019.
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Affiliation(s)
- Roisin Tully
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland
- The Royal College of Surgeons in Ireland, St. Stephens Green, Dublin, Ireland
| | - Lisa Loughney
- The Royal College of Surgeons in Ireland, St. Stephens Green, Dublin, Ireland
- ExWell Medical, Santry Sports Link, Dublin, Ireland
| | - Jarlath Bolger
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland
| | - Jan Sorensen
- The Royal College of Surgeons in Ireland, St. Stephens Green, Dublin, Ireland
| | - Oliver McAnena
- Department of Upper GI Surgery, University Hospital, Galway, Ireland
| | - Chris G Collins
- Department of Upper GI Surgery, University Hospital, Galway, Ireland
| | - Paul A Carroll
- Department of Upper GI Surgery, University Hospital, Galway, Ireland
| | - Mayilone Arumugasamy
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland
- The Royal College of Surgeons in Ireland, St. Stephens Green, Dublin, Ireland
| | - Tomas J Murphy
- Department of Upper GI Surgery, Mercy University Hospital, Cork, Ireland
| | - William B Robb
- Department of Upper GI Surgery, Beaumont Hospital, Dublin, Ireland.
- The Royal College of Surgeons in Ireland, St. Stephens Green, Dublin, Ireland.
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32
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Vetter D, Gutschow CA. Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction. Langenbecks Arch Surg 2020; 405:1069-1077. [PMID: 32651652 PMCID: PMC7686179 DOI: 10.1007/s00423-020-01926-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/18/2022]
Abstract
Background Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research. Purpose The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery. Conclusions There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.
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Affiliation(s)
- Diana Vetter
- Division Head Upper Gastrointestinal Surgery, Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christian A Gutschow
- Division Head Upper Gastrointestinal Surgery, Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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Piraux E, Caty G, Reychler G, Forget P, Deswysen Y. Feasibility and Preliminary Effectiveness of a Tele-Prehabilitation Program in Esophagogastric Cancer Patients. J Clin Med 2020; 9:jcm9072176. [PMID: 32660126 PMCID: PMC7408844 DOI: 10.3390/jcm9072176] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 12/13/2022] Open
Abstract
Tele-rehabilitation provides better access to healthcare services and optimizes exercise adherence. However, its feasibility and effectiveness are unknown in the preoperative period in esophagogastric cancer patients. We aimed to assess the feasibility and the preliminary effects of a “tele-prehabilitation” program in esophagogastric cancer patients requiring surgery. Enrolled participants performed an internet-based tele-prehabilitation including aerobic, resistance and inspiratory muscle training over 2–4 weeks. The primary outcome was feasibility, measured in terms of recruitment, retention and attendance rates, adverse events and patient satisfaction. Secondary outcomes (functional exercise capacity, fatigue, quality of life, anxiety and depression) were assessed at baseline, presurgery, and 4 and 12 weeks postsurgery. Among the 24 eligible subjects, 23 were enrolled, 22 performed the intervention and 15 completed the study. Recruitment and retention rates were both 96%. Attendances to aerobic and resistance sessions and inspiratory muscle training were 77% and 68%, respectively. No adverse events occurred, and the satisfaction was excellent. After prehabilitation, participants significantly improved fatigue (p = 0.039), quality of life (p = 0.009), physical well-being (p = 0.034), emotional well-being (p = 0.005) and anxiety (p = 0.044). This study demonstrated the feasibility of a tele-prehabilitation in esophagogastric cancer patients undergoing surgery, with a high recruitment rate, retention rate and satisfaction, a good attendance to exercise sessions and no exercise-related adverse events.
