Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial

The impact of external oblique intercostal block on early postoperative pain and recovery in patients undergoing J-shaped incisions for upper abdominal surgery: a single-center prospective randomized controlled study

BACKGROUND

The aim of this study was to investigate the effects of external oblique intercostal nerve block (EOIB) on early postoperative pain and recovery in patients undergoing J-shaped incision surgery in the upper abdomen.

METHODS

Patients aged 18-85 years, classified as ASA I-III, undergoing elective open upper abdominal J-shaped incision surgery under general anesthesia were included in this study. Patients were randomized into two groups: the external oblique intercostal nerve block group (Group E ) and the control group (Group C ). Following induction of general anesthesia, Group E received 30 ml of 0.375% ropivacaine and 4 mg dexamethasone for ultrasound-guided EOIB on the surgical side, while Group C received no nerve block. Postoperatively, both groups utilized fentanyl patient-controlled intravenous analgesia. The primary outcome of the study was the 24-hour fentanyl consumption recorded for both groups. Patients with a Numeric Rating Scale (NRS) score > 4 were administered 40 mg parecoxib sodium as rescue analgesia.

RESULTS

Postoperative fentanyl consumption at 24 h was significantly lower in Group E compared to Group C (832.92 ± 66.42 μg vs. 1021.25 ± 76.63 μg, p = 0.001). Group E demonstrated lower NRS scores at rest and during movement at 0, 2, 4, 12, and 24 h postoperatively compared to Group C, but similar scores at 48 h. The time to first ambulation (49.92 ± 4.21 h vs. 58.38 ± 2.95 h, p = 0.001) and time to first flatus (59.79 ± 2.49 h vs. 67.83 ± 2.48 h, p = 0.001) were both shorter in Group E than in Group C, with higher Quality of Recovery-15 (QoR-15) scores in Group E (108.00 ± 3.80 vs. 97.00 ± 5.13, p = 0.001).

CONCLUSION

EOIB significantly enhances postoperative analