Preoperative evaluation of cardiopulmonary reserve with the use of expired gas analysis during exercise testing in patients with squamous cell carcinoma of the thoracic esophagus

Deep learned representations of the resting 12-lead electrocardiogram to predict at peak exercise

AIMS

To leverage deep learning on the resting 12-lead electrocardiogram (ECG) to estimate peak oxygen consumption (V˙O2peak) without cardiopulmonary exercise testing (CPET).

METHODS AND RESULTS

V ˙ O 2 peak estimation models were developed in 1891 individuals undergoing CPET at Massachusetts General Hospital (age 45 ± 19 years, 38% female) and validated in a separate test set (MGH Test, n = 448) and external sample (BWH Test, n = 1076). Three penalized linear models were compared: (i) age, sex, and body mass index ('Basic'), (ii) Basic plus standard ECG measurements ('Basic + ECG Parameters'), and (iii) basic plus 320 deep learning-derived ECG variables instead of ECG measurements ('Deep ECG-V˙O2'). Associations between estimated V˙O2peak and incident disease were assessed using proportional hazards models within 84 718 primary care patients without CPET. Inference ECGs preceded CPET by 7 days (median, interquartile range 27-0 days). Among models, Deep ECG-V˙O2 was most accurate in MGH Test [r = 0.845, 95% confidence interval (CI) 0.817-0.870; mean absolute error (MAE) 5.84, 95% CI 5.39-6.29] and BWH Test (r = 0.552, 95% CI 0.509-0.592, MAE 6.49, 95% CI 6.21-6.67). Deep ECG-V˙O2 also outperformed the Wasserman, Jones, and FRIEND reference equations (P < 0.01 for comparisons of correlation). Performance was higher in BWH Test when individuals with heart failure (HF) were excluded (r = 0.628, 95% CI 0.567-0.682; MAE 5.97, 95% CI 5.57-6.37). Deep ECG-V˙O2 estimated V˙O2peak <14 mL/kg/min was associated with increased risks of incident atrial fibrillation [hazard ratio 1.36 (95% CI 1.21-1.54)], myocardial infarction [1.21 (1.02-1.45)], HF [1.67 (1.49-1.88)], and death [1.84 (1.68-2.03)].

CONCLUSION

Deep learning-enabled analysis of the resting 12-lead ECG can estimate exercise capacity (V˙O2peak) at scale to enable efficient cardiovascular risk stratification.

Implementing a virtual mind-body prehabilitation program for patients undergoing thoracic surgery: A quality improvement project

Background

Prehabilitation before thoracic surgery has been found to improve outcomes in patients with cancer; however, COVID-19 presented challenges to access on-site programs. We describe the development, implementation, and evaluation of a synchronous, virtual mind-body prehabilitation program developed in response to COVID-19.

Methods

Eligible participants were patients seen at a thoracic oncology surgical department of an academic cancer center, aged 18 years or older with a diagnosis of thoracic cancer and referred at least 1 week before surgery. The program offered 2 45-minute preoperative mind-body fitness classes each week delivered via Zoom (Zoom Video Communications, Inc). We collected data for referrals, enrollment, participation, and evaluated patient-reported satisfaction and experience. We conducted brief semistructured interviews about participants' experience.

Results

Among 278 patients referred, 260 were approached, and of those 197 (76%) patients agreed to participate. Among participants, 140 (71%) attended at least 1 class, with an average of 11 attendees per class. The majority of participants reported being extremely satisfied (97.8%), extremely likely to recommend the classes to others (91.2%), and indicated that classes were very much helpful in preparing for surgery (90.8%). Patients also reported that the classes helped reduce anxiety/stress (94.2%), fatigue (88.5%), pain (80.7%), and shortness of breath (86.5%). Qualitative data further suggest that the program made participants feel stronger, more connected to their peers, and better prepared for surgery.

Conclusions

This virtual mind-body prehabilitation program was well received with high satisfaction and benefits and is highly feasible to implement. This approach may help overcome some of the challenges to in-person participation.

Effect of a multimodal prehabilitation program on postoperative recovery and morbidity in patients undergoing a totally minimally invasive esophagectomy

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.

Cardiopulmonary exercise testing for cardiovascular risk assessment in patients undergoing gastric and oesophageal cancer surgery: results from a prospective interventional cohort study

Background

Cardiopulmonary exercise testing (CPET) has shown to be useful for preoperative risk stratification in various types of intra-abdominal and thoracic surgery. However, data about the predictive value of CPET for cardiovascular outcome after gastric or oesophageal cancer surgery are inconclusive. The aim of this study was to evaluate the prognostic value of CPET parameters for the prediction of cardiovascular complications in patients with this type of surgery.

Methods

This is a prospective single-centre interventional cohort study including 200 consecutive patients who underwent elective surgery for oesophageal and/or gastric cancer. Symptom-limited CPET was performed preoperatively to evaluate the potential of various test-derived parameters including anaerobic threshold (AT) to predict cardiovascular complications within 30 days after surgery.

Results

200 patients (mean age 68±14.2 years) met inclusion and exclusion criteria: oesophageal surgery 54 pts, gastric surgery 132 pts and combined oesophageal/gastric surgery 14 pts. 41/200 pts (20.5%) experienced cardiovascular complications during and within 30 days after surgery including 4 non-fatal myocardial infarctions (2%), 1 stroke (0.5%); 6 dead from cardiovascular causes (3%) and less serious complications in 30 patients (15%) including angina attacks and antiarrhythmic therapy for ventricular arrhythmias or for atrial fibrillation/flutter. Results from preoperative CPET indicate that an AT level below 11 mL/kg/min was highly predictive for any cardiovascular complication (p=0.02, OR 6.33, 95% CI 1.78 to 22.47). An AT level <9.5 had the best predictive accuracy for major perioperative cardiac complications (sensitivity 93%, specificity 68%, positive predicative value 75%, negative predicative value 98.8%).

Conclusion

CPET is a useful perioperative risk assessment tool for patients undergoing surgery for oesophageal and gastric cancer, which carries a particularly high risk for cardiovascular complications. An AT <9.5 mL/kg/min turned out to be the most reliable predictor for major cardiovascular complications.

Clinical covariates that improve surgical risk prediction and guide targeted prehabilitation: an exploratory, retrospective cohort study of major colorectal cancer surgery patients evaluated with preoperative cardiopulmonary exercise testing

BACKGROUND

Preoperative risk stratification is used to derive an optimal treatment plan for patients requiring cancer surgery. Patients with reversible risk factors are candidates for prehabilitation programmes. This pilot study explores the impact of preoperative covariates of comorbid disease (Charlson Co-morbidity Index), preoperative serum biomarkers, and traditional cardiopulmonary exercise testing (CPET)-derived parameters of functional capacity on postoperative outcomes after major colorectal cancer surgery.

