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

Prospective Evaluation of Multimodal Prehabilitation in Esophagogastric Cancer Surgery: Enhancing Patient Outcomes

BACKGROUND

The significance of prehabilitation in contemporary esophagogastric surgical procedures is yet to be fully understood, due to heterogeneity in the available research. This research was conducted to assess the impact of a structured home-based multimodal prehabilitation approach on the postsurgical outcomes of patients undergoing surgery for esophagogastric cancer.

METHODS

This study was a prospective, nonrandomized investigation carried out on individuals scheduled for curative esophagogastric cancer surgery. Participants underwent a home-based, multimodal prehabilitation regimen that incorporated structured physical exercises, nutritional support, psychological counseling, and assistance in quitting smoking and alcohol use. The primary outcome measured was the incidence of postoperative pneumonia, defined according to the revised Uniform Pneumonia Scoring system from day 1 to day 4 post-surgery.

RESULTS

A total of 94 patients were analyzed. A total of 50 patients underwent multimodal prehabilitation for a minimum of 2 weeks with a compliance rate of more than 60% and were included in the intervention group, whereas the rest 44 with compliance less than 60% or unwilling to undergo prehabilitation were included in the control group. A statistically significant difference was seen in the incidence of postoperative pneumonia between the two groups.

CONCLUSION

Structured multimodal prehabilitation done for 2 weeks before surgery improves outcomes in patients undergoing esophagogastric cancer surgery.

Boosting recovery before surgery: The impact of prehabilitation on upper gastrointestinal cancer patients - A quantitative comparative analysis

BACKGROUND

Emerging research presents divergent perspectives on the efficacy of prehabilitation for patients scheduled for surgery due to upper gastrointestinal (GI) cancers, capturing the attention of both the scientific community and surgical professionals. This quantitative comparative analysis seeks to assess the association of prehabilitation to ameliorate postoperative outcomes in individuals with upper GI cancers, thereby providing a comprehensive evaluation of its potential benefits within a surgical context.

MATERIALS AND METHODS

Medline, Embase, Cochrane Library and Web of Science were searched up to February 2024. Studies reporting the association between prehabilitation, and postoperative complications, readmissions or other outcomes of interest were included. Fixed or random effect models were used, and forest plots were applied to show the results of the quantitative comparative analysis.

RESULTS

A total of 198 studies were initially screened based on titles and abstracts, with 129 studies subsequently excluded. Overall, 69 full-text studies were identified, of which 12 studies were finally included for qualitative analysis in the quantitative comparative analysis after determining whether the inclusion and exclusion criteria were met. The pooled results indicated that prehabilitation significantly reduced the overall postoperative complication rates in patients with upper GI cancer undergoing surgical therapy with the pooled OR of 0.59 (95%CI: 0.39-0.88). Moreover, prehabilitation was also shown to be a protective factor of pulmonary complications (OR: 0.54, 95%CI: 0.36-0.80) and ICU readmissions (OR: 0.23, 95%CI: 0.06-0.89).

CONCLUSION

The correlation between prehabilitation and a reduction in overall postoperative complications, pulmonary complications, and ICU readmissions among patients with upper GI cancer is substantiated by significant data. This pivotal finding necessitates further empirical investigation to validate these initial results and ascertain the clinical efficacy of prehabilitation protocols, thereby informing future surgical practice strategies.

The course of physical fitness and nutritional status in patients following prehabilitation before esophageal cancer surgery: Results from the PRIOR study

INTRODUCTION

This study evaluates the course of physical fitness and nutritional status during curative therapy for esophageal cancer, after implementation of a prehabilitation program. Additionally, the impact of baseline physical fitness level and severe postoperative complications on the course of individual patients were explored.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients with esophageal cancer following curative treatment. Prehabilitation, consisting of supervised exercise training and nutritional counseling was offered as standard care to patients after neoadjuvant therapy, prior to surgery. Primary outcome measures included change of exercise capacity, hand grip strength, self-reported physical functioning, Body Mass Index, and malnutrition risk from diagnosis to 2-6 months postoperatively. Analyses over time were performed using linear mixed models, and linear mixed regression models to investigate the impact of baseline level and severe postoperative complications.