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Affiliation(s)
- Elise Piraux
- Pôle de Neuro Musculo Skeletal Lab, Pôle de Pneumologie, ORL & Dermatologie, Institut de Recherche Expérimentale et Clinique, Clinical Neuroscience, Institute of Neurosciences, Université Catholique de Louvain, 1200 Brussels, Belgium
- Correspondence:
| | - Gilles Caty
- Pôle de Neuro Musculo Skeletal Lab, Institut de Recherche Expérimentale et Clinique, Clinical Neuroscience, Institute of Neurosciences, Université Catholique de Louvain, Service de Médecine Physique et Réadaptation, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
| | - Gregory Reychler
- Pôle de Pneumologie, ORL & Dermatologie, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Haute Ecole Léonard de Vinci, PARNASSE-ISEI, Secteur de kinésithérapie, Service de Pneumologie, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
| | - Patrice Forget
- Institute of Applied Health Sciences, Epidemiology Group, University of Aberdeen, NHS Grampian, Department of Anaesthetics, Aberdeen AB25 2ZD, UK;
| | - Yannick Deswysen
- Upper Gastrointestinal Surgery Unit, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
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Heger P, Probst P, Wiskemann J, Steindorf K, Diener MK, Mihaljevic AL. A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366). J Gastrointest Surg 2020; 24:1375-1385. [PMID: 31228083 DOI: 10.1007/s11605-019-04287-w] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Physical exercise prehabilitation has been proposed to improve postoperative outcomes in patients undergoing major abdominal surgery. The aim of this systematic review was to investigate the effect of preoperative exercise training compared with standard care on postoperative outcomes in major abdominal surgery. METHODS Randomized controlled trials (RCT) comparing prehabilitation with standard care were identified by a systematic literature search of MEDLINE and CENTRAL. Qualitative and quantitative analyses of perioperative outcome data were conducted. Meta-analyses were performed wherever possible and meaningful. RESULTS A total of eight trials including 442 patients met the inclusion criteria. These trials investigated the effect of prehabilitation in patient cohorts undergoing major liver, colorectal, gastroesophageal, and general abdominal surgery. Quantitative analyses of all included trials showed a significant reduction in postoperative pulmonary complications (OR 0.37; 0.20 to 0.67; p = 0.001) as well as in postoperative overall morbidity (OR 0.52; 0.30 to 0.88; p = 0.01) in the prehabilitation group compared with standard care. The length of hospital stay showed no significant differences between the groups (MD - 0.58; - 1.28 to 0.13; p = 0.11). Risk of bias and methodological quality varied substantially among the trials, most of which were small single-center studies. CONCLUSION Prehabilitation including a physical exercise intervention may lead to a reduction of postoperative pulmonary complications as well as less overall morbidity compared with standard care in patients undergoing major abdominal surgery. Further, well-designed RCT are needed to evaluate these potential positive effects in more detail and to identify suitable target populations. PROTOCOL REGISTRATION PROSPERO 2017 CRD42017080366.
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Affiliation(s)
- Patrick Heger
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Joachim Wiskemann
- National Center of Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Karen Steindorf
- National Center of Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
- German Cancer Research Center (DKFZ), Division of Physical Activity, Prevention and Cancer, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Papaconstantinou D, Vretakakou K, Paspala A, Misiakos EP, Charalampopoulos A, Nastos C, Patapis P, Pikoulis E. The impact of preoperative sarcopenia on postoperative complications following esophagectomy for esophageal neoplasia: a systematic review and meta-analysis. Dis Esophagus 2020; 33:doaa002. [PMID: 32193528 DOI: 10.1093/dote/doaa002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/15/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022]
Abstract
Esophageal cancer is characterized by profound changes in body composition due to dysphagia and generalized cachexia. Sarcopenia or muscle wasting is a component of cachexia associated with poor postoperative performance status. The skeletal muscle index (SMI) calculated by computed tomography scans at the level of the third lumbar vertebra is an easily quantifiable and reproducible measure of sarcopenia. The aim of this meta-analysis is to investigate the impact of preoperative sarcopenia (low SMI) on postoperative complications after esophagectomy for neoplastic lesions. In this context, a comprehensive literature search was undertaken to identify studies reporting short-term postoperative outcomes in relation to their preoperative SMI values. Cumulative risk ratios (RR) and risk differences (RD) and their respective 95% confidence intervals (CIs) were calculated using a random-effect model. A total of 11 studies incorporating 1,979 total patients (964 patients with sarcopeniaversus 1,015 without sarcopenia) were included in the final analysis. The results demonstrated a significant increase in overall morbidity (RR 1.16, 95% CI 1.01-1.33), respiratory complications (RR 1.64, 95% CI 1.21-2.22) and anastomotic leaks (RR 1.39, 95% CI 1.10-1.76) in patients with sarcopenia. No statistically significant difference was noted in overall mortality (RD 0, 95% CI -0.02-0.02) or Clavien-Dindo grade III or greater complications (RR 1.17, 95% CI 0.96-1.42). The above results demonstrate the validity of the SMI as a predictive factor for post-esophagectomy complications. Although the risk associated with sarcopenia is not prohibitive for surgery, patients with low SMI require closer vigilance during their postoperative course due to the increased propensity for respiratory and anastomotic complications.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Konstantina Vretakakou
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Anna Paspala
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Evangelos P Misiakos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Anestis Charalampopoulos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Constantinos Nastos
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Paul Patapis
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Emmanouil Pikoulis
- Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
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36
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Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ 2020; 368:m540. [PMID: 32161042 PMCID: PMC7190038 DOI: 10.1136/bmj.m540] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION Prospero CRD42016035662.
