Prehabilitation in perioperative care

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review

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.

The value of perioperative physical activity in older patients undergoing surgery for lung cancer

INTRODUCTION

With a median age at diagnosis of 70, lung cancer represents an enormous public health problem among older Americans. An estimated 19,000 people age 65 and older undergo lung cancer surgery annually in the US. Older adults undergoing lung cancer surgery are often frail with limited physiologic reserves, multi-morbidities, and functional impairments. Physical function, dyspnea, and quality of life return to baseline slower in older adults compared with younger adults after lung surgery.

AREAS COVERED

In this review, we summarize available data about perioperative physical activity interventions that may improve outcomes for older adults undergoing lung cancer surgery. We also review the limitations of existing studies and discuss emerging data on the roles of telehealth and family caregiver inclusion in peri-operative physical activity interventions.

EXPERT OPINION

We propose that future perioperative physical activity interventions in older adults undergoing lung cancer surgery should include a comprehensive geriatric assessment to guide personalized interventions. Interventions should be conceptually based, with a focus on enhancing self-efficacy, motivation, and adherence through classic behavior change strategies that are proven to impact outcomes. Finally, interventions should be designed with attention to feasibility and scalability. Exercise programs delivered via telehealth (telephone or tele-video) may improve access and convenience for patients.

The Impact of Prehabilitation on Post-operative Outcomes in Oesophageal Cancer Surgery: a Propensity Score Matched Comparison

BACKGROUND

Patients undergoing oesophageal cancer surgery are often frail with a high risk of post-operative complications. Prehabilitation has been shown to reduce post-operative complications in specific patient populations but evidence in oesophageal cancer patients is inconclusive.

METHODS

Between January 2016 and April 2019, all patients with resectable oesophageal cancer who underwent curative treatment at a specialist tertiary centre participated in a personalised, home-based, multimodal prehabilitation programme. Post-operative complications and hospital stay in this group were compared to a control sample. Propensity score matching was used to control for differences in baseline characteristics.

RESULTS

Seventy-two patients who completed prehabilitation and 39 control patients were studied; following propensity score matching, there were 38 subjects in each group. In comparison to matched controls, patients in the prehabilitation group had a lower incidence of post-operative pneumonia (prehabilitation = 26%; control = 66%; p = 0.001) and a shorter length of stay (prehabilitation = median 10 days, IQR 8-17 days; control = median 13 days, IQR 11-20 days; p = 0.018). On multivariate regression analysis, participation in prehabilitation was associated with a 77% lower incidence of post-operative pneumonia (OR 0.23, 95% CI 0.09 to 0.55 p = 0.001). There was no significant difference in the incidence of overall complications or severe complications.

CONCLUSION

Prehabilitation was associated with a lower incidence of post-operative pneumonia and shorter hospital length of stay following oesophagectomy. This model of home based, personalised, and supervised prehabilitation is effective and relevant to centralised cancer services.

Functional Impairments and Quality of Life in Older Adults With Upper Gastrointestinal Cancers

BACKGROUND

Functional impairments (measured by activities of daily living [ADLs]) and health-related quality of life (HRQOL) may complicate outcomes in older adults diagnosed with cancer. In this retrospective cohort analysis, we characterized ADLs and HRQOL in adults older than 65 y with upper gastrointestinal (UGI) cancers and evaluated for an association to cancer-specific survival.

MATERIALS AND METHODS

Patients with UGI cancers aged 65 y or older were selected from the Surveillance, Epidemiology and End Results and the Medicare Health Outcomes Survey-linked database. Demographics, comorbidities, stage, ADLs, and HRQOL were summarized by patients managed with and without surgery. Because of the wide variety of cancers, we subdivided patients into cohorts of esophagogastric [EG; n = 88] or hepatobiliary/pancreatic [n = 68]. Cancer-specific survival curves were modeled for changes in ADL and HRQOL scores after diagnosis. Risk factors for cancer-specific survival were assessed with hazard ratios (HRs) and adjusted for demographics, stage, comorbidities, and disease cohorts.

RESULTS

HRQOL scores declined after diagnosis, with a sharper decline in nonsurgery patients. On multivariate analysis, inability to perform specific ADLs was associated with worse survival in multiple cohorts: hepatobiliary/pancreatic nonsurgery patients unable to eat (HR 3.3 95% confidence interval (CI) 1.7-6.5); all patients with EG unable to use the toilet (HR 3.3 95% CI 1.5-7.9); EG nonsurgery cohort unable to dress or use the toilet (dress HR 14.1 95% CI 4.0-49.0; toilet HR 4.7 95% CI 1.8-12.3).

CONCLUSIONS

Older survivors with UGI cancers report declines in HRQOL, especially those not undergoing surgery. The ability to perform ADLs may be linked to survival in this population.

Symptom and functional recovery monitoring in thoracic surgery

Curative-intent surgery is the treatment of choice for thoracic malignancies, including lung cancer. There is significant complexity and uncertainty associated with the diagnosis, prognosis, and surgical treatment decision-making in thoracic surgery. From a patient point of view, this complexity and uncertainty can be overwhelming. Therefore, for high-quality cancer care, an emphasis on patient-centered care-including the improvement in quality of life (QOL) through symptom and functional monitoring-is essential. Using the current literature and our previous research, the purpose of this paper is to: (I) review the current evidence on symptom and functional monitoring in surgery; (II) describe strategies to monitor symptoms and functional recovery in surgery; and (III) describe a model of patient-centered care in thoracic surgery.

Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn’t.