RESULTS

Hundred sixty-eight patients were included (mean age 65.9 ± 8.6 years; 78.0 % male). All parameters (except for malnutrition risk) showed a decline during neoadjuvant therapy (p < .05), an improvement during prehabilitation (p < .005) and a decline postoperatively (p < .001), with a high heterogeneity between patients. Change in the outcomes from baseline to postoperatively was not different for patients with or without a severe complication. Better baseline physical fitness and nutritional status were significantly associated with a greater decline postoperatively (p < .001).

CONCLUSION

This study demonstrates a notable decline during neoadjuvant therapy, that fully recovers during prehabilitation, and a subsequent long lasting decline postoperatively. The heterogeneity in the course of physical fitness and nutritional status underlines the importance of individualized monitoring.

Prehabilitation of Patients With Oesophageal Malignancy Undergoing Peri-Operative Treatment (Pre-EMPT): Outcomes From a Prospective Controlled Trial

BACKGROUND

The Pre-EMPT study aimed to determine if structured exercise could reduce length of stay, post-operative complications and improve fitness and health-related quality of life (HQRL) in patients undergoing neoadjuvant chemotherapy (NAC) and oesophagectomy.

METHODS

A prospective non-randomised trial compared a standard care pathway (control) to a structured prehabilitation exercise programme (intervention) commenced before NAC and surgery for oesophageal adenocarcinoma. Length of hospital stay and post-operative complications were recorded. Cardiopulmonary exercise testing (CPEX), body composition analyses, lymphocyte levels and HRQL questionnaires were performed at multiple time points.

RESULTS

Median length of stay was similar in both groups. There were 6 versus 11 complications observed (intervention vs control p = 0.086). Cardio-pulmonary fitness (VO2peak) declined after NAC, but less in the intervention group (intervention -13.54% vs control -21.40%, p = 0.02). Body composition improved in the intervention group (FMi/FFMi -5.5% intervention, 10.7% control p = 0.043). Performance, cognitive, sleep and emotional function scores improved following NAC in the intervention group. Lymphocyte subsets increased in the intervention group compared to the control group after chemotherapy (p = 0.034). Chemotherapy response was improved in the intervention group (p = 0.022).

CONCLUSION

A structured exercise programme may mitigate cardiopulmonary deconditioning, reduce sarcopenia and offset lymphopenia, during chemotherapy, in patients undergoing NAC and oesophagectomy.

Identification of subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation

PURPOSE

To identify subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation, and to investigate whether training outcomes varied between subgroups.

MATERIALS AND METHODS

Data from a multicentre cohort study were used, involving participants following prehabilitation before oesophagectomy. Hierarchical cluster analysis was performed using four cluster variables (intensity of aerobic exercise, the Borg score during resistance exercise, intensity of physical activity, and degree of fatigue). Aerobic capacity and muscle strength were estimated before and after prehabilitation.

RESULTS

In 64 participants, three clusters were identified based on exercise intensity. Cluster 1 (n = 23) was characterised by fatigue and physical inactivity, cluster 2 (n = 9) by a low training capacity, despite high physical activity levels, and cluster 3 (n = 32) by a high training capacity. Cluster 1 showed the greatest improvement in aerobic capacity (p = 0.37) and hand grip strength (p = 0.03) during prehabilitation compared with other clusters.

CONCLUSIONS

This cluster analysis identified three subgroups with distinct patterns in exercise intensity during prehabilitation. Participants who were physically fit were able to train at high intensity. Fatigued participants trained at lower intensity but showed the greatest improvement. A small group of participants, despite being physically active, had a low training capacity and could be considered frail.

Electrical vagus nerve stimulation is a promising approach to reducing pulmonary complications after an esophagectomy: an experimental rodent model

After esophagectomy, an imbalanced inflammatory response increases the risk of postoperative morbidity. The vagus nerve modulates local and systemic inflammatory responses, but its pulmonary branches are transected during esophagectomy as part of the oncological resection, which may account for the high incidence of postoperative (pulmonary) complications. This study investigated the effect of electrical vagus nerve stimulation (VNS) on lipopolysaccharide (LPS)-induced lung injury in rats. Rats (n = 60) were randomly assigned to a non-vagotomy or cervical vagotomy group, with VNS or without (NOSTIM). There were four non-vagotomy groups: NOSTIM and bilateral VNS with 100, 50, or 10 µA. The four vagotomy groups were NOSTIM and VNS with fixed amplitude (50 µA) bilaterally before (VNS-50-before) or after bilateral vagotomy (VNS-50-after), or unilaterally (left) before ipsilateral vagotomy (VNS-50-unilaterally). LPS was administered intratracheally after surgery. Pulmonary function, pro-inflammatory cytokines in serum, broncho-alveolar lavage fluid (BALF), and histopathological lung injury (LIS) were assessed 180 min post-procedure. In non-vagotomized rats, neutrophil influx in BALF following intra-tracheal LPS (mean 30 [± 23]; P = 0.075) and LIS (mean 0.342 [± 0.067]; P = 0.142) were similar after VNS-100, compared with NOSTIM. VNS-50 reduced neutrophil influx (23 [± 19]; P = 0.024) and LIS (0.316 [± 0.093]; P = 0.043). VNS-10 reduced neutrophil influx (15 [± 6]; P = 0.009), while LIS (0.331 [± 0.053]; P = 0.088) was similar. In vagotomized rats, neutrophil influx (52 [± 37]; P = 0.818) and LIS (0.407 [SD ± 0.037]; P = 0.895) in VNS-50-before were similar compared with NOSTIM, as well as in VNS-50-after (neutrophils 30 [± 26]; P = 0.090 and LIS 0.344 [± 0.053]; P = 0.073). In contrast, VNS-50-unilaterally reduced neutrophil influx (26 [± 10]; P = 0.050) and LIS (0.296 [± 0.065]; P = 0.005). Systemic levels of cytokines TNF-α and IL-6 were undetectable in all groups. Pulmonary function was not statistically significantly affected. In conclusion, VNS limited influx of neutrophils in lungs in non-vagotomized rats and may attenuate LIS. Unilateral VNS attenuated lung injury even after ipsilateral vagotomy. This effect was absent for bilateral VNS before and after bilateral vagotomy. It is suggested that the effect of VNS is dependent on (partially) intact vagus nerves and that the level of the vagotomy during esophagectomy may influence postoperative pulmonary outcomes.

Exercise During Chemotherapy for Cancer: A Systematic Review

Exercise prehabilitation may improve the tolerance and effectiveness of anticancer treatments such as chemotherapy. This systematic review assesses the impact of exercise on chemotherapy outcomes and identifies research priorities. Nineteen studies (1418 patients) were reviewed, including 11 randomised controlled trials and eight observational studies. Exercise led to improvements in body composition, fitness, strength and quality of life (QoL) across studies. Exercise can be safely and effectively delivered during chemotherapy. Limited standardisation and small sample sizes highlight the need for larger, better-designed studies to optimise this low-cost intervention.

Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review

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.

Current perioperative care in patients undergoing a beyond total mesorectal excision procedure for rectal cancer: What are the differences with the colorectal enhanced recovery after surgery protocol?

AIM

Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS-related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol.

METHOD

This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS-related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients.

RESULTS

Seven studies reported on ERAS-related outcomes in patients undergoing bTME. Median length of hospital stay was 9-19 days, median stay in the intensive care unit was 2-4 days and 30-day postoperative major complication rates were 22.6%-61.3%. Seventy-five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization.

CONCLUSION

Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS-related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC.

Effect of nutrition-based prehabilitation on the postoperative outcomes of patients with esophagogastric cancer undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Meta-analyses have primarily focused on the effects of exercise-based prehabilitation on postoperative outcomes and ignored the role of nutritional intervention. In this study, we filled this gap by investigating the effect of nutrition-based prehabilitation on the postoperative outcomes of patients who underwent esophagectomy and gastrectomy.

METHODS

Five electronic databases, namely, PubMed, the Web of Science, Embase, Cochrane Library, and CINAHL, were searched. Adults diagnosed with esophagogastric cancer who were scheduled to undergo surgery and had undergone uni- or multimodal prehabilitation, with at least a week of mandatory nutritional intervention, were included. Forest plots were used to extract and visualize the data from the included studies. The occurrence of any postoperative complication was considered the primary endpoint.

RESULTS

Eight studies met the eligibility criteria, with five randomized controlled trials (RCTs) and three cohort studies. In total, 661 patients were included. Any prehabilitation, that is, unimodal (only nutrition) and multimodal prehabilitation, collectively decreased the risk of any postoperative complication by 23% (95% confidence interval [CI] = 0.66-0.90). A similar effect was exclusively observed for multimodal prehabilitation (risk ratio [RR] = 0.78, 95% CI = 0.66-0.93); however, it was not significant for unimodal prehabilitation. Any prehabilitation significantly decreased the length of hospital stay (LOS) (weighted mean difference = -0.77, 95% CI = -1.46 to -0.09).

CONCLUSIONS

Nutrition-based prehabilitation, particularly multimodal prehabilitation, confers protective effects against postoperative complications after esophagectomy and gastrectomy. Our findings suggest that prehabilitation slightly decreases LOS; however, the finding is not clinically significant. Therefore, additional rigorous RCTs are warranted for further substantiation.

Predictors and Significance of Readmission after Esophagogastric Surgery: A Nationwide Analysis

Objective

The aim of this study is to identify risk factors for readmission after elective esophagogastric cancer surgery and characterize the impact of readmission on long-term survival. The study will also identify whether the location of readmission to either the hospital that performed the primary surgery (index hospital) or another institution (nonindex hospital) has an impact on postoperative mortality.

Background

Over the past decade, the center-volume relationship has driven the centralization of major cancer surgery, which has led to improvements in perioperative mortality. However, the impact of readmission, especially to nonindex centers, on long-term mortality remains unclear.

Methods

This was a national population-based cohort study using Hospital Episode Statistics of adult patients undergoing esophagectomy and gastrectomy in England between January 2008 and December 2019.

Results

This study included 27,592 patients, of which overall readmission rates were 25.1% (index 15.3% and nonindex 9.8%). The primary cause of readmission to an index hospital was surgical in 45.2% and 23.7% in nonindex readmissions. Patients with no readmissions had significantly longer survival than those with readmissions (median: 4.5 vs 3.8 years; P < 0.001). Patients readmitted to their index hospital had significantly improved survival as compared to nonindex readmissions (median: 3.3 vs 4.7 years; P < 0.001). Minimally invasive surgery and surgery performed in high-volume centers had improved 90-day mortality (odds ratio, 0.75; P < 0.001; odds ratio, 0.60; P < 0.001).

Conclusion

Patients requiring readmission to the hospital after surgery have an increased risk of mortality, which is worsened by readmission to a nonindex institution. Patients requiring readmission to the hospital should be assessed and admitted, if required, to their index institution.

Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

Evaluation of nutrition components within prehabilitation programs in gastrointestinal cancers: Is prehab worth the hype?

Nutrition impact symptoms and unintended weight loss are prevalent in patients with gastrointestinal cancers, especially during the perioperative period or while prescribed anticancer treatments. Because patients may experience loss of lean body mass and malnutrition, aggressive nutrition intervention prior to surgery should be considered. Cancer prehabilitation is a process spanning the care continuum from diagnosis to the time of surgery encompassing nutrition support, psychological and physical assessment, and targeted interventions. Thirteen studies published between 2013 and 2023 were included in this review and evaluated prehabilitation programs' impact on postoperative outcomes in patients with gastrointestinal cancers. Literature continues to emerge supporting the integration of nutrition into a prehabilitation program because of its potential to contribute to improved clinical outcomes, quality of life, and cost-effectiveness, but considerable variation exists with respect to the specific recommendations provided by current prehabilitation programs.

The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive esophagectomy: a nationwide analysis

BACKGROUND

Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE.

METHOD

Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix.

RESULTS

Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals.

CONCLUSION

In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.

Effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer: a systematic review and meta-analysis

PURPOSE

To evaluate the effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer.

METHODS

We conducted a systematic search of the PubMed, Embase, CINAHL, Web of Science, and Cochrane Library (CENTRAL) databases from database inception to May 5, 2023, for randomized controlled trials (RCTs) and cohort studies that investigated prehabilitation in the context of esophagogastric cancer. A random-effects model was used for meta-analysis.

RESULTS

We identified 2,994 records and eventually included 12 studies (6 RCTs and 6 cohort studies) with a total of 910 patients. According to random-effects pooled estimates, prehabilitation reduced the incidence of all complications (RR = 0.79, 95% CI: 0.66 to 0.93, P = 0.006), pulmonary complications (RR = 0.61, 95% CI: 0.47 to 0.79, P = 0.0002), and severe complications (RR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002), and shortened the length of stay (MD = -1.92, 95% CI: -3.11 to -0.73, P = 0.002) compared to usual care. However, there were no statistically significant differences in 30-day readmission rates or in-hospital mortality. Subgroup analysis showed that multimodal prehabilitation was effective in reducing the risk of all complications and severe complications, while unimodal prehabilitation was not.

CONCLUSIONS

Our findings suggested that prehabilitation may be beneficial in reducing postoperative complications and length of stay. We recommend preoperative prehabilitation to improve postoperative outcomes and hasten recovery following esophagogastric cancer surgery, and multimodal prehabilitation seems to be more advantageous in reducing complications. However, further studies are needed to confirm these results.

Exploring the Modulatory Effect of High-Fat Nutrition on Lipopolysaccharide-Induced Acute Lung Injury in Vagotomized Rats and the Role of the Vagus Nerve

During esophagectomy, the vagus nerve is transected, which may add to the development of postoperative complications. The vagus nerve has been shown to attenuate inflammation and can be activated by a high-fat nutrition via the release of acetylcholine. This binds to α7 nicotinic acetylcholine receptors (α7nAChR) and inhibits α7nAChR-expressing inflammatory cells. This study investigates the role of the vagus nerve and the effect of high-fat nutrition on lipopolysaccharide (LPS)-induced lung injury in rats. Firstly, 48 rats were randomized in 4 groups as follows: sham (sparing vagus nerve), abdominal (selective) vagotomy, cervical vagotomy and cervical vagotomy with an α7nAChR-agonist. Secondly, 24 rats were randomized in 3 groups as follows: sham, sham with an α7nAChR-antagonist and cervical vagotomy with an α7nAChR-antagonist. Finally, 24 rats were randomized in 3 groups as follows: fasting, high-fat nutrition before sham and high-fat nutrition before selective vagotomy. Abdominal (selective) vagotomy did not impact histopathological lung injury (LIS) compared with the control (sham) group (p > 0.999). There was a trend in aggravation of LIS after cervical vagotomy (p = 0.051), even after an α7nAChR-agonist (p = 0.090). Cervical vagotomy with an α7nAChR-antagonist aggravated lung injury (p = 0.004). Furthermore, cervical vagotomy increased macrophages in bronchoalveolar lavage (BAL) fluid and negatively impacted pulmonary function. Other inflammatory cells, TNF-α and IL-6, in the BALF and serum were unaffected. High-fat nutrition reduced LIS after sham (p = 0.012) and selective vagotomy (p = 0.002) compared to fasting. vagotomy. This study underlines the role of the vagus nerve in lung injury and shows that vagus nerve stimulation using high-fat nutrition is effective in reducing lung injury, even after selective vagotomy.

Perceived facilitators and barriers by esophageal cancer survivors participating in a post-treatment exercise program

PURPOSE

Participation in a post-treatment exercise program improves cardiorespiratory fitness and aspects of quality of life for esophageal cancer survivors. For optimal effects, high adherence to the exercise intervention is important. We assessed which facilitators and barriers to exercise adherence are perceived by esophageal cancer survivors, who participate in a post-treatment exercise program.

METHODS

The current qualitative study was performed within the randomized controlled PERFECT trial, in which we investigated effects of a 12-week supervised exercise program with moderate-to-high intensity and daily physical activity advice. Semi-structured interviews were conducted with patients randomized to the exercise group. A thematic content approach was used to derive perceived facilitators and barriers.

RESULTS

Thematic saturation was reached after inclusion of sixteen patients. Median session attendance was 97.9% (IQR 91.7-100%), and relative dose intensity (compliance) to all exercises was ≥90.0%. Adherence to the activity advice was 50.0% (16.7-60.4%). Facilitators and barriers were captured in seven themes. The most important facilitators were patients' own intention to engage in exercise and supervision by a physiotherapist. Barriers were mainly experienced in completion of the activity advice, and included logistic factors and physical complaints.

