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Cuijpers ACM, Lubbers T, Dronkers JJ, Heldens AFJM, Zoethout SB, Leistra D, van Kuijk SMJ, van Meeteren NLU, Stassen LPS, Bongers BC. Development and external validation of preoperative clinical prediction models for postoperative outcomes including preoperative aerobic fitness in patients approaching elective colorectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108338. [PMID: 38728861 DOI: 10.1016/j.ejso.2024.108338] [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: 12/19/2023] [Revised: 03/01/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
INTRODUCTION Preoperative aerobic fitness is associated with postoperative outcomes after elective colorectal cancer (CRC) surgery. This study aimed to develop and externally validate two clinical prediction models incorporating a practical test to assess preoperative aerobic fitness to distinguish between patients with and without an increased risk for 1) postoperative complications and 2) a prolonged time to in-hospital recovery of physical functioning after elective colorectal cancer (CRC) surgery. MATERIALS AND METHODS Models were developed using prospective data from 256 patients and externally validated using prospective data of 291 patients. Postoperative complications were classified according to Clavien-Dindo. The modified Iowa level of assistance scale (mILAS) was used to determine time to postoperative in-hospital physical recovery. Aerobic fitness, age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, neoadjuvant treatment, surgical approach, tumour location, and preoperative haemoglobin level were potential predictors. Areas under the curve (AUC), calibration plots, and Hosmer-Lemeshow tests evaluated predictive performance. RESULTS Aerobic fitness, sex, age, ASA, tumour location, and surgical approach were included in the final models. External validation of the model for complications and postoperative recovery presented moderate to fair discrimination (AUC 0.666 (0.598-0.733) and 0.722 (0.651-0.794), respectively) and good calibration. High sensitivity and high negative predictive values were observed in the lower predicted risk categories (<40 %). CONCLUSION Both models identify patients with and without an increased risk of complications or a prolonged time to in-hospital physical recovery. They might be used for improving patient-tailored preoperative risk assessment and targeted and cost-effective application of prehabilitation interventions.
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Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, GROW, Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - Jaap J Dronkers
- Expertise Centre Healthy Urban Living, Research Group Innovation of Human Movement Care, HU University of Applied Sciences Utrecht, Utrecht, the Netherlands.
| | - Aniek F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Siebrand B Zoethout
- Department of Physical Therapy, Deventer Hospital, Deventer, the Netherlands.
| | - Duncan Leistra
- Department of Physical Therapy, Nij Smellinghe Hospital, Drachten, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), The Hague, the Netherlands; Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands.
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - Bart C Bongers
- Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands; Department of Nutrition and Movement Sciences, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
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Roxburgh BH, Campbell HA, Cotter JD, Reymann U, Williams MJA, Gwynne-Jones D, Thomas KN. Upper-Limb High-Intensity Interval Training or Passive Heat Therapy to Optimize Cardiorespiratory Fitness Prior to Total Hip or Knee Arthroplasty: A Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2024; 76:393-402. [PMID: 37728076 DOI: 10.1002/acr.25238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Preoperative exercise training, or prehabilitation, aims to optimize cardiorespiratory fitness before surgery to reduce the risk of adverse perioperative events and delayed recovery. However, traditional exercise such as walking and cycling can be difficult for people with degenerative joint diseases of the lower limbs, such as osteoarthritis. The purpose of this study was to compare the effect of three low-impact interventions on cardiorespiratory fitness, physical function, and subjective health before total hip or knee arthroplasty. METHODS This was a randomized controlled trial involving 93 participants with severe knee or hip osteoarthritis awaiting joint replacement surgery. Participants underwent cardiopulmonary exercise testing (to measure peak oxygen consumption [V ̇ $$ \dot{V} $$ O2 ]), then were randomized to heat therapy (Heat; 20-30 min immersed in 40°C water followed by ~15 min light-resistance exercise), high-intensity interval training (HIIT; 6-8 × 60 s intervals on a cross-trainer or arm ergometer at ~90%-100% peakV ̇ $$ \dot{V} $$ O2 ), or home-based exercise (Home; ~15 min light-resistance exercise); for up to 36 sessions (3 sessions per week for 12 weeks). RESULTS PeakV ̇ $$ \dot{V} $$ O2 increased by 16% across HIIT and to a greater extent than Heat (+2.5 mL × min-1 × kg-1 [95% CI: 0.5-4.4], P = 0.009) and Home (+3.2 mL × min-1 × kg-1 [1.2-5.2], P = 0.001). The anaerobic threshold increased across HIIT (+1.5 mL × min-1 × kg-1 [0.7-2.3], P < 0.001) and Heat (+1.2 mL × min-1 × kg-1 [0.4-1.9], P = 0.004), but not Home (-0.5 mL × min-1 × kg-1 [-1.3 to 0.3], P = 0.248). Subjective severity of osteoarthritis was unchanged with any intervention (P ≥ 0.250). CONCLUSION Heat therapy and HIIT improved indices of cardiorespiratory fitness preoperatively in patients who have difficulty performing lower-limb exercise.