METHODS

Consecutive patients who underwent CPET prior to colorectal cancer surgery over a 2-year period were identified and a minimum of 2-year postoperative follow-up was performed. Postoperative assessment included: Clavien-Dindo complication score, Comprehensive Complication Index, Days at Home within 90 days (DAH-90) after surgery, and overall survival.

RESULTS

The Charlson Co-morbidity Index did not discriminate postoperative complications, or overall survival. In contrast, low preoperative haemoglobin, low albumin, or high neutrophil count were associated with postoperative complications and reduced overall survival. CPET-derived parameters predictive of postoperative complications, DAH-90, and reduced overall survival included measures of VCO₂ kinetics at anaerobic threshold (AT), peakVO₂ (corrected to body surface area), and VO₂ kinetics during the post-exercise recovery phase. Inflammatory parameters and CO₂ kinetics added significant predictive value to peakVO₂ within bi-variable models for postoperative complications and overall survival (P < 0.0001).

CONCLUSION

Consideration of modifiable 'triple low' preoperative risk (anaemia, malnutrition, deconditioning) factors and inflammation will improve surgical risk prediction and guide prehabilitation. Gas exchange parameters that focus on VCO₂ kinetics at AT and correcting peakVO₂ to body surface area (rather than absolute weight) may improve CPET-derived preoperative risk assessment.

'Fit for surgery': The relationship between cardiorespiratory fitness and postoperative outcomes

New Findings

What is the topic of this review?

The relationships and physiological mechanisms underlying the clinical benefits of cardiorespiratory fitness (CRF) in patients undergoing major intra‐abdominal surgery.

What advances does it highlight?

Elevated CRF reduces postoperative morbidity/mortality, thus highlighting the importance of CRF as an independent risk factor. The vascular protection afforded by exercise prehabilitation can further improve surgical risk stratification and postoperative outcomes.

Abstract

Surgery accounts for 7.7% of all deaths globally and the number of procedures is increasing annually. A patient's ‘fitness for surgery’ describes the ability to tolerate a physiological insult, fundamental to risk assessment and care planning. We have evolved as obligate aerobes that rely on oxygen (O₂). Systemic O₂ consumption can be measured via cardiopulmonary exercise testing (CPET) providing objective metrics of cardiorespiratory fitness (CRF). Impaired CRF is an independent risk factor for mortality and morbidity. The perioperative period is associated with increased O₂ demand, which if not met leads to O₂ deficit, the magnitude and duration of which dictates organ failure and ultimately death. CRF is by far the greatest modifiable risk factor, and optimal exercise interventions are currently under investigation in patient prehabilitation programmes. However, current practice demonstrates potential for up to 60% of patients, who undergo preoperative CPET, to have their fitness incorrectly stratified. To optimise this work we must improve the detection of CRF and reduce potential for interpretive error that may misinform risk classification and subsequent patient care, better quantify risk by expressing the power of CRF to predict mortality and morbidity compared to traditional cardiovascular risk factors, and improve patient interventions with the capacity to further enhance vascular adaptation. Thus, a better understanding of CRF, used to determine fitness for surgery, will enable both clinicians and exercise physiologists to further refine patient care and management to improve survival.

Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial

BACKGROUND

Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO₂), skeletal muscle mass, QOL, and neoadjuvant therapy completion.

METHODS

This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months.

RESULTS

Fifty-four participants were randomized (prehabilitation group, n = 26; control group, n = 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO₂ decline {-0.4 [95% confidence interval (CI) -0.8 to 0.1] vs. -2.5 [95% CI -2.8 to -2.2] mL/kg/min; p = 0.022}, less muscle loss [-11.6 (95% CI -14.2 to -9.0) vs. -15.6 (95% CI -18.7 to -15.4) cm²/m²; p = 0.049], and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose [prehabilitation group, 18 (75%) vs. control group, 13 (46%); p = 0.036]. No adverse events were reported.

CONCLUSIONS

This study has demonstrated some retention of cardiopulmonary fitness (peak VO₂), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes. Trial Registration ClinicalTrials.gov NCT02950324.

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses

BACKGROUNDS

There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.

METHODS

A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO₂), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (V_E/V_CO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.

RESULTS

Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO₂ was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and V_E/V_CO2 also demonstrated some positive trends. None of the included studies reported a negative trend.

CONCLUSIONS

This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO₂, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.

Does Cardiopulmonary Testing Help Predict Long-Term Survival After Esophagectomy?

Background

Esophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes of major surgery. Variables derived from cardiopulmonary exercise testing (CPET) have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing esophagectomy is associated with long-term survival. This study aimed to evaluate whether any of the CPET variables routinely derived from patients with esophageal cancer may aid in predicting long-term survival after esophagectomy.

Methods

Patients undergoing CPET followed by trans-thoracic esophagectomy for esophageal cancer with curative intent between January 2013 and January 2017 from single high-volume center were retrospectively analyzed. The relationship between predictive co-variables, including CPET variables and survival, was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was performed to find cutoff values for CPET variables predictive of 3-year survival.

Results

The study analyzed 313 patients. The ventilatory equivalent for carbon dioxide (VE/VCO₂) at the anerobic threshold was the only CPET variable independently predictive of long-term survival in the multivariable analysis (hazard ratio [HR], 1.049; 95% confidence interval [CI], 1.011–1.088; p = 0.011). Pathologic stages 3 and 4 disease was the other co-variable found to be independently predictive of survival. An ROC analysis of the VE/VCO₂ failed to demonstrate a predictive cutoff value of 3-year survival (area under the curve, 0.564; 95% CI, 0.499–0.629; p = 0.056).

Conclusions

A high VE/VCO₂ before esophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for clinicians to consider when counseling patients.

Efficacy of enhanced prehabilitation for patients with esophageal cancer undergoing esophagectomy

BACKGROUND

Several studies have demonstrated that prehabilitation helps reduce the incidence of postoperative complications. In this study, we investigated the safety and efficacy of enhanced prehabilitation (EP) in the hospital for patients with esophageal cancer.

METHODS

We retrospectively reviewed the data of 48 consecutive patients who underwent radical esophagectomy with gastric tube reconstruction between September 2015 and June 2019. EP program had been introduced in August 2017. In the EP group, patients received the EP program during hospitalization 7 days before surgery in addition to conventional perioperative rehabilitation. The EP program consisted of aerobic exercise and muscle strength training in the morning and afternoon. Operative outcomes were compared between patients who received EP (EP group; 23 patients) and patients who did not receive EP (control group; 25 patients).

RESULTS

The preoperative (EP group vs. control group, 492.9 ± 79.7 vs. 418.9 ± 71.8 m, p < 0.001) and postoperative (EP group vs. control group, 431.5 ± 80 vs. 378 ± 68.7 m, p < 0.001) 6-min walk distance was significantly higher in the EP group than in the control group. The respiratory complications rate was significantly lower in the EP group (4.3%) than in the control group (36%) (p = 0.007). The incidence of atelectasis was particularly significantly lower in the EP group (0%) than in the control group (24%) (p = 0.012).

CONCLUSIONS

EP was performed safely for patients before esophagectomy. EP improved the exercise tolerance of the patients before esophagectomy and might be useful in preventing respiratory complications.

Cardiopulmonary Exercise Testing in Oesophagogastric Surgery: a Systematic Review

BACKGROUND

Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery.

METHODS

Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool.

RESULTS

Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay.

CONCLUSION

Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity.

Wearable Technology in the Perioperative Period: Predicting Risk of Postoperative Complications in Patients Undergoing Elective Colorectal Surgery

BACKGROUND

The implementation of protocolized care pathways has resulted in major improvements in surgical outcomes. Additional gains will require focused efforts to alter preexisting risk. Prehabilitation programs provide a promising avenue for risk reduction.

OBJECTIVE

This study used wearable technology to monitor activity levels before colorectal surgery to evaluate the impact of preoperative activity on postoperative outcomes.

DESIGN

This was a prospective nonrandomized observational study.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

Patients undergoing elective colorectal surgery from January 2018 to February 1, 2019, were included.

MAIN OUTCOME MEASURES

Patients were trained in the usage of wearable activity-tracking devices and instructed to wear the device for 30 days before surgery. Patients were stratified as active (≥5000 steps per day) and inactive (<5000 steps per day) based on preoperative step counts. Univariate analyses compared postoperative outcomes. Multivariable regression models analyzed the impact of preoperative activity on postoperative complications, adjusting for each patient's baseline risk as calculated using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Models were rerun without the addition of activity and the predictive ability of the models compared.

RESULTS

Ninety-nine patients were included, with 40 (40.4%) classified as active. Active patients experienced fewer overall complications (11/40 (27.5%) vs 33/59 (55.9%); p = 0.005) and serious complications (2/40 (5%) vs 12/59 (20.3%); p = 0.032). Increased preoperative activity was associated with a decreased risk of any postoperative complication (OR = 0.386; p = 0.0440) on multivariable analysis. The predictive ability of the models for complications and serious complications was improved with the addition of physical activity.

LIMITATIONS

The study was limited by its small sample size and single institution.

CONCLUSIONS

There is significant room for improvement in baseline preoperative activity levels of patients undergoing colorectal surgery, and poor activity is associated with increased postoperative complications. These data will serve as the basis for an interventional trial investigating whether wearable devices help improve surgical outcomes through a monitored preoperative exercise program. See Video Abstract at http://links.lww.com/DCR/B145. TECNOLOGÍA PORTÁTIL EN EL PERÍODO PERIOPERATORIO: PREDICCIÓN DEL RIESGO DE COMPLICACIONES POSTOPERATORIAS EN PACIENTES SOMETIDOS A CIRUGÍA COLORRECTAL ELECTIVA: La implementación de vías de atención protocolizadas ha dado lugar a importantes mejoras en los resultados quirúrgicos. Para obtener más beneficios será necesario realizar esfuerzos concentrados para modificar el riesgo preexistente. Los programas de rehabilitación proporcionan una vía prometedora para la reducción del riesgo.Este estudio utilizó tecnología portátil para monitorear los niveles de actividad antes de la cirugía colorrectal para evaluar el impacto de la actividad preoperatoria en los resultados postoperatorios.Estudio observacional prospectivo no aleatorizado.Gran centro médico académico.Pacientes sometidos a cirugía colorrectal electiva desde enero de 2018 hasta el 1 de febrero de 2019.Los pacientes fueron entrenados en el uso de dispositivos portátiles para el seguimiento de la actividad y se les indicó usar el dispositivo durante 30 días antes de la cirugía. Los pacientes fueron estratificados como activos (> 5000 pasos / día) e inactivos (<5000 pasos / día) en base a los recuentos de pasos preoperatorios. Los análisis univariados compararon los resultados postoperatorios. Los modelos de regresión multivariable analizaron el impacto de la actividad preoperatoria en las complicaciones postoperatorias, ajustando el riesgo de referencia de cada paciente según lo calculado utilizando la Calculadora de riesgo quirúrgico del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos. Los modelos se volvieron a ejecutar sin agregar actividad, y se comparó la capacidad de predicción de los modelos.Noventa y nueve pacientes fueron incluidos con 40 (40.4%) clasificados como activos. Los pacientes activos experimentaron menos complicaciones generales [11/40 (27,5%) frente a 33/59 (55,9%); p = 0,005] y complicaciones graves [2/40 (5%) frente a 12/59 (20,3%); p = 0,032]. El aumento de la actividad preoperatoria se asoció con una disminución del riesgo de cualquier complicación postoperatoria (OR 0.386, p = 0.0440) en el análisis multivariable. La capacidad predictiva de los modelos para complicaciones y complicaciones graves mejoró con la adición de actividad física.Tamaño de muestra pequeño, una sola institución.Existe un margen significativo para mejorar los niveles basales de actividad preoperatoria de los pacientes de cirugía colorrectal, y la escasa actividad se asocia con mayores complicaciones postoperatorias. Estos datos servirán de base para un ensayo intervencionista que investigue si los dispositivos portátiles ayudan a mejorar los resultados quirúrgicos a través de un programa de ejercicio preoperatorio monitoreado. Consulte Video Resumen en http://links.lww.com/DCR/B145.

Preoperative six-minute walk distance as a predictor of postoperative complication in patients with esophageal cancer

Surgery for esophageal cancer is associated with high morbidity and mortality. Reduced pulmonary functions and exercise capacity are known as risk factors for complications after esophagectomy. The 6-minute walk distance (6MWD) measured by the 6-minute walk test (6MWT) is a simple field test that can be used to evaluate the functional exercise capacity of patients who undergo thoracic surgery. The aim of this study was to evaluate the association of the preoperative 6MWD with postoperative complications in patients with esophageal cancer. Records of a total of 111 patients who underwent thoracic surgery followed by postoperative rehabilitation from January 2013 to December 2015 were retrospectively reviewed. Data of patients who experienced Clavien-Dindo grade II or severer (grade ≥ II) complications were compared with those who experienced grade ≤I complications. The 6MWD was significantly correlated with age, serum albumin concentration, hemoglobin concentration, and hand grip strength. A total of 42 patients experienced grade ≥II. The 6MWD of patients with grade ≥ II complications was significantly shorter than that of those with grade ≤I complications. In receiver operating characteristic analysis, 6MWD ≤ 454 m was a threshold for predicting grade ≥II complications with 71.0% sensitivity and 54.8% specificity. The incidence of grade ≥II complications led to delayed ambulation and longer stays in hospital. In the multiple regression analysis, the preoperative risk factors for incidence of grade ≥II complications included lower levels of preoperative 6MWD and % of the predicted value of forced expiratory volume in 1 second. Our results indicate that the 6MWT is useful to assess preoperative physical status in patients with esophageal cancer.

Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review

INTRODUCTION

Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance.

METHODS

After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables.

RESULTS

We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality.

CONCLUSIONS

In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.

Cardiopulmonary Exercise Testing for Preoperative Evaluation: What Does the Future Hold?

Purpose of Review

Cardiopulmonary exercise testing (CPET) informs the preoperative evaluation process by providing individualised risk profiles; guiding shared decision-making, comorbidity optimisation and preoperative exercise training; and informing perioperative patient management. This review summarises evidence on the role of CPET in preoperative evaluation and explores the role of novel and emerging CPET variables and alternative testing protocols that may improve the precision of preoperative evaluation in the future.

Recent Findings

CPET provides a wealth of physiological data, and to date, much of this is underutilised clinically. For example, impaired chronotropic responses during and after CPET are simple to measure and in recent studies are predictive of both cardiac and noncardiac morbidity following surgery but are rarely reported. Exercise interventions are increasingly being used preoperatively, and endurance time derived from a high intensity constant work rate test should be considered as the most sensitive method of evaluating the response to training. Further research is required to identify the clinically meaningful difference in endurance time. Measuring efficiency may have utility, but this requires exploration in prospective studies.

Summary

Further work is needed to define contemporaneous risk thresholds, to explore the role of other CPET variables in risk prediction, to better characterise CPET’s role in combination with other tools in multifactorial risk stratification and increasingly to evaluate CPET’s utility for preoperative exercise prescription in prehabilitation.

Perioperative exercise capacity in chronic liver injury patients with hepatocellular carcinoma undergoing hepatectomy

Dynamic assessment of preoperative exercise capacity may be a useful predictor of postoperative prognosis. We aimed to clarify whether perioperative exercise capacity was related to long-term survival in hepatocellular carcinoma patients with chronic liver injury undergoing hepatectomy. One hundred-six patients with hepatocellular carcinoma underwent pre- and postoperative cardiopulmonary exercise testing to determine their anaerobic threshold, defined as the point between carbon dioxide production and oxygen consumption per unit of time. Testing involved 35 items including blood biochemistry analysis, in-vivo component analysis, dual-energy X-ray absorptiometry, and cardiopulmonary exercise testing preoperatively and 6 months postoperatively. We classified patients with anaerobic threshold ≥ 90% 6 months postoperatively compared with the preoperative level as the maintenance group (n = 78) and patients with anaerobic threshold < 90% as the decrease group (n = 28). Five-year recurrence-free survival rates were 39.9% vs. 9.9% (maintenance vs. decrease group) (hazard ratio: 1.87 [95% confidence interval: 1.12–3.13]; P = 0.018). Five-year overall survival rates were maintenance: 81.9%, and decrease: 61.7% (hazard ratio: 2.95 [95% confidence interval: 1.37–6.33]; P = 0.006). Multivariable Cox proportional hazards models showed that perioperative maintenance of anaerobic threshold was an independent prognostic indicator for both recurrence-free- and overall survival. Although the mean anaerobic threshold from preoperative to postoperative month 6 decreased in the exercise-not-implemented group, the exercise-implemented group experienced increased anaerobic threshold, on average, at postoperative month 6. The significant prognostic factor affecting postoperative survival for chronic liver injury patients with HCC undergoing hepatectomy was maintenance of anaerobic threshold up to 6 months postoperatively.

Cardiopulmonary fitness predicts postoperative major morbidity after esophagectomy for patients with cancer

Surgery for radical treatment of esophageal cancer (EC) carries significant inherent risk. The objective identification of patients who are at high risk of complications is of importance. In this study the prognostic value of cardiopulmonary fitness variables (CPF) derived from cardiopulmonary exercise testing (CPET) was assessed in patients undergoing potentially curative surgery for EC within an enhanced recovery program. OC patients underwent preoperative CPET using automated breath-by-breath respiratory gas analysis, with measurements taken during a ramped exercise test on a bicycle. The prognostic value of V ˙ O 2 Peak , Anaerobic Threshold (AT) and VE/VCO2 derived from CPET were studied in relation to post-operative morbidity, which was collected prospectively, and overall survival. Consecutive 120 patients were included for analysis (median age 65 years, 100 male, 75 neoadjuvant therapy). Median AT in the cohort developing major morbidity (Clavien-Dindo classification >2) was 10.4 mL/kg/min compared with 11.3 mL/kg/min with no major morbidity (P = 0.048). Median V ˙ O 2 Peak in the cohort developing major morbidity was 17.0 mL/kg/min compared with 18.7 mL/kg/min in the cohort (P = 0.009). V ˙ O 2 Peak optimum cut-off was 17.0 mL/kg/min (sensitivity 70%, specificity 53%) and for AT was 10.5 mL/kg/min (sensitivity 60%, specificity 44%). Multivariable analysis revealed V ˙ O 2 Peak to be the only independent factor to predict major morbidity (OR 0.85, 95% CI 0.75-0.97, P = 0.018). Cumulative survival was associated with operative morbidity severity (χ2  = 4.892, df = 1, P = 0.027). These results indicate that V ˙ O 2 Peak as derived from CPET is a significant predictor of major morbidity after oesophagectomy highlighting the physiological importance of cardiopulmonary fitness.

CPET and cardioesophagectomy: A single centre 10-year experience

INTRODUCTION

CPET is a routine investigation prior to cardioesophagectomy. Over a 10-year period 200 patients had CPET before elective cardioesophagectomy. We examine the relationship between CPET and outcomes in these patients.

MATERIALS AND METHODS

Complication data were prospectively collected using the Clavien-Dindo system. Logistic regression analysis was used to determine whether 90-day mortality and morbidity were significantly different between fitter and less fit patients.

RESULTS

90-day mortality was 5.5%. In univariate analysis the following factors were associated with a significantly increased risk of death at 90 days: anaerobic threshold <11 ml kg^-1 min^-1 OR (95% CI) = 4.38 (1.23,15.6), p = 0.023; V̇O2 peak <15 ml kg^-1 min^-1 O₂ OR (95% CI) = 5.0 (1.42,15.55), p = 0.012; V̇E/V̇CO₂ > 34 OR (95% CI) = 4.07 (1.19,14.0), p = 0.026; diabetes mellitus OR (95% CI) = 5.76 (1.55,21.35) p = 0.009. In multivariate logistic regression analysis both diabetes (OR = 5.76 [1.55,21.4] p = 0.009) and presence of ≥ 1 subthreshold CPET value (OR = 6.72 [1.32,29.8] p = 0.021) were significantly associated with increased risk of death at 90 days. Median (95% CI) survival for patients who had a CPET with 'normal' parameters was 1176 (565, 1787) days, compared with 642 (336, 948) days for patients with ≥ one subthreshold parameter. 15.5% of patients had ECG ischaemia; there were no deaths in this group.

CONCLUSION

Presence of at least one sub-threshold CPET value at pre-operative testing is associated with increased risk of 90-day mortality and shorter long term survival. These results allow us to better define risks during shared decision-making with patients.

The association between preoperative cardiopulmonary exercise-test variables and short-term morbidity after esophagectomy: A hospital-based cohort study

BACKGROUND

Postoperative complications after esophagectomy are thought to be associated with reduced fitness. This observational study explored the associations between aerobic fitness, as determined objectively by preoperative cardiopulmonary exercise testing (CPEX), and 30-day morbidity after esophagectomy.

METHODS

We retrospectively identified 254 consecutive patients who underwent esophagectomy at a single academic teaching hospital between September 2011 and March 2017. Postoperative complication data were measured using the Esophageal Complications Consensus Group definitions and graded using the Clavien-Dindo classification system of severity (blinded to cardiopulmonary exercise testing values). Associations between preoperative cardiopulmonary exercise testing variables and postoperative outcomes were estimated using logistic regression.

RESULTS

A total of 206 patients (77% male) were included in the analyses, with a mean age of 67 years (SD 9). The mean values for the maximal oxygen consumed at the peak of exercise (VO_2peak) and the anaerobic threshold were 21.1 mL/kg/min (SD 4.5) and 12.4 mL/kg/min (SD 2.8), respectively. The vast majority of patients (98.5%) had malignant disease-predominantly adenocarcinoma (84.5%), for which most received neoadjuvant chemotherapy (79%) and underwent minimally invasive Ivor Lewis esophagectomy (53%). Complications at postoperative day 30 occurred in 111 patients (54%), the majority of which were cardiopulmonary (72%). No associations were found between preoperative cardiopulmonary exercise testing variables and morbidity for either VO_2peak (OR 1.00, 95% CI 0.94-1.07) or anaerobic threshold (OR 0.98, 95% CI 0.89-1.09).

CONCLUSION

Preoperative cardiopulmonary exercise testing variables were not associated with 30-day complications after esophagectomy. The findings do not support the use of cardiopulmonary exercise testing as an isolated preoperative screening tool to predict short-term morbidity after esophagectomy. This modestly sized observational work highlights the need for larger studies examining associations between preoperative cardiopulmonary exercise testing and outcomes after esophagectomy to look for consistency in our findings.

Functional Diagnostic Methods in Cardiac Prognosis in Major Abdominal Surgery in Patients with Heart Disease or Over 65 Years Old

PURPOSE OF THE STUDY

Evaluation of the value of the results of the use of cardiac functional examination methods for the stratification of the risk of developing cardiovascular complications in planned abdominal surgical interventions in patients over 65 years of age or with cardiac pathology.

MATERIALS AND METHODS

The study included 179 patients over 65 years of age or with a history of heart disease who underwent elective abdominal surgery. The median age was 70 years. During the operation and for 30 days after it, cardiac complications were recorded: severe (myocardial infarction, stroke, death from cardiovascular disease), others (strokes of exertional angina, ischemic dynamics of the ST segment on the electrocardiogram - ECG - rest, paroxysmal fibrillation / flutter atrial). All patients underwent basic examination - examination, anamnesis, ECG, blood test, assessment of respiratory function, ECG monitoring. Additionally, echocardiography (EchoCG) and ergospirometry (ESM) were performed.

RESULTS

In 30 (16.8 %) patients, various MTRs were detected: 6 (3.4 %) of fatal myocardial infarctions, 2 (1.1 %) of fatal strokes; 3 (1.7 %) cases of sudden cardiac death, angina attacks were recorded in 4 (2.2 %) patients, 7 (3.9 %) had ischemic ECG dynamics, 11 (6.1 %) had fibrillation episodes or atrial flutter. Chronic obstructive pulmonary disease, intervention on the colon, blood hemoglobin level &lt;100 g / l, serum creatinine &gt;103 μmol / l, presence of any pathological changes in the resting ECG were associated with the development of SSO; according to EchoCG - VTI (linear velocity integral) in the outflow tract of the left ventricle (LV) &lt;21.5 cm, volume of the left atrium&gt; 57 ml, global LV myocardial deformity is less than 18 %, increase in heart rate (HR) at the 1st minute load test&gt; 27 %, peak oxygen consumption at ESM &lt;15.8 ml / kg / min. The optimal plan for preoperative examination in men is to perform a basic model, and for women it is advisable to combine a basic examination with an ESM or an assessment of the degree of myocardial deformity using the speckle-tracking method for EchoCG.

CONCLUSION

The risk of perioperative MTS during planned abdominal operations in patients older than 65 years or with a history of heart disease is relatively high - 16.8 %. When assessing the risk associated with the operation, it is advisable to additionally conduct echocardiography with VTI assessment in the LV outflow tract and myocardial deformity indicators, as well as ESM with the determination of HR increase in the 1st minute of the test and peak oxygen consumption.

A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol

INTRODUCTION

Neoadjuvant therapy prior to oesophagogastric resection is the gold standard of care for patients with T2 and/or nodal disease. Despite this, studies have taught us that chemotherapy decreases patients' functional capacity as assessed by cardiopulmonary exercise (CPX) testing. We aim to show that a multimodal prehabilitation programme, comprising supervised exercise, psychological coaching and nutritional support, will physically, psychologically and metabolically optimise these patients prior to oesophagogastric cancer surgery so they may better withstand the immense physical and metabolic stress placed on them by radical curative major surgery.

