Preoperative weight loss in women with obesity in gynaecologic oncology: A retrospective study

All Wales Ovarian Cancer Prehabilitation Project (AWOCPP)

Over 50% of patients with ovarian cancer are diagnosed with advanced disease (stage 3+) in Wales when treatment typically involves chemotherapy, combined with cytoreductive surgery. Postoperative morbidity is common resulting in prolonged hospital stays and delays in returning to chemotherapy. Patients with advanced ovarian cancer commonly have modifiable risk factors that can be targeted for improvement with personalised prehabilitation. Multimodal personalised prehabilitation has been shown to have a positive impact on perioperative outcomes and length of stay (LOS).Quality improvement methods were used to implement a multimodal prehabilitation programme for all patients with advanced ovarian cancer planned for surgery in Wales. A unique approach to determining an individual patient's modifiable risk factors was devised that enabled a personalised prehabilitation programme to be created including exercise, smoking cessation, medical and nutritional optimisation and emotional support. Data were collected to enable future health economic evaluation of the programme in anticipation of national role out as standard of care. To evaluate if the prehabilitation intervention was impacting the quality of care, the following outcome measures were assessed: LOS, postoperative complications and surgery to chemotherapy interval (SCI). These measures were compared with a historical Welsh data set from 2018 to 2019 when access to prehabilitation was not available.Following the implementation of prehabilitation for ovarian cancer, the median LOS reduced from 6 to 5 days (p=0.29). There was a reduction in postoperative complications: from 16.9% to 12.7% (Grade 2), 4.4% to 1.8% (Grade 3), 0.6% to 0% (Grade 4+5). The median SCI following prehabilitation was 43.5 days (range 27-91) compared with 40 days (range 15-182 (p=0.65)).Prehabilitation has had a positive impact on the treatment pathways for advanced ovarian cancer in Wales. Means of improving patient engagement and establishing cost-effective delivery need to be developed to make this intervention standard of care.

A scoping review of preoperative weight loss interventions on postoperative outcomes for patients with gastrointestinal cancer

BACKGROUND

Obesity is associated with increased risk of surgical complications in some settings.

OBJECTIVE

As a precursor to a systematic review, we conducted a scoping review of intentional preoperative weight loss to describe these interventions, their feasibility and effectiveness for patients with gastrointestinal cancer.

METHODS

In April 2024, Ovid MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for primary studies of intentional weight loss before elective gastrointestinal cancer surgery. Extracted data encompassed recruitment and attrition, intervention types, adherence, anthropometric and body composition changes, and surgical outcomes. Study quality was assessed using the Risk of Bias In Non-randomized Studies of Interventions tool.

RESULTS

The search produced 7 articles (4 non-randomized clinical trials), which were all conducted in Japan, and involved 258 participants with a baseline BMI ≥25 kg/m2. Weight loss interventions included dietary modification (n = 3), exercise (n = 1), and combination (n = 3). None of the articles reported rates of recruitment, 2 adherence (97-100 %), and 4 reported attrition rates (0-18 %). All reported weight reductions of -1.3 to -6 kg and 4.5-6.9 % (n = 7), compared to baseline. Three of four non-randomized trials observed a reduction in postoperative complications, as compared to control; yet all trials were at critical risk of bias.

CONCLUSION

Strong conclusions could not be made due to the limited reporting and critical risk of bias; further systematic review is not recommended at this time. To establish more robust evidence, there is a clear need for high-quality trials.

Very low energy diets before nonbariatric surgery: A systematic review and meta-analysis

BACKGROUND

Very low energy diets serve as an intensive approach to weight loss in a short period of time. Although the preoperative use of very low energy diets to optimize patients with obesity before bariatric surgery is well established, the evidence for very low energy diets before other types of surgery remains unclear. The aim of this review was to determine the impact of preoperative very low energy diets on perioperative outcomes in nonbariatric surgery.

METHODS

Medline, EMBASE, CENTRAL, and PubMed were systematically searched from inception through to July 2021. Articles were included if they evaluated very low energy diets use before any type of nonbariatric surgery. The primary outcome was postoperative morbidity. Secondary outcomes included compliance, safety, and preoperative weight loss. A pairwise meta-analyses using inverse variance random effects was performed.

RESULTS

From 792 citations, 13 studies with 395 patients (mean age: 56.5 years, 55.8% female) receiving very low energy diets preoperatively in preparation for nonbariatric surgery were included. Mean duration of preoperative very low energy diets was 6.6 weeks (range, 0.42-17 weeks). Target daily caloric intake ranged from 450 kcal to 1,400 kcal. Compliance with very low energy diets ranged from 94% to 100%. The mean preoperative weight loss ranged from 3.2 kg to 19.2 kg. There were no significant differences in postoperative morbidity (odds ratio, 1.10; 95% confidence interval, 0.64-1.91; P = .72), operative time (standard mean difference -0.35; 95% confidence interval, 1.13-0.43, P = .38), or postoperative length of stay (standard mean difference 0.40, 95% confidence interval -0.11-0.91, P = .12) with very low energy diets.

CONCLUSION

Although the currently available evidence is heterogenous, preoperative very low energy diets are safe, well tolerated, and effectively induce preoperative weight loss in patients undergoing nonbariatric surgery for both benign and malignant disease. Further prospective studies are warranted.

Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity?

The literature evaluating the effect of prehabilitation programmes on postoperative outcomes and quality of life of patients with gynaecological cancer undergoing surgery was reviewed. Databases including Pubmed, Medline, EMBASE (Ovid) and PsycINFO were systematically searched to identify studies evaluating the effect of prehabilitation programmes on patients with gynaecological cancer. Both unimodal and multimodal prehabilitation programmes were included encompassing physical exercise and nutritional and psychological support. Primary outcomes were surgical complications and quality of life. Secondary outcomes were anthropometric changes and adherence to the prehabilitation programme. Seven studies fulfilled the inclusion criteria, comprising 580 patients. Included studies were nonrandomised prospective studies (n = 4), retrospective studies (n = 2) and one case report. Unimodal programmes and multimodal programmes were included. In patients with ovarian cancer, multimodal prehabilitation resulted in significantly reduced hospital stay and time to chemotherapy. In patients with endometrial and cervical cancer, prehabilitation was associated with significant weight loss, but had no significant effects on surgical complications or mortality. No adverse events of the programmes were reported. Evidence on the effect of prehabilitation for patients with gynaecological cancer is limited. Future studies are needed to determine the effects on postoperative complications and quality of life.