Effect of preoperative inspiratory muscle training on physical functioning following esophagectomy

Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer

Esophagectomy is an exemplar of complex oncological surgery and is associated with a relatively high risk of major morbidity and mortality. In the modern era, where specific complications are targeted in prevention and treatment pathways, and where the principles of enhanced recovery after surgery are espoused, optimum outcomes are targeted via a number of approaches. These include comprehensive clinical and physiological risk assessment, specialist perioperative care by a high-volume team, and multimodal inputs throughout the patient journey that aim to preserve or restore nutritional deficits, muscle mass and function.

Effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft surgery

Coronary artery disease is one of the main causes of mortality and morbidity among chronic heart diseases worldwide. Patients reported chronic chest pain as the primary symptom of coronary artery disease. Due to its progressive nature, it affects the health status and functional capacity of the patients. The current study was planned to compare the effects of prehabilitation resistance training in mild to moderate clinically frail patients awaiting coronary artery bypass graft (CABG). A randomized controlled trial was conducted on 74 patients awaiting CABG at the Faisalabad Institute of Cardiology, Faisalabad, Pakistan. A Modified Healthy Heart Questionnaire was used for screening of the patients. Interventions applied were resistance training by using cuff weights/dumbbells at light intensity (40%-50%) of a maximum of one repetition (10-15 repetitions for one to three times a day) per major muscle groups of upper and lower limbs of the body on weekly basis. The main outcome measures were the 6-minute walk test (6MWT), the New York Heart Association (NYHA) for heart failure, the clinical frailty score, and the essential frailty toolset. Significant differences between group A (resistance training group) and group B (conventional physical therapy group) patients were observed. The mean ranks for 6MWT in group A and group B were 1.70 and 1.55, respectively. The mean ranks of NYHA in group A and group B were 1.68 and 2.84, respectively. Clinical frailty scores in group A and group B were 2.68 and 2.74, respectively, with the essential frailty toolset in group A and group B were 1.14 and 1.11, respectively. There were significant (p < 0.05) differences within and between groups for prehabilitation resistance training after CABG. The study showed that the resistance training group had improved the clinical frailty score, strength, endurance, and functional capacity in patients who underwent elective CABG.

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.

Preoperative inspiratory muscle weakness as a risk factor of postoperative pulmonary complications in patients with esophageal cancer

OBJECTIVE

We examined whether preoperative inspiratory muscle weakness (IMW) is a risk factor for postoperative pulmonary complications (PPCs) in patients with esophageal cancer who underwent subtotal esophagectomy.

METHODS

This single-center retrospective cohort study enrolled patients with esophageal cancer who underwent a scheduled subtotal esophagectomy between June 2020 and May 2022. Maximal inspiratory pressure (MIP) was measured as inspiratory muscle strength using a respiratory dynamometer, and we defined IMW as MIP < 80% of the predicted value. Our primary outcome comprised overall PPCs. We investigated the relationship between IMW and PPCs using the Bayesian logistic regression model.

RESULTS

After exclusion, 72 patients were included in this study. IMW was identified in 26 patients (36%), and PPCs developed in 28 patients (39%). Among patients with IMW, 15 (58%) developed PPCs. Preoperative IMW was associated with PPCs (mean odds ratio [OR]: 3.58; 95% credible interval [95% CrI]: 1.29, 9.73) in the unweighted model. A similar association was observed in the weighted model adjusted for preoperative and intraoperative contributing factors (mean OR: 4.15; 95% CrI: 2.04, 8.45).

CONCLUSIONS

Preoperative IMW was associated with PPCs in patients with esophageal cancer who underwent subtotal esophagectomy. This association remained after adjusting for preoperative and intraoperative contributing factors.

Respiratory muscle training with electronic devices in the postoperative period of hepatectomy: A randomized study

BACKGROUND

Many studies have been developed with a focus on surgical techniques and drugs, but few that address the importance of rehabilitation in the pre and postoperative period, and the specific benefits for each surgical procedure or type of neoplasm, aiming to minimize respiratory complications in the postoperative period.

AIM

To compare the strength of the respiratory muscles in the pre and postoperative periods of hepatectomy by laparotomy and to verify the incidence of postoperative pulmonary complications among the groups studied.