METHODS AND ANALYSIS

This will be a prospective, randomised, controlled, parallel, single-centre superiority trial comparing a multimodal 'prehabilitation' intervention with 'standard care' in patients with oesophagogastric malignancy who are treated with neoadjuvant therapy prior to surgical resection. The primary aim is to demonstrate an improvement in baseline cardiopulmonary function as assessed by anaerobic threshold during CPX testing in an interventional (prehab) group following a 15-week preoperative exercise programme, throughout and following neoadjuvant treatment, when compared with those that undergo standard care (control group). Secondary objectives include changes in peak oxygen uptake and work rate (total watts achieved) at CPX testing, insulin resistance, quality of life, chemotherapy-related toxicity and completion, nutritional assessment, postoperative complication rate, length of stay and overall mortality.

ETHICS AND DISSEMINATION

This study has been approved by the London-Bromley Research Ethics Committee and registered on ClinicalTrials.gov. The results will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02950324; Pre-results.

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.

Cardiopulmonary Exercise Testing and Surgery

The surgical patient population is increasingly elderly and comorbid and poses challenges to perioperative physicians. Accurate preoperative risk stratification is important to direct perioperative care. Reduced aerobic fitness is associated with increased postoperative morbidity and mortality. Cardiopulmonary exercise testing is an integrated and dynamic test that gives an objective measure of aerobic fitness or functional capacity and identifies the cause of exercise intolerance. Cardiopulmonary exercise testing provides an individualized estimate of patient risk that can be used to predict postoperative morbidity and mortality. This technology can therefore be used to inform collaborative decision-making and patient consent, to triage the patient to an appropriate perioperative care environment, to diagnose unexpected comorbidity, to optimize medical comorbidities preoperatively, and to direct individualized preoperative exercise programs. Functional capacity, evaluated as the anaerobic threshold and peak oxygen uptake ([Formula: see text]o₂peak) predicts postoperative morbidity and mortality in the majority of surgical cohort studies. The ventilatory equivalents for carbon dioxide (an index of gas exchange efficiency), is predictive of surgical outcome in some cohorts. Prospective cohort studies are needed to improve the precision of risk estimates for different patient groups and to clarify the best combination of variables to predict outcome. Early data suggest that preoperative exercise training improves fitness, reduces the debilitating effects of neoadjuvant chemotherapy, and may improve clinical outcomes. Further research is required to identify the most effective type of training and the minimum duration required for a positive effect.

Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer

Background

Neoadjuvant chemotherapy may have a detrimental impact on cardiorespiratory reserve. Determination of oxygen uptake at the anaerobic threshold by cardiopulmonary exercise testing (CPET) provides an objective measure of cardiorespiratory reserve. Anaerobic threshold can be used to predict perioperative risk. A low anaerobic threshold is associated with increased morbidity after oesophagogastrectomy. The aim of this study was to establish whether neoadjuvant chemotherapy has an adverse effect on fitness, and whether there is recovery of fitness before surgery for oesophageal and gastric adenocarcinoma.

Methods

CPET was completed before, immediately after (week 0), and at 2 and 4 weeks after neoadjuvant chemotherapy. The ventilatory anaerobic threshold and peak oxygen uptake (Vo2 peak) were used as objective, reproducible measures of cardiorespiratory reserve. Anaerobic threshold and Vo2 peak were compared before and after neoadjuvant chemotherapy, and at the three time intervals.

Results

Some 31 patients were recruited. The mean anaerobic threshold was lower following neoadjuvant treatment: 15·3 ml per kg per min before chemotherapy versus 11·8, 12·1 and 12·6 ml per kg per min at week 0, 2 and 4 respectively (P &lt; 0·010). Measurements were also significantly different at each time point (P &lt; 0·010). The same pattern was noted for Vo2 peak between values before chemotherapy (21·7 ml per kg per min) and at weeks 0, 2 and 4 (17·5, 18·6 and 19·3 ml per kg per min respectively) (P &lt; 0·010). The reduction in anaerobic threshold and Vo2 peak did not improve during the time between completion of neoadjuvant chemotherapy and surgery.

Conclusion

There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.

Multimodal Prehabilitation Programs as a Bundle of Care in Gastrointestinal Cancer Surgery: A Systematic Review

BACKGROUND

Prehabilitation reflects a proactive process of preoperative optimization undertaken between cancer diagnosis and definitive surgical treatment, with the intent of improving physiological capacity to withstand the major insult of surgery. Prehabilitation before GI cancer surgery is currently not widely adopted, and most research has focused on unimodal interventions such as exercise therapy, nutritional supplementation, and hematinic optimization. A review of the existing literature was undertaken to investigate the impact of multimodal prehabilitation programs as a "bundle of care."

DATA SOURCE

A systematic literature search was performed utilizing Medline, PubMed, Embase, Cinahl, Cochrane, and Google Scholar databases.

STUDY SELECTION

The quality of studies was assessed by using the Cochrane tool for assessing risk of bias (randomized trials) and the Newcastle-Ottawa Quality Assessment scale (cohort studies).

INTERVENTION

Studies were chosen that involved pre-operative optimization of patients before GI cancer surgery.

MAIN OUTCOMES

The primary outcome measured was the impact of prehabilitation programs on preoperative fitness and postoperative outcomes.

RESULTS

Of the 544 studies identified, 20 were included in the qualitative analysis. Two trials investigated the impact of multimodal prehabilitation (exercise, nutritional supplementation, anxiety management). Trials exploring prehabilitation with unimodal interventions included impact of exercise therapy (7 trials), impact of preoperative iron replacement (5 trials), nutritional optimization (5 trials), and impact of preoperative smoking cessation (2 trials). Compliance within the identified studies was variable (range: 16%-100%).

LIMITATIONS

There is a lack of adequately powered trials that utilize objective risk stratification and uniform end points. As such, a meta-analysis was not performed because of the heterogeneity in study design.

CONCLUSION

Although small studies are supportive of multimodal interventions, there are insufficient data to make a conclusion about the integration of prehabilitation in GI cancer surgery as a bundle of care. Larger, prospective trials, utilizing uniform objective risk stratification and structured interventions, with predefined clinical and health economic end points, are required before definitive value can be assigned to prehabilitation programs.

Subcellular Energetics and Metabolism: Potential Therapeutic Applications

Part I of this review discussed the similarities between embryogenesis, mammalian adaptions to hypoxia (primarily driven by hypoxia-inducible factor-1 [HIF-1]), ischemia-reperfusion injury (and its relationship with reactive oxygen species), hibernation, diving animals, cancer, and sepsis, and it focused on the common characteristics that allow cells and organisms to survive in these states. Part II of this review describes techniques by which researchers gain insight into subcellular energetics and identify potential future tools for clinicians. In particular, P nuclear magnetic resonance to measure high-energy phosphates, serum lactate measurements, the use of near-infrared spectroscopy to measure the oxidation state of cytochrome aa3, and the ability of the protoporphyrin IX-triplet state lifetime technique to measure mitochondrial oxygen tension are discussed. In addition, this review discusses novel treatment strategies such as hyperbaric oxygen, preconditioning, exercise training, therapeutic gases, as well as inhibitors of HIF-1, HIF prolyl hydroxylase, and peroxisome proliferator-activated receptors.