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Trul-Kreuze IA, Akkerman M, Kieboom EAM, Nieuwenhuis MK, Houdijk H, Bongers BC. Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review. Arch Phys Med Rehabil 2024:S0003-9993(24)00827-X. [PMID: 38412899 DOI: 10.1016/j.apmr.2024.02.717] [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: 09/08/2023] [Revised: 01/29/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Providing an overview of the clinimetric properties of the steep ramp test (SRT)-a short-term maximal exercise test-to assess cardiorespiratory fitness (CRF), describing its underlying physiological responses, and summarizing its applications in current clinical and research practice. DATA SOURCES MEDLINE (through PubMed), CINAHL Complete, Cochrane Library, EMBASE, and PsycINFO were searched for studies published up to July 2023, using keywords for SRT and CRF. STUDY SELECTION Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch. DATA EXTRACTION Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated. DATA SYNTHESIS In total, 370 studies were found, of which 39 were included in this study. In several healthy and patient populations, correlation coefficients between the work rate at peak exercise (WRpeak) attained at the SRT and oxygen uptake at peak exercise during cardiopulmonary exercise testing (CPET) ranged from .771-.958 (criterion validity). Repeated measurements showed intraclass correlation coefficients ranging from .908-.996 for WRpeak attained with the first and second SRT (test-retest reliability). Physiological parameters, like heart rate and minute ventilation at peak exercise, indicated that the SRT puts a lower burden on the cardiopulmonary system compared to CPET. The SRT is mostly used to assess CRF, among others as part of preoperative risk assessment, and to personalize interval training intensity. CONCLUSIONS The SRT is a practical short-term maximal exercise test that is valid for CRF assessment and to monitor changes in CRF over time in various healthy and patient populations. Its clinimetric properties and potential applications make the SRT of interest for a widespread implementation of CRF assessment in clinical and research practice and for personalizing training intensity and monitoring longitudinal changes in CRF.
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Affiliation(s)
- Ingeborg A Trul-Kreuze
- Association of Dutch Burn Centers, Burn Center Groningen, Martini Hospital, Groningen; Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen; Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen
| | - Moniek Akkerman
- Association of Dutch Burn Centers, Burn Center Groningen, Martini Hospital, Groningen; Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen
| | - Eleonora A M Kieboom
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen
| | - Marianne K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Center Groningen, Martini Hospital, Groningen; Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen; Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen
| | - Han Houdijk
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen
| | - Bart C Bongers
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen; Department of Nutrition and Movement Sciences, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht; Department of Surgery, NUTRIM, Institute of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
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den Boer RB, Defize IL, Veldhuis W, Steenhagen E, Kerst A, van Hillegersberg R, de Jong PA, Ruurda JP. Impact of body composition and physical strength changes during chemoradiotherapy on complications and survival after oesophagectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107017. [PMID: 37586126 DOI: 10.1016/j.ejso.2023.107017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The aim of this study was to assess body composition and physical strength changes during neoadjuvant chemoradiotherapy (nCRT) and assess their predictive value for (severe) postoperative complications and overall survival in patients who underwent oesophagectomy for oesophageal cancer. METHODS Consecutive patients who underwent nCRT and oesophagectomy with curative intent in a tertiary referral center were included in the study. Perioperative data were collected in a prospectively maintained database. The CT images before and after nCRT were used to assess skeletal muscle index (SMI), subcutaneous fat index (SFI), and visceral fat index (VFI). To assess physical strength, handgrip strength (HGS) and the exercise capacity of the steep ramp test (SRT Wpeak) were acquired before and after nCRT. RESULTS Between 2015 and 2020, 126 patients were included. SMI increased in female subgroups and decreased in male subgroups (35.38 to35.60 cm2/m2 for females, P value 0.048, 46.89 to 45.34 cm2/m2 for males, P value < 0.001). No significant changes in SFI, VFI, HGS, and SRT Wpeak were observed. No predictive value of changes in SMI, HGS, and SRT Wpeak was shown for (severe) postoperative complications and overall survival. CONCLUSIONS A significant but minimal decrease in SMI during nCRT was observed for males only, it was not associated with postoperative complications or overall survival. Physical strength measurements did not decrease significantly over the course of nCRT. No associations with postoperative complications or overall survival were observed.
