Respiratory Prehabilitation for the Prevention of Postoperative Pulmonary Complications after Major Surgery

Effect of short-term exercise-based prehabilitation program for patients undergoing liver cancer surgery: A randomized controlled trial

BACKGROUND

Patients with liver cancer usually experience postoperative complications and reduced perioperative functional capacity. This study aimed to assess the effect of a short-term, exercise-based prehabilitation program on postoperative clinical outcomes and perioperative functional capacity in patients with liver cancer undergoing hepatectomy.

METHODS

This single-center, prospective, open-labeled randomized controlled trial was conducted with 205 patients. Patients in the prehabilitation group (n = 104) received a 1-week exercise intervention program before surgery, including aerobic and resistance exercises, and respiratory training. Patients in the control group (n = 101) received the usual clinical care. The assessors were blinded to the patient allocation. The primary outcome was the incidence of postoperative pulmonary complication during hospitalization, which the multivariate logistic regression model analyzed. Other outcomes included functional capacity measured as the 6-minute walk distance, postoperative complications, length of stay, hospital readmissions, hospitalization cost, and patient-reported outcomes. Post hoc subgroup analyses were performed.

RESULTS

The median duration of prehabilitation was 8 days. There was no between-group difference in the incidence of postoperative pulmonary complication (adjusted odds ratio, 0.70; 95% confidence interval, 0.37-1.29; P = .249). There were no differences in postoperative clinical outcomes and patient-reported outcomes, except for 6-minute walk distance (33.36 m higher in the prehabilitation group, 95% CI, 22.02-44.70; P < .001).

CONCLUSION

This exercise prehabilitation program did not affect postoperative clinical outcomes or patient-reported outcomes of patients with liver cancer, but it showed improvement in preoperative functional capacity.

Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Major surgery for gastrointestinal cancer carries a 50% risk of postoperative complications. Physiotherapists commonly provide interventions to patients undergoing gastrointestinal surgery for cancer with the intent of preventing complications and improving recovery. However, the evidence is unclear if physiotherapy is effective compared to providing no physiotherapy, nor if timing of service delivery during the perioperative pathway influences outcomes. The objective of this review is to evaluate and synthesise the evidence examining the effects of perioperative physiotherapy interventions delivered with prophylactic intent on postoperative outcomes compared to no treatment or early mobilisation alone.

METHODS

A protocol was prospectively registered with PROSPERO and a systematic review performed of four databases. Randomised controlled trials examining prophylactic physiotherapy interventions in adults undergoing gastrointestinal surgery for cancer were eligible for inclusion.

RESULTS

Nine publications from eight randomised controlled trials were included with a total sample of 1418 participants. Due to inconsistent reporting of other perioperative complications, meta-analysis of the effect of physiotherapy was only possible specific to postoperative pulmonary complications (PPCs). This found an estimated 59% reduction in risk with exposure to physiotherapy interventions (RR 0.41, 95%CI 0.23 to 0.73, p < 0.001). Sub-group analysis demonstrated that timing of delivery may be important, with physiotherapy delivered only in the preoperative phase or combined with a postoperative service significantly reducing PPC risk (RR 0.32, 95%CI 0.17 to 0.60, p < 0.001) and hospital length of stay (MD-1.4 days, 95%CI -2.24 to -0.58, p = 0.01), whilst the effect of postoperative physiotherapy alone was less certain.

CONCLUSIONS

Preoperative-alone and perioperative physiotherapy is likely to minimise the risk of PPCs in patients undergoing gastrointestinal surgery for cancer. This challenges current traditional paradigms of providing physiotherapy only in the postoperative phase of surgery. A review with broader scope and component network analysis is required to confirm this.

Perioperative Pulmonary Complications in the Older Adults: The Forgotten System

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

Preoperative physiotherapy prevents postoperative pulmonary complications after major abdominal surgery: a meta-analysis of individual patient data

QUESTIONS

Among patients having elective abdominal surgery, how much does preoperative physiotherapy education with breathing exercise training reduce the incidence of postoperative pulmonary complications (PPCs), hospital length of stay and 12-month mortality? How stable are the treatment effects across different PPC definitions, including pneumonia? How much do the treatment effects on PPC, hospital length of stay and mortality vary within clinically relevant subgroups?