The physiotherapist and the esophageal cancer patient: from prehabilitation to rehabilitation

Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches, the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoperative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobilization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies, however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored. While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign: A Scientific Statement From the American Heart Association

Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes. The purpose of this statement is to review current knowledge related to the association between CRF and health outcomes, increase awareness of the added value of CRF to improve risk prediction, and suggest future directions in research. Although the statement is not intended to be a comprehensive review, critical references that address important advances in the field are highlighted. The underlying premise of this statement is that the addition of CRF for risk classification presents health professionals with unique opportunities to improve patient management and to encourage lifestyle-based strategies designed to reduce cardiovascular risk. These opportunities must be realized to optimize the prevention and treatment of cardiovascular disease and hence meet the American Heart Association's 2020 goals.

Changes in exercise capacity, muscle strength, and health-related quality of life in esophageal cancer patients undergoing esophagectomy

Background

Surgery for cancer of the thoracic esophagus is a challenging procedure associated with high morbidity and mortality. Perioperative rehabilitation has been introduced to promote early mobilization of the patients and to prevent postoperative pulmonary complications. The purpose of the present study was to characterize the preoperative functional exercise capacity, muscle strength, anxiety, depression, and health-related quality of life (QOL) in patients with esophageal cancer, and to evaluate the impact of radical esophagectomy on these parameters.

Methods

We performed a retrospective review of 34 consecutive patients with newly diagnosed resectable esophageal cancer who underwent esophagectomy followed by postoperative rehabilitation from January to December 2014. Patients were tested for 6-min walk distance (6MWD), knee-extensor muscle strength, hand grip strength, the Hospital Anxiety and Depression Scale (HADS), and the chronic obstructive pulmonary disease (COPD) assessment test (CAT) before and two weeks after the surgery. Before surgery, the pulmonary function test, and components of the MOS 36-item Short-Form Health Survey (SF-36) Questionnaire for general health were assessed.

Results

The mean age was 67.3 ± 8.1 years. The patients were predominantly male (76.4 %), had high rates of smoking history (91.2 %), and squamous cell carcinoma (97.1 %). The predicted value for forced expiratory volume in 1 s was 94.0 ± 15.9 %, and 12 patients (35.3 %) had COPD. The clinical stage was 0-I in 12 patients, II in 4 patients, III in 16 patients, and IV in 2 patients. Thirty-one patients (91.2 %) underwent open surgery. At the baseline, components of the SF-36 scores significantly correlated with CAT and HADS scores, and the physical status was significantly poorer in patients with COPD than those without. Comparisons between the preoperative and postoperative values revealed significant decreases in 6MWD, hand grip strength, isometric knee extensor muscle strength, and a significant increase in CAT scores but not in HADS scores after surgery. In multiple regression analysis, decreases in 6MWD after the surgery significantly correlated with the preoperative physical component summary of SF-36.

Conclusions

Our results indicate that surgery remained detrimental to health outcomes at two weeks. Further research should investigate whether prehabilitation would improve the postoperative outcomes, QOL, and physical fitness.

Electronic supplementary material

The online version of this article (doi:10.1186/s13102-016-0060-y) contains supplementary material, which is available to authorized users.

The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study

Background

In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery.

Methods

This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L).

Discussion

The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival.

Trial registration

ClinicalTrials.gov NCT01325883 - 29^th March 2011.

Preoperative physical therapy treatment did not influence postoperative pain and disability outcomes in patients undergoing shoulder arthroscopy: a prospective study

Background

There is limited literature investigating preoperative physical therapy (pre-op PT) treatment on pain intensity and disability after musculoskeletal surgery. The purposes of the present cohort study were to describe patient characteristics for those who had and did not have pre-op PT treatment and determine whether pre-op PT influenced the length of postoperative physical therapy (post-op PT) treatment (number of sessions) and 3-month and 6-month postsurgical outcomes, such as pain intensity and disability.

Patients and methods

A total of 124 patients (mean age =43 years, 81 males) with shoulder pain were observed before and after shoulder arthroscopic surgery. Demographic data, medical history, and validated self-report questionnaires were collected preoperatively and at 3 months and 6 months after surgery. Analysis of variance models were performed to identify differences across measures for patients who had pre-op PT treatment and those who did not and to examine outcome differences at 3 months and 6 months. Alpha was set at the 0.05 level for statistical significance.

Results

Males had less participation in pre-op PT than females (P=0.01). In contrast, age, pain intensity, disability, and pain-associated psychological factors did not differ between pre-op PT treatment groups (P>0.05). Subacromial bursectomies were more commonly performed in patients having pre-op PT treatment (P<0.05). Pre-op PT treatment did not influence length of post-op PT treatment and did not affect 3-month and 6-month pain intensity and disability outcomes. Differences in distribution of pre-op PT for males and females and subacromial bursectomy did not influence 3-month or 6-month postsurgical outcomes.

Conclusion

Receiving pre-op PT treatment did not influence post-op PT treatment or pain and disability outcomes at 3 months and 6 months. This prospective cohort study provides no evidence of benefit for pre-op PT on post-op PT treatment or postsurgical outcomes. Females or patients receiving certain surgical procedures are more likely to undergo pre-op PT treatment. However, these differences did not influence postoperative outcomes in this cohort.

The impact of cardiopulmonary exercise testing on patients over the age of 80 undergoing elective colorectal cancer surgery

AIM

Advanced age and occult cardiorespiratory disease are associated with increased morbidity and mortality following surgery. Cardiopulmonary exercise testing (CPET) may allow the identification of high-risk patients and facilitate planned postoperative critical care support. The aim of this study was to determine whether preoperative CPET in patients aged over 80 undergoing elective colorectal cancer resection was associated with improved outcome.

METHOD

All patients aged 80 years and above undergoing elective colorectal cancer resection between 1 March 2011 and 1 September 2013 were retrospectively analysed. Referral for CPET testing was at the discretion of the operating surgeon. Postoperative critical care unit (CCU) admission was based upon the CPET results.