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Affiliation(s)
- R B den Boer
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - I L Defize
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - W Veldhuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - E Steenhagen
- Department of Dietetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - A Kerst
- Department of Rehabilitation, Physiotherapy Science, and Sport, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - P A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
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Franssen RFW, Vos TJ, Bongers BC, van Meeteren NLU. Letter to the Editor: Should we put more emphasis on the functional impact instead of the incidence of postoperative complications to evaluate quality of care in surgical oncology? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1320-1321. [PMID: 36997413 DOI: 10.1016/j.ejso.2023.03.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo, the Netherlands; Department of Epidemiology, GROW School for Oncology and Reproduction, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Tessel J Vos
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - 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 Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Nico L U van Meeteren
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, the Netherlands; Top Sector Life Sciences & Health, The Hague, the Netherlands.
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Bongers BC. Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology. J Surg Oncol 2023; 127:891-895. [PMID: 36621860 DOI: 10.1002/jso.27201] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/13/2022] [Accepted: 12/30/2022] [Indexed: 01/10/2023]
Affiliation(s)
- 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
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Berkel AEM, Bongers BC, Kotte H, Weltevreden P, de Jongh FHC, Eijsvogel MMM, Wymenga M, Bigirwamungu-Bargeman M, van der Palen J, van Det MJ, van Meeteren NLU, Klaase JM. Effects of Community-based Exercise Prehabilitation for Patients Scheduled for Colorectal Surgery With High Risk for Postoperative Complications: Results of a Randomized Clinical Trial. Ann Surg 2022; 275:e299-e306. [PMID: 33443905 PMCID: PMC8746915 DOI: 10.1097/sla.0000000000004702] [Citation(s) in RCA: 113] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in high-risk patients scheduled for elective colorectal resection for (pre)malignancy. SUMMARY BACKGROUND DATA Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications. METHODS This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold <11 mL/kg/min at the baseline cardiopulmonary exercise test was the final inclusion criterion. Inclusion was based on a power analysis. Patients in the prehabilitation group participated in a personalized 3-week (3 sessions per week, nine sessions in total) supervised exercise program given in community physical therapy practices before colorectal resection. Patients in the reference group received usual care. The primary outcome was the number of patients with one or more complications within 30 days of surgery, graded according to the Clavien-Dindo classification. Data were analyzed on an intention-to-treat basis. RESULTS Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024). CONCLUSIONS Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.