METHODS

Prospective, randomized, clinical trial study that compared the inspiratory muscle training group (GTMI) with the control group (CG). After the collection of sociodemographic and clinical data, in both groups, preoperatively, on the first and fifth postoperative days, vital signs and pulmonary mechanics were evaluated and recorded. Albumin and bilirubin values were recorded for the albumin-bilirubin (ALBI) score. After randomization and allocation of participants, those in the CG underwent conventional physical therapy and those in the GTMI underwent conventional physical therapy plus inspiratory muscle, in both groups for five postoperative days.

RESULTS

Of 76 subjects met eligibility criteria. The collection of 41 participants was completed: 20 in the CG and 21 in the GTMI. The most frequent diagnosis was 41.5% with liver metastasis, followed by 26.8% with hepatocellular carcinoma. As for respiratory complications in the GTMI, there was no incidence. In the CG, there were three respiratory complications. Patients in the CG classified as ALBI score 3 presented, statistically, a higher energy value compared to patients classified as ALBI score 1 and 2 (P = 0.0187). Respiratory variables, measured preoperatively and on the first postoperative day, had a significant drop in both groups from the preoperative to the first postoperative day (P ≤ 0.0001). When comparing the preoperative period and the fifth postoperative day between the GTMI and the CG, the maximal inspiratory pressure variable in the GTMI was statistically significant (P = 0.0131).

CONCLUSION

All respiratory measures showed a reduction in the postoperative period. Respiratory muscle training using the Powerbreathe^® device increased maximal inspiratory pressure and this may have contributed to a shorter hospital stay and better clinical outcome.

Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Clinical frailty is a risk factor of adverse outcomes in patients with esophageal cancer undergoing esophagectomy: analysis of 2011-2017 US hospitals

Frailty is an aggregate of medical and geriatric conditions that affect elderly and vulnerable patients; as frailty is known to affect postoperative outcomes, we evaluate the effects of frailty in patients undergoing esophageal resection surgery for esophageal cancer. 2011-2017 National Inpatient Sample was used to isolate younger (18 to <65) and older (65 or greater) patients undergoing esophagectomy for esophageal cancer, substratified using frailty (defined by Johns-Hopkins ACG frailty indicator) into frail patients and non-frail controls; the controls were 1:1 matched with frail patients using propensity score. Endpoints included mortality, length of stay (LOS), costs, discharge disposition, and postsurgical complications. Following the match, there were 363 and equal number controls in younger cohort; 383 and equal number controls in older cohort. For younger cohort, frail patients had higher mortality (odds ratio [OR] 3.14 95% confidence interval [CI] 1.39-7.09), LOS (20.5 vs. 13.6 days), costs ($320,074 vs. $190,235) and were likely to be discharged to skilled nursing facilities; however, there was no difference in postsurgical complications. In multivariate, frail patients had higher mortality (aOR 3.00 95%CI 1.29-6.99). In older cohort, frail patients had higher mortality (OR 1.96 95%CI 1.07-3.60), LOS (19.9 vs. 14.3 days), costs ($301,335 vs. $206,648) and were more likely to be discharged to short-term hospitals or skilled nursing facilities; the frail patients were more likely to suffer postsurgical respiratory failure (OR 2.03 95%CI 1.31-3.15). In multivariate, frail patients had higher mortality (aOR 1.93 95%CI 1.04-3.58). Clinical frailty adversely affects both younger and older patients undergoing esophagectomy for esophageal cancer.

OUP accepted manuscript

Background

Wearable devices have been proposed as a novel method for monitoring patients after surgery to track recovery, identify complications early, and improve surgical safety. Previous studies have used a heterogeneous range of devices, methods, and analyses. This review aimed to examine current methods and wearable devices used for monitoring after abdominal surgery and identify knowledge gaps requiring further investigation.

Methods

A scoping review was conducted given the heterogeneous nature of the evidence. MEDLINE, EMBASE, and Scopus databases were systematically searched. Studies of wearable devices for monitoring of adult patients within 30 days after abdominal surgery were eligible for inclusion.