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Affiliation(s)
- Peter M Odor
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Sohail Bampoe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - David Gilhooly
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Benedict Creagh-Brown
- Surrey Perioperative Anaesthesia Critical care collaborative Research (SPACeR) Group, Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - S Ramani Moonesinghe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
- UCL/UCLH Surgical Outcomes Research Centre, UCL Centre for Perioperative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
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Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: A systematic review and meta-analysis. Surgery 2020; 167:540-549. [DOI: 10.1016/j.surg.2019.07.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/15/2019] [Accepted: 07/29/2019] [Indexed: 12/26/2022]
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Santos SC, Fréz AR, Ruaro JA, Wouk J, Daniel CR. Risk factors and postoperative complications in oncologic surgeries. FISIOTERAPIA EM MOVIMENTO 2020. [DOI: 10.1590/1980-5918.033.ao53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract Introduction: Oncological patients who are submitted to surgical procedures might have postoperative pulmonary complications (PPCs). Thus, preoperative physical conditions must be considered, since it is an important predictor of postoperative development. Objective: The purpose of this study was to analyze the risk factors for postoperative pulmonary complications that might compromise the recovery after oncologic surgery. Method: The present observational transversal study was made between March and October of 2015. Patients diagnosed with cancer were analyzed to determine pulmonary and functional condition and to identify the risk factors for the development of PPCs. The post-surgery recovery was followed through medical records. Data collected from patients’ analyses was correlated with post-surgery development. Results: Thirty patients were analyzed. A negative and moderate correlation was found between maximal inspiratory pressure (MIP) and PPCs (r=-0.39; p=0.032). A positive correlation between the time of permanence in the Intensive Care Unit (ICU) and hospitalization days (r=0.40; p=0.02) was observed. Correlations between PPCs and mechanical ventilation (r=0.36; p=0.04) and hospitalization days (r=0.40; p=0.02) were also noticed in the present study. Conclusion: PPCs might prejudice post-surgery outcome. The greater are physical condition and pulmonary functions of the patients before surgery, the better is their recovery.
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39
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Gonçalves CG, Groth AK. Prehabilitation: how to prepare our patients for elective major abdominal surgeries? ACTA ACUST UNITED AC 2019; 46:e20192267. [PMID: 31778394 DOI: 10.1590/0100-6991e-20192267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/10/2019] [Indexed: 12/21/2022]
Abstract
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.
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40
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Kow AWC. Prehabilitation and Its Role in Geriatric Surgery. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2019. [DOI: 10.47102/annals-acadmedsg.v48n11p386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
As the world’s population ages rapidly, many elderly people are living to a much more advanced age than before. Consequently, medical conditions that require surgical interventions such as solid organ cancers are also getting more common. While young and fit patients may be able to withstand surgical stresses and recover rapidly after operation, older adults may find these challenging. Rehabilitation that is instituted in the postoperative period aims to help patients regain physical fitness and robustness to preoperative levels. However, recent studies have shown that prehabilitation may be more effective in bringing the fitness level of elderly patients to a higher level before they go for surgery. There are many controversies regarding the effectiveness of prehabilitation, the components of this intervention―be it mono- or multimodalities―and the duration of prehabilitation. This paper looks at the current evidence of this hot topic revolving geriatric surgery.
Key words: Frail, Nutritional Intervention, Preoperative exercise, Psychological support
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Affiliation(s)
- Alfred WC Kow
- University Surgical Cluster, National University Hospital, Singapore
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41
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Bolger JC, Loughney L, Tully R, Cunningham M, Keogh S, McCaffrey N, Hickey W, Robb WB. Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: a systematic review. Dis Esophagus 2019; 32:5519688. [PMID: 31206582 DOI: 10.1093/dote/doz058] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/30/2019] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
Cancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.
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Affiliation(s)
- Jarlath C Bolger
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
| | - Lisa Loughney
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Roisin Tully
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
| | | | | | - Noel McCaffrey
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | | | - William B Robb
- Beaumont Hospital.,School of Medicine, Royal College of Surgeons in Ireland
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42
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Hartog J, Blokzijl F, Dijkstra S, DeJongste MJL, Reneman MF, Dieperink W, van der Horst ICC, Fleer J, van der Woude LHV, van der Harst P, Mariani MA. Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial. BMJ Open 2019; 9:e031738. [PMID: 31537574 PMCID: PMC6756317 DOI: 10.1136/bmjopen-2019-031738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care. METHODS AND ANALYSIS Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery. ETHICS AND DISSEMINATION This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT02984449.
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Affiliation(s)
- Johanneke Hartog
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fredrike Blokzijl
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sandra Dijkstra
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike J L DeJongste
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel F Reneman
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joke Fleer
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lucas H V van der Woude
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardio-thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
BACKGROUND Postoperative complications after complex visceral oncological surgery can lead to substantial impairment of patients. In addition, preoperative physical performance and the severity of postoperative complications determine the long-term recovery process of physical function. Therefore, preconditioning in the preoperative period should be an important part of the preoperative/neoadjuvant treatment. OBJECTIVE The aim of this article is a critical appraisal of current concepts of prehabilitation as well as their development potential and applicability in visceral surgery. MATERIAL AND METHODS Based on a selective literature review, current studies and implemented concepts are presented and therapy algorithms are provided. RESULTS This study differs in primary outcome, design and temporal framework of the intervention. The study results showed positive effects of an active increase in physical fitness in the preoperative period with respect to the quality of life, convalescence and postoperative pulmonary complication rate. DISCUSSION In addition to the assessment of the individual risk of complications by means of spiroergometry, a targeted nutrition and exercise program can increase the individual performance level prior to visceral surgery and, thus, influence the postoperative risk of complications. The performance should be understood as a modifiable risk factor, which can also be positively influenced in the preoperative phase, even in a short time period. Individual preoperative care optimizes the physical and psychological situation of patients. To ensure the required individual care, approaches must be created and pursued, which can be implemented in a decentralized way.
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Girotti PNC, Königsrainer I. Surgical concepts in esophageal cancer. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2019; 12:46-50. [DOI: 10.1007/s12254-018-0467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/12/2018] [Indexed: 08/30/2023]
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Ge XQ, Wang WJ, Yang KP, Luo QQ. Reducing postoperative pulmonary complications: Still a long way to go. J Thorac Cardiovasc Surg 2019; 157:e176-e177. [PMID: 33198030 DOI: 10.1016/j.jtcvs.2018.10.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/12/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Xiao-Qing Ge
- Department of Thoracic Surgery, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wen-Jie Wang
- Second Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Kun-Peng Yang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qing-Quan Luo
- Department of Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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46
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Licker M, Diaper J. Clinical impact of preoperative inspiratory muscle training: We need further studies! J Thorac Cardiovasc Surg 2019; 157:e175-e176. [PMID: 33198028 DOI: 10.1016/j.jtcvs.2018.09.076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 01/23/2023]
Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anesthesiology, Pharmacology & Intensive Care, University Hospital of Geneva, Geneva, Switzerland
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Meng S, Yang F, Dai F, Chen S, Huang C, Tan Q, Niu H. [Effect of A High Intensive Preoperative Rehabilitation on the Perioperative
Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible
for Lung Cancer Surgery]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018; 21:841-848. [PMID: 30454546 PMCID: PMC6247008 DOI: 10.3779/j.issn.1009-3419.2018.11.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
背景与目的 慢性阻塞性肺病(chronic obstructive pulmonary diseases, COPD)降低患者心肺功能,可导致患者围手术期风险增加。本研究拟探讨术前短期高强度肺康复训练对肺癌合并COPD患者肺功能及术后并发症的影响。 方法 分析2016年6月-2016年12月101例肺癌合并COPD患者的临床资料,其中肺康复训练组43例,常规治疗组58例,比较两组患者肺功能、术后肺部并发症、住院时间等指标,同时比较肺康复训练组训练前后肺功能相关指标。 结果 两组患者术前一般资料及肺功能无显著差异,康复训练组住院时间更长[(17.23±4.18) d vs (14.41±4.03) d],但术后住院时间与常规治疗组无显著差异[(8.93±3.78) d vs (9.62±3.98) d],两组患者术后肺部感染[8例(18.6%) vs 17例(29.3%)]、肺不张[1例(2.3%) vs 1例(1.7%)]、呼吸衰竭[1例(2.3%) vs 2例(3.4%)]等无显著差异。肺康复训练组训练前后FEV1[(2.06±0.45) L vs (2.15±0.45) L, P < 0.001]、PEF[(4.32±0.90) L/s vs (5.15±1.05) L/s, P < 0.001]、PCO2[(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009]改善明显,按亚组分析,康复训练后中-重度COPD亚组FEV1[(0.16±0.05) L (8.6%) vs (0.06±0.05) L (2.8%)]增加值较轻度COPD亚组更明显。 结论 术前短期肺康复训练可改善肺癌合并COPD患者肺功能,其中中-重度COPD患者肺功能改善更明显。
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Affiliation(s)
- Shenglan Meng
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Fan Yang
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Fuqiang Dai
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Shuang Chen
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Chaoqiong Huang
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Qunyou Tan
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Huijun Niu
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
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48
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Meng S, Yang F, Dai F, Chen S, Huang C, Tan Q, Niu H. [Effect of A High Intensive Preoperative Rehabilitation on the Perioperative
Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible
for Lung Cancer Surgery]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018; 21:841-848. [PMID: 30454546 DOI: 10.3779/10.3779/j.issn.1009-3419.2018.11.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) will reduce the cardiopulmonary function and increase perioperative risk. The aim of this study is to investigate the effect of preoperative short-term high intensity lung rehabilitation training on lung function and postoperative complications in patients with COPD who are eligible for lung cancer surgery. METHODS We analysis of 101 patients with COPD and a diagnosis of lung cancer, with 43 patients in pulmonary rehabilitation group and 58 patients in conventional group. The pulmonary function, postoperative pulmonary complications (PPCs) and length of stay (LOS) will be compared between the two groups, the lung function will be compared before and after the rehabilitation at the same time. RESULTS There were no significant difference between the two groups in general information, lung function before surgery, postoperative pulmonary infection [8 (18.6%) vs 17 (29.3%)], atelectasis [1 (2.3%) vs 1 (1.7%)], respiratory failure [1 (2.3%) vs 2 (3.4%)] and postoperative LOS [(8.93±3.78) d vs (9.62±3.98) d, P>0.05]. In the rehabilitation group, the FEV1 [(2.06±0.45) L vs (2.15±0.45) L, P<0.001] and PEF [(4.32±0.90) L/s vs (5.15±1.05) L/s, P<0.001) were higher, and PCO2 [(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009] was lower after rehabilitation, significantly. The increase value of FEV1 in moderate to severe COPD group was higher than that of the mild COPD group after the rehabilitation [(0.16±0.05) L, 8.6% vs (0.06±0.05) L, 2.8%, P<0.001). CONCLUSIONS The short-term highly-intensity lung rehabilitation can improve lung function in lung cancer patients with COPD, and the improvement of pulmonary function in moderate to severe COPD patients is more obviously.
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Affiliation(s)
- Shenglan Meng
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Fan Yang
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Fuqiang Dai
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Shuang Chen
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Chaoqiong Huang
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Qunyou Tan
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
| | - Huijun Niu
- The Third Affiliated Hospital of Army Medical University (Research Institute of Surgery), Chongqing 400042, China
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Luther A, Gabriel J, Watson RP, Francis NK. The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review. World J Surg 2018; 42:2781-2791. [PMID: 29546448 DOI: 10.1007/s00268-018-4569-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite advances in perioperative care, post-operative clinical and functional outcomes after major abdominal surgery can be suboptimal. Prehabilitation programmes attempt to optimise a patient's preoperative condition to improve outcomes. Total body prehabilitation includes structured exercise, nutritional optimisation, psychological support and cessation of negative health behaviours. This systematic review aims to report on the current literature regarding the impact of total body prehabilitation prior to major abdominal surgery. METHODS Relevant studies published between January 2000 and July 2017 were identified using MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, PubMed, and the Cochrane Database. All studies published in a peer-reviewed journal, assessing post-operative clinical and functional outcomes, following a prehabilitation programme prior to major abdominal surgery were included. Studies with less than ten patients, or a prehabilitation programme lasting less than 7 days were excluded. RESULTS Sixteen studies were included, incorporating 2591 patients, with 1255 undergoing a prehabilitation programme. The studies were very heterogeneous, with multiple surgical sub-specialties, prehabilitation techniques, and outcomes assessed. Post-operative complication rate was reduced in six gastrointestinal studies utilising either preoperative exercise, nutritional supplementation in malnourished patients or smoking cessation. Improved functional outcomes were observed following a multimodal prehabilitation programme. Compliance was variably measured across the studies (range 16-100%). CONCLUSIONS There is substantial heterogeneity in the prehabilitation programmes used prior to major abdominal surgery. A multimodal approach is likely to have better impact on functional outcomes compared to single modality; however, there is insufficient data either to identify the optimum programme, or to recommend routine clinical implementation.
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Affiliation(s)
- Alison Luther
- Department of General Surgery, Dorset County Hospital NHS Foundation Trust, Williams Avenue, Dorchester, DT1 2JY, UK
| | - Joseph Gabriel
- Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Castle Lane East, Bournemouth, BH7 7DW, UK
| | - Richard P Watson
- University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
| | - Nader K Francis
- Clinical Research Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK. .,University of Bath, Wessex House 3.22, Bath, BA2 7JU, UK.
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Milder DA, Pillinger NL, Kam PCA. The role of prehabilitation in frail surgical patients: A systematic review. Acta Anaesthesiol Scand 2018; 62:1356-1366. [PMID: 30094821 DOI: 10.1111/aas.13239] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/17/2018] [Accepted: 07/21/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Increasing emphasis is being placed on the detection of frailty in the pre-operative setting given its association with surgical morbidity and mortality. Prehabilitation seeks to increase the physiological reserve of frail patients, attenuating the risk of irreversible functional decline following surgery. AIM/HYPOTHESIS This systematic review appraises the evidence available for prehabilitation in frail surgical patients. We proposed that exercise prehabilitation would especially benefit frail patients, with improvements in pre-operative functional capacity, and reductions in complications and length of hospital stay. METHODS A literature search was conducted in MEDLINE, PubMed and CINAHL databases. Studies were included if they consisted of a prehabilitation intervention in frail patients undergoing surgery and specified a frailty model/index. Eight studies were included for analysis, 2 of which are ongoing studies. RESULTS In 3 studies, prehabilitation consisted of an exercise intervention alone. There was a high feasibility of prehabilitation and a trend to improved pre-operative function, however, no evidence of improved post-operative functional recovery was there. In 2 studies, prehabilitation consisted of both exercise and nutritional interventions. Reductions in mortality and duration of hospital stay were reported, but the quality of evidence was judged to be very low. There was a lack of evidence of improved outcomes following pre-operative inspiratory muscle training in frail patients. DISCUSSION This systematic review focuses on prehabilitation in frail surgical patients and reports that evidence supporting any outcome is limited, despite high feasibility and acceptability. There is a need for large randomised controlled trials to better establish the effects of prehabilitation in frail patients.
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Affiliation(s)
| | - Neil L. Pillinger
- Department of Anaesthetics Royal Prince Alfred Hospital University of Sydney Camperdown NSW Australia
- The University of Sydney Sydney Medical School NSW Australia
| | - Peter C. A. Kam
- Department of Anaesthetics Royal Prince Alfred Hospital University of Sydney Camperdown NSW Australia
- The University of Sydney Sydney Medical School NSW Australia
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