CONCLUSIONS

Esophageal cancer survivors are well capable to attend a moderate-to-high intensity post-treatment exercise program, and to fulfill the exercises according to protocol. This is facilitated by patients' own intention to engage in exercise and supervision of the physiotherapist, and only minimally affected by barriers as logistic factors and physical complaints.

IMPLICATIONS FOR CANCER SURVIVORS

When implementing postoperative exercise programs in clinical care, it can be useful to be aware of perceived facilitators and barriers of cancer survivors in order to achieve optimal exercise adherence and maximize beneficial exercise effects.

TRIAL REGISTRATION

Dutch Trial Register NTR 5045.

Old age and intense chemotherapy exacerbate negative prognostic impact of postoperative complication on survival in patients with esophageal cancer who received neoadjuvant therapy: a nationwide study from 85 Japanese esophageal centers

BACKGROUND

The prognostic impact of docetaxel, cisplatin, and 5-FU (DCF) reported in JCOG1109 was successfully validated using real-world data in patients < 75 years old. However, DCF was not reported to be beneficial in elderly patients with a relatively higher postoperative complication incidence. This study aimed to clarify the impact of postoperative complications on the prognosis of ESCC and the difference in the magnitude of the impact by age and regimen.

METHODS

Patients with esophageal squamous cell carcinoma (ESCC) who underwent subtotal esophagectomy at 85 authorized institutes were retrospectively reviewed from 2010 to 2015. The prognostic impact of postoperative anastomotic leakage (AL) and pneumonia on survival was evaluated. The prognostic value of the postoperative complications was assessed by stratifying patients according to age and neoadjuvant chemotherapy regimen.

RESULTS

Patients with AL, pneumonia, and infectious complications (ICs: a combination of pneumonia and AL) showed significantly worse overall survival (OS). IC served as a negative prognostic factor of OS and recurrence-free survival, and its negative prognostic impact was more evident in patients aged > 75 years. When the patients were further stratified by chemotherapeutic regimens, using the CF/IC(-) group as a reference, the DCF/IC (+) group showed significantly shorter OS in patients aged > 75 years with a hazard ratio (HR) of 2.551. The HR of the CF/IC (+) group was 1.503.

CONCLUSIONS

The negative impact of postoperative complications on survival was confirmed in this nationwide study. Furthermore, its magnitude was higher in elderly patients who received triplet chemotherapy.

Splenic arterial neurovascular bundle stimulation in esophagectomy: A feasibility and safety prospective cohort study

INTRODUCTION

The autonomic nervous system is a key regulator of inflammation. Electrical stimulation of the vagus nerve has been shown to have some preclinical efficacy. However, only a few clinical studies have been reported to treat inflammatory diseases. The present study evaluates, for the first time, neuromodulation of the splenic arterial neurovascular bundle (SpA NVB) in patients undergoing minimally invasive esophagectomy (MIE), in which the SpA NVB is exposed as part of the procedure.

METHODS

This single-center, single-arm study enrolled 13 patients undergoing MIE. During the abdominal phase of the MIE, a novel cuff was placed around the SpA NVB, and stimulation was applied. The primary endpoint was the feasibility and safety of cuff application and removal. A secondary endpoint included the impact of stimulation on SpA blood flow changes during the stimulation, and an exploratory point was C-reactive protein (CRP) levels on postoperative day (POD) 2 and 3.

RESULTS

All patients successfully underwent placement, stimulation, and removal of the cuff on the SpA NVB with no adverse events related to the investigational procedure. Stimulation was associated with an overall reduction in splenic arterial blood flow but not with changes in blood pressure or heart rate. When compared to historic Propensity Score Matched (PSM) controls, CRP levels on POD2 (124 vs. 197 mg/ml, p = 0.032) and POD3 (151 vs. 221 mg/ml, p = 0.033) were lower in patients receiving stimulation.

CONCLUSION

This first-in-human study demonstrated for the first time that applying a cuff around the SpA NVB and subsequent stimulation is safe, feasible, and may have an effect on the postoperative inflammatory response following MIE. These findings suggest that SpA NVB stimulation may offer a new method for immunomodulatory therapy in acute or chronic inflammatory conditions.