DESIGN

Individual participant-level meta-analysis (n = 800) from two randomised controlled trials analysed with multivariable regression.

PARTICIPANTS

Adults undergoing major elective abdominal surgery.

INTERVENTIONS

Experimental participants received a single preoperative session with a physiotherapist within 4 weeks of surgery and educated on PPC prevention with breathing exercises and early mobilisation. They were taught breathing exercises and instructed to start them immediately on waking from surgery. The control group received no preoperative or postoperative physiotherapy, or early ambulation alone.

OUTCOME MEASURES

PPC, hospital length of stay and 12-month mortality.

RESULTS

Participants who received preoperative physiotherapy had 47% lower odds of developing a PPC (adjusted OR 0.53, 95% CI 0.34 to 0.85). This effect was stable regardless of PPC definition. Effects were greatest in participants who smoked, were aged ≤ 45 years, had abnormal body weight, had multiple comorbidities, or were undergoing bariatric or upper gastrointestinal surgery. Participants having operations ≤ 3 hours in duration were least responsive to preoperative physiotherapy. Participants with multiple comorbidities were more likely to have a shorter hospital stay if provided with preoperative physiotherapy (adjusted MD -3.2 days, 95% CI -6.2 to -0.3). Effects on mortality were uncertain.

CONCLUSION

There is strong evidence to support preoperative physiotherapy in preventing PPCs after elective abdominal surgery.

Current landscape and support for practical initiation of oncological prehabilitation translatable to thyroid cancer: A position paper

Despite a growing body of evidence for the effectiveness of prehabilitation, the uptake of prehabilitation in Europe remains low. Contributing factors range from limited awareness and understanding of prehabilitation to a lack of supporting infrastructure and reimbursement challenges. In this position paper, the authors propose a new comprehensive definition of prehabilitation and identify differentiated thyroid cancer as a type of cancer particularly well-suited for prehabilitation. To support clinicians with the implementation of prehabilitation programs in their clinics, the authors discuss the following practical solutions: a) find the most appropriate prehabilitation program for each patient; b) raise awareness among peers; c) develop evidence to demonstrate the effectiveness of prehabilitation; d) expand the interdisciplinary team; e) expand your network and make use of existing assets; f) utilize learnings from the COVID-19 pandemic.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Perioperative Pulmonary Complications in the Elderly: The Forgotten System

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

The Role of Exercise Before Cancer Treatment

OBJECTIVES

We aim to describe on the role of exercise in preparation for cancer treatments (prehabilitation) that include surgery and neoadjuvant or nonsurgical approaches. We discuss the evidence for the role of exercise and provide guidelines to exercise prescription and examples of the structure of prehabilitation exercise programs.

DATA SOURCE

We use peer-reviewed articles obtained through PubMed searches with search terms: exercise, oncology, cancer surgery, exercise physiology, respiratory exercises, prehabilitation, and behavior change.

CONCLUSION

The emergence of prehabilitation in preparing patients for cancer care has followed a rapidly upward trajectory over the past 20 years. Exercise prehabilitation remains the cornerstone of management, particularly in patients attending for major surgery. Multimodal approaches to supporting patients before cancer treatment are now well accepted and include screening and individualized treatments of functional, nutritional, and psychological impairments. Respiratory training before surgery and the addition of behavior change strategies to improve adherence to interventions and promote improved longer-term outcomes are now included in many prehabilitation programs. For exercise to be an effective treatment in improving fitness and strength, supervised aerobic and resistance exercises at moderate intensity are recommended. There remains debate regarding the use of higher-intensity exercise, the appropriate outcome to measure efficacy, and the mechanisms driving the efficacy of exercise.

IMPLICATIONS FOR NURSING PRACTICE

We provide background evidence and knowledge pertaining to the role and provision of exercise prehabilitation. Understanding screening, risk factors, and potential efficacy assists in knowing who to refer for prehabilitation and what the programs include. This enables more effective com munication with patients attending for cancer treatments.