Feasibility of setting up a pre-operative optimisation 'pre-hab' service for lung cancer surgery in the UK

Pre-operative optimisation ‘pre-hab’ is a growing area in peri-operative medicine. This is usually undertaken with the aim of reducing post-operative complications. In the case of early-stage lung cancer, surgery is the treatment modality with the best-proven cure rates. With this in mind, we set up a pre-hab service, not merely to reduce the risk of post-operative complications, but to enable patients of borderline fitness for surgery to safely undergo this potentially lifesaving treatment. We believe this service to be one of the first of its kind in the UK, here we describe the challenges we faced in setting it up and the outcomes from our first 50 patients.

Use of a Perioperative Web-Based Exercise Program for a Patient with Barrett's Carcinoma Scheduled for Esophagectomy

A poor preoperative functional capacity increases the perioperative risk. Therefore, a web-based exercise approach has been initiated for a careful supervision and individual support of patients during their perioperative cancer therapy. Here, we present the data of a 57-year-old patient, scheduled for esophagectomy. Beside a five-week neoadjuvant chemoradiotherapy (CRT), the patient performed 10 weeks of a web-based prehabilitation exercise training (preconditioning) and continued the exercise program for 14 weeks after surgery. The patient performed 42 of 44 recommended training sessions in the preconditioning period in his home environment. This corresponds to a mean of 131 (±38) min of total training per week. The patient performed 52 of 48 recommended training sessions in the postconditioning period. This corresponds to a mean of 165 (±87) min of total training per week. The patient could maintain his functional capacity during CRT and enhanced his submaximal performance level to the end of the intervention. The patient's adherence to the program was noteworthy. The most important features of this approach are the personalized design and the flexible scheduling precisely in tune with the patient's needs, concerns, and therapy related downtimes. Thus, the patient nearly fulfilled the exercise guidelines at a sufficient exercise intensity even during the neoadjuvant therapy. The preconditional exercise prevented a presumed CRT-induced and tumor-associated loss of functional capacity. The postoperative exercise led to a structured and adequate return into regular physical activities after surgery. Finally, this approach complements a comprehensive clinical care, in a health-promoting, cost-effective, and patient-safely manner.

Fit for Cancer Treatment: a prospective feasibility study of primary care initiated prehabilitation for patients with suspected cancer

Background

Risk profile assessment and corrective interventions using optimisation of health status and prehabilitation represent an important strategy in the management of patients with a suspected cancer diagnosis.

Aim

To determine the feasibility of pre-treatment optimisation and prehabilitation commenced at index primary care consultation, to improve patients’ preparation for treatment by maximising the time available.

Design & setting

Between January 2015 and May 2016, 195 patients presenting to 12 GP practices were deemed eligible to enter the study, of which 189 (96.9%, median age 60 [21–91] years and 65 months; 124 female) were recruited and consented to the prehabilitation bundle.

Method

All patients were simultaneously referred to secondary care using urgent suspected cancer (USC) pathways. The primary outcome measures were definitive diagnosis and treatment plan.

Results

Fifteen patients (7.9%) were diagnosed with cancer (three breast, three colon, two lung, two skin [one melanoma, one sarcoma], one tonsil, one vocal cord, one pancreas, one prostate, one ependymoma) and 62 were diagnosed with other significant medical conditions (47 gastrointestinal, 13 sepsis, two respiratory) requiring secondary care assessment and treatment. Of the 15 patients with cancer, 11 (73.3%) underwent potentially curative treatment, and four (26.7%) palliative treatment. Of the total study cohort, 84 (44%) required a form of optimisation in primary care, and patients with cancer were more likely to require optimisation than others (n = 10 [63%] versus n = 74 [43%], χ² 9.384, P = 0.002).

Conclusion

One in 12 primary care USC patients had cancer (5.6% receiving potentially curative treatment), one in three had other systemic health issues, and overall two in five benefited from healthcare intervention. Primary care optimisation was feasible and associated with important allied health benefits.

CCR-CARESS score for predicting operative mortality in patients with colorectal cancer

BACKGROUND

The aim of this study was to assess factors associated with outcomes after surgery for colorectal cancer and to design and internally validate a simple score for predicting perioperative mortality.

METHODS

Patients undergoing surgery for primary invasive colorectal cancer in 22 centres in Spain between June 2010 and December 2012 were included. Clinical variables up to 30 days were collected prospectively. Multiple logistic regression techniques were applied and a risk score was developed. The Hosmer-Lemeshow test was applied and the area under the receiver operating characteristic (ROC) curve (AUC, with 95 per cent c.i.) was estimated.

RESULTS

A total of 2749 patients with a median age of 68·5 (range 24-97) years were included; the male : female ratio was approximately 2 : 1. Stage III tumours were diagnosed in 32·6 per cent and stage IV in 9·5 per cent. Open surgery was used in 39·3 per cent, and 3·6 per cent of interventions were urgent. Complications were most commonly infectious or surgical, and 25·5 per cent of patients had a transfusion during the hospital stay. The 30-day postoperative mortality rate was 1·9 (95 per cent c.i. 1·4 to 2·4) per cent. Predictive factors independently associated with mortality were: age 80 years or above (odds ratio (OR) 2·76), chronic obstructive pulmonary disease (COPD) (OR 3·62) and palliative surgery (OR 10·46). According to the categorical risk score, a patient aged 80 years or more, with COPD, and who underwent palliative surgery would have a 23·5 per cent risk of death within 30 days of the intervention.

CONCLUSION

Elderly patients with co-morbidity and palliative intention of surgery have an unacceptably high risk of death.