Results

A total of 78 articles from 65 study cohorts, with 5153 patients were included. Thirty-one different wearable devices were used to measure vital signs, physiological measurements, or physical activity. The duration of postoperative wearable device use ranged from 15 h to 3 months after surgery. Studies mostly focused on physical activity metrics (71.8 per cent). Continuous vital sign measurement and physical activity tracking both showed promise for detecting postoperative complications earlier than usual care, but conclusions were limited by poor device precision, adherence, occurrence of false alarms, data transmission problems, and retrospective data analysis. Devices were generally well accepted by patients, with high levels of acceptance, comfort, and safety.

Conclusion

Wearable technology has not yet realized its potential to improve postoperative monitoring. Further work is needed to overcome technical limitations, improve precision, and reduce false alarms. Prospective assessment of efficacy, using an intention-to-treat approach should be the focus of further studies.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

Effects of Prehabilitation on Functional Capacity in Aged Patients Undergoing Cardiothoracic Surgeries: A Systematic Review

Background: an increasing number of advanced age patients are considered for cardiothoracic surgeries. Prehabilitation optimizes the patients’ functional capacity and physiological reserve. However, the effectiveness of prehabilitation on physical functioning and postoperative recovery in the scope of cardiothoracic surgery is still uncertain. Objective: to assess the effectiveness of prehabilitation on pre- and/or postoperative functional capacity and physiological reserve in aged patients that are considered for cardiothoracic surgeries. Methods: this systematic review was registered in PROSPERO (CRD42021247117). The searches were conducted in PubMed, Web of Science, Scopus, and Cochrane CENTRAL until 18 April 2021. Randomized clinical trials that compared different prehabilitation strategies with usual care on the pre- and-postoperative results in aged patients undergoing cardiothoracic surgeries were included. Methodological quality was assessed by means of the Jadad scale, and the effectiveness of the interventions according to the Consensus on Therapeutic Exercise Training. Results: nine studies with 876 participants aged from 64 to 71.5 years old were included. Risk of bias was moderate due to the absence of double-blinding. The content of the interventions (multimodal prehabilitation n = 3; based on physical exercises n = 6) and the result measures presented wide variation, which hindered comparison across the studies. In general, the trials with better therapeutic quality (n = 6) reported more significant improvements in physical functioning, cardiorespiratory capacity, and in the postoperative results in the participants under-going prehabilitation. Conclusions: prehabilitation seems to improve functional capacity and postoperative recovery in aged patients undergoing cardiothoracic surgeries. However, due to the significant heterogeneity and questionable quality of the trials, both the effectiveness of prehabilitation and the optimum content are still to be determined.

Effectiveness of telerehabilitation on short-term quality of life of patients after esophageal cancer surgery during COVID-19: a single-center, randomized, controlled study

Background

The occurrence of postoperative complications may lead to delayed recovery and a decline in physical function in the first 3 months after esophagectomy. The outbreak of COVID-19 imposed physical and emotional obstacles for traditional face-to-face rehabilitation. Meanwhile, the effectiveness of telerehabilitation remained unknown. In this study, we aimed to investigate the effectiveness of telerehabilitation.

Methods

A cohort of 86 patients who received minimally invasive esophagectomy between September 2020 and January 2021 was randomly allocated into two groups. The telerehabilitation group received additional online consulting and training, including (I) precautions for nutritional support; (II) swallowing function training; (III) respiratory function training; (IV) guidance and feedback on matters such as patient's current vital signs, wound status, medication, and sleep status. The primary outcome was the change of quality of life (QOL) of each patient at 3 months after surgery.

Results

No serious adverse events were observed in either group. The telerehabilitation group showed significant improvements in pain using the OLQ-C30 scale (P<0.001), and in choking using the QLQ-OES18 scale (P<0.001). The comparison of the QLQ-C30 and QES-18 score changes at three months after discharge revealed that nearly all aspects in the telerehabilitation group displayed more score changes with significant changes in the appetite loss and pain part (P<0.001 and P<0.05, respectively). The score changes in QLQ-OES18 revealed significant improvement in swallowing saliva (P<0.05), as well slight improvements in choking, dry mouth, taste, and cough without significance.