RESULTS

Ninety-four patients were identified, of whom 48 underwent CPET testing. The CPET group were significantly older than the non-CPET group (85 vs 83 years, P = 0.04) and were more likely to have a planned admission to CCU postoperatively (P < 0.0001). Despite the increased use of CCU resources, the overall CCU length of stay (LOS) in the CPET group did not differ from the non-CPET group, but the non-CPET group had a higher proportion of Level-3 care. There were no differences in the incidence of unplanned CCU admission between the CPET and the non-CPET group (P = 0.23). There were no differences in overall LOS between the two groups (P = 0.42). There was no difference in mortality (P = 0.11), overall complications (P = 0.53) or severe complications (P = 0.3).

CONCLUSION

Preoperative CPET testing in patients aged over 80 undergoing elective colorectal cancer resection allows identification of higher-risk patients and mitigation of risk by preemptive admission to a CCU. This stratification allows equivalent results to be achieved in high- and low-risk elderly patients undergoing colorectal surgery.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Anesthesia for esophagectomy

Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.

Cardiopulmonary exercise testing for risk prediction in major abdominal surgery

Reduced exercise capacity is associated with increased postoperative morbidity. Cardiopulmonary exercise testing variables can be used to risk stratify patients. This information can be used to help guide the choice of surgical procedure and to decide on the most appropriate postoperative care environment. Thus CPET can aid collaborative decision making and improve the process of informed consent. In the future, CPET may be combined with other risk predictors to improve outcome prediction. Furthermore early evidence suggests that CPET can be used to guide prehabilitation training programs, improving fitness and thereby reducing perioperative risk.

The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery

BACKGROUND

Neoadjuvant chemotherapy (NAC) followed by surgery for resectable oesophageal or gastric cancer improves outcome when compared with surgery alone. However NAC has adverse effects. We assess here whether NAC adversely affects physical fitness and whether such an effect is associated with impaired survival following surgery.

METHODS

We prospectively studied 116 patients with oesophageal or gastric cancer to assess the effect of NAC on physical fitness, of whom 89 underwent cardiopulmonary exercise testing (CPET) before NAC and proceeded to surgery. 39 patients were tested after all cycles of NAC but prior to surgery. Physical fitness was assessed by measuring oxygen uptake (VO₂ in ml kg(-1) min(-1)) at the estimated lactate threshold (θL) and at peak exercise (VO₂ peak in ml kg(-1) min(-1)).

RESULTS

VO₂ at θL and at peak were significantly lower after NAC compared to pre-NAC values: VO₂ at θL 14.5 ± 3.8 (baseline) vs. 12.3 ± 3.0 (post-NAC) ml kg(-1) min(-1); p ≤ 0.001; VO₂ peak 20.8 ± 6.0 vs. 18.3 ± 5.1 ml kg(-1) min(-1); p ≤ 0.001; absolute VO₂ (ml min(-1)) at θL and peak were also lower post-NAC; p ≤ 0.001. Decreased baseline VO₂ at θL and peak were associated with increased one year mortality in patients who completed a full course of NAC and had surgery; p = 0.014.

CONCLUSION

NAC before cancer surgery significantly reduced physical fitness in the overall cohort. Lower baseline fitness was associated with reduced one-year-survival in patients completing NAC and surgery, but not in patients who did not complete NAC. It is possible that in some patients the harms of NAC may outweigh the benefits. Trials Registry Number: NCT01335555.

Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery

BACKGROUND

Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery.

METHODS

Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures.

RESULTS

One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events.

DISCUSSION

CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.

Assessment of preoperative exercise capacity in hepatocellular carcinoma patients with chronic liver injury undergoing hepatectomy

Background

Cardiopulmonary exercise testing measures oxygen uptake at increasing levels of work and predicts cardiopulmonary performance under conditions of stress, such as after abdominal surgery. Dynamic assessment of preoperative exercise capacity may be a useful predictor of postoperative prognosis. This study examined the relationship between preoperative exercise capacity and event-free survival in hepatocellular carcinoma (HCC) patients with chronic liver injury who underwent hepatectomy.

Methods

Sixty-one HCC patients underwent preoperative cardiopulmonary exercise testing to determine their anaerobic threshold (AT). The AT was defined as the break point between carbon dioxide production and oxygen consumption per unit of time (VO₂). Postoperative events including recurrence of HCC, death, liver failure, and complications of cirrhosis were recorded. Univariate and multivariate analyses were performed to evaluate associations between 35 clinical factors and outcomes, and identify independent prognostic indicators of event-free survival and maintenance of Child-Pugh class.

Results

Multivariate analyses identified preoperative branched-chain amino acid/tyrosine ratio (BTR) <5, alanine aminotransferase level ≥42 IU/l, and AT VO₂ <11.5 ml/min/kg as independent prognostic indicators of event-free survival. AT VO₂ <11.5 ml/min/kg and BTR <5 were identified as independent prognostic indicators of maintenance of Child-Pugh class.

Conclusions

This study identified preoperative exercise capacity as an independent prognostic indicator of event-free survival and maintenance of Child-Pugh class in HCC patients with chronic liver injury undergoing hepatectomy.

Preoperative cardiopulmonary exercise testing in England - a national survey

Background

Cardiopulmonary exercise testing (CPET) has become well established in the preoperative assessment of patients presenting for major surgery in the United Kingdom. There is evidence supporting its use in risk-stratifying patients prior to major high-risk surgical procedures.

We set out to establish how CPET services in England have developed since the only survey on this subject was undertaken in 2008 (J Intensive Care Soc 2009, 10:275–278).

Methods

Availability of preoperative CPET and contact details were collected via a telephone survey and email invites to complete the online survey were sent to all contacts. The survey was live during March and April 2011.

Results

We received 123 (74%) responses from the 166 emails that were sent out. In total, 32% (53/166) of all adult anesthetic departments in England have access to preoperative CPET services and a further 4% (6) were in the process of setting up services. The number of departments offering preoperative CPET, including those in the process of setting up services, has risen from 42 in 2008 to 59 in 2011, a rise of over 40%. Only 61% of the clinics are run by anesthetists and 39% of clinics have trained cardiorespiratory technicians assisting in the performance of the test. Most of the clinics (55%) rely solely on a bicycle ergometer. Vascular surgical patients are the largest group of patients tested, and the majority of tests are run to a symptom-limited maximum. We estimate that 15,000 tests are performed annually for preoperative assessment in England. Only 37% of respondents were confident that the tests performed were being billed for.

Conclusions

CPET is increasing in popularity as a preoperative risk assessment tool. There remains a lack of consistency in the way tests are reported and utilized. The results highlight the extent and diversity of the use of preoperative CPET and the potential for further research into its use in unstudied patient groups.