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Affiliation(s)
- Annefleur E M Berkel
- Department of Surgery, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, PO Box 616, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, Maastricht, The Netherlands
| | - Hayke Kotte
- Fysio Twente, J.J. van Deinselaan 34a, Enschede, The Netherlands
| | | | - Frans H C de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Michiel M M Eijsvogel
- Department of Pulmonology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Machteld Wymenga
- Department of Internal Medicine, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | | | - Job van der Palen
- Department of Epidemiology, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, Almelo, The Netherlands
| | - Nico L U van Meeteren
- Top Sector Life Sciences & Health (Health∼Holland), PO Box 93035, The Hague, The Netherlands
- Department of Anesthesiology, Erasmus Medical Center, PO Box 2040, Rotterdam, The Netherlands
| | - Joost M Klaase
- Department of Surgery, Medisch Spectrum Twente, PO Box 50000, Enschede, The Netherlands
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, Groningen, The Netherlands
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Cuijpers ACM, Heldens AFJM, Bours MJL, van Meeteren NLU, Stassen LPS, Lubbers T, Bongers BC. Relation between preoperative aerobic fitness estimated by steep ramp test performance and postoperative morbidity in colorectal cancer surgery: prospective observational study. Br J Surg 2021; 109:155-159. [PMID: 34536001 PMCID: PMC10364754 DOI: 10.1093/bjs/znab292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/21/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
Steep ramp test (SRT) performance provides an estimation of preoperative aerobic fitness that is associated with postoperative outcomes. Patients with a better SRT-estimated aerobic fitness are less likely to develop postoperative complications and more likely to experience a shorter time to recovery. The SRT might be a useful and clinically accessible tool in preoperative risk assessment to identify patients at risk of postoperative morbidity and who might benefit from preoperative exercise interventions.
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Affiliation(s)
- A C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - A F J M Heldens
- Department of Physical Therapy, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M J L Bours
- Department of Epidemiology, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - N L U van Meeteren
- Top Sector Life Sciences and Health (Health∼Holland), the Hague, the Netherlands.,Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - T Lubbers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - B 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
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Varghese C, Wells CI, Lee S, Pathak S, Siriwardena AK, Pandanaboyana S. Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery. Surgery 2021; 171:490-497. [PMID: 34417025 DOI: 10.1016/j.surg.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown. METHODS MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak. RESULTS Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies. CONCLUSION The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/chrisvarghese98
| | - Cameron Iain Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/drcamwells
| | - Shiela Lee
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Samir Pathak
- Department of Oncology and Surgery, St James Hospital, Leeds, UK. https://twitter.com/Drsampathak
| | - Ajith K Siriwardena
- Department of Hepatobiliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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van der Hulst HC, Bastiaannet E, Portielje JEA, van der Bol JM, Dekker JWT. Can physical prehabilitation prevent complications after colorectal cancer surgery in frail older patients? Eur J Surg Oncol 2021; 47:2830-2840. [PMID: 34127328 DOI: 10.1016/j.ejso.2021.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/26/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Frail patients with colorectal cancer (CRC) are at increased risk of complications after surgery. Prehabilitation seems promising to improve this outcome and therefore we evaluated the effect of physical prehabilitation on postoperative complications in a retrospective cohort of frail CRC patients. METHODS The study consisted of all consecutive non-metastatic CRC patients ≥70 years who had elective surgery from 2014 to 2019 in a teaching hospital in the Netherlands, where a physical prehabilitation program was implemented from 2014 on. We performed both an intention-to-treat and per protocol analysis to evaluate postoperative complications in the physical prehabilitation (PhP) and non-prehabilitation (NP) group. RESULTS Eventually, 334 elective patients were included. The 124 (37.1%) patients in the PhP-group presented with higher age, higher comorbidity scores and walking-aid use compared to the NP-group. Medical complications occurred in 26.6% of the PhP-group and in 20.5% of the NP-group (p = 0.20) and surgical complications in 19.4% and 14.3% (p = 0.22) respectively. In all frailty subgroups, the medical complications were lower in the PhP-group compared to the NP-group (35.9% vs. 45.5% for patients with ≥2 comorbidities, 36.2% vs. 39.1% for ASA score ≥ III, 29.2% vs. 45.8% for walking-aid use). Differences were not significant. CONCLUSIONS In this study, patients selected for physical prehabilitation had a worse frailty profile and therefore a higher a priori risk of postoperative complications. However, the postoperative complication rate was not increased compared to patients who were less frail at baseline and without prehabilitation. Hence, physical prehabilitation may prevent postoperative complications in frail CRC patients ≥70 years.
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Affiliation(s)
- Heleen C van der Hulst
- Department of Surgery, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands.
| | - Esther Bastiaannet
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Jessica M van der Bol
- Department of Geriatric Medicine, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Jan Willem T Dekker
- Department of Surgery, Reinier De Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
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