Conclusions

Our study demonstrated that telerehabilitation was at least an important supplement to traditional face-to-face consulting and training for patients after esophageal cancer surgery during the COVID-19 period.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100049186.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

OBJECTIVE

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

DATA SOURCES

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

STUDY SELECTION

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

DATA EXTRACTION AND SYNTHESIS

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

RESULTS

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

CONCLUSIONS

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019151475.

A scoping review of interventions using accelerometers to measure physical activity or sedentary behaviour during hospitalization

Objective:

To identify interventions using wearable accelerometers to measure physical activity and/or sedentary behaviour in adults during hospitalization for an acute medical/surgical condition.

Data sources:

Four databases were searched in August 2019 (MEDLINE, CINAHL, Scopus, EMBASE).

Review methods:

Studies were selected if they described an intervention in adults with a medical/surgical condition, and concurrently reported an accelerometer-derived measure of physical activity and/or sedentary behaviour while participants were admitted. Items were screened for eligibility in duplicate. Included studies were synthesized to describe intervention types, feasibility and potential effectiveness.

Results:

Twenty-two studies were included, reporting on 3357 participants (2040 with accelerometer data). Identified types of interventions were: pre-habilitation ( n = 2) exercise ( n = 3), patient behaviour change with self-monitoring ( n = 6), models of care ( n = 5), implementing system change ( n = 2), surgical technique ( n = 2) patients wearing day clothes ( n = 1) and education about activity in hospital ( n = 1). Of 16 studies that reported intervention effects on physical activity, 11 reported a favourable impact including studies of: pre-habilitation, self-monitoring (accelerometry or an activity whiteboard), physiotherapy, an early mobility bundle, minimally invasive surgery, an education booklet and by implementing system change. Of the six studies that reported intervention effects on sedentary behaviour, there was a favourable impact with an activity whiteboard, models of care and an education booklet.

Conclusion:

Accelerometer-derived measures of physical activity and/or sedentary behaviour have been used to describe sample characteristics and intervention effects in studies of hospitalized adults. Interventions may involve a range of health professionals, but less is known about sedentary behaviour in this setting.

Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PRE-HIIT): protocol for a randomized controlled trial

BACKGROUND

Patients with cancer of the lung or oesophagus, undergoing curative treatment, usually require a thoracotomy and a complex oncological resection. These surgeries carry a risk of major morbidity and mortality, and risk assessment, preoperative optimisation, and enhanced recovery after surgery (ERAS) pathways are modern approaches to optimise outcomes. Pre-operative fitness is an established predictor of postoperative outcome, accordingly, targeting pre-operative fitness through exercise prehabilitation has logical appeal. Exercise prehabilitation is challenging to implement however due to the short opportunity for intervention between diagnosis and surgery. Therefore, individually prescribed, intensive exercise training protocols which convey clinically meaningful improvements in cardiopulmonary fitness over a short period need to be investigated. This project will examine the influence of exercise prehabilitation on physiological outcomes and postoperative recovery and, through evaluation of health economics, the impact of the programme on hospital costs.

METHODS

The PRE-HIIT Randomised Controlled Trial (RCT) will compare a 2-week high intensity interval training (HIIT) programme to standard preoperative care in a cohort of thoracic and oesophageal patients who are > 2-weeks pre-surgery. A total of 78 participants will be recruited (39 per study arm). The primary outcome is cardiorespiratory fitness. Secondary outcomes include, measures of pulmonary and physical and quality of life. Outcomes will be measured at baseline (T0), and post-intervention (T1). Post-operative morbidity will also be captured. The impact of PRE-HIIT on well-being will be examined qualitatively with focus groups/interviews post-intervention (T1). Participant's experience of preparation for surgery on the PRE-HIIT trial will also be explored. The healthcare costs associated with the PRE-HITT programme, in particular acute hospital costs, will also be examined.

DISCUSSION

The overall aim of this RCT is to examine the effect of tailored, individually prescribed high intensity interval training aerobic exercise on pre-operative fitness and postoperative recovery for patients undergoing complex surgical resections, and the impact on use of health services.

TRIAL REGISTRATION

The study is registered with Clinical Trials.Gov (NCT03978325). Registered on 7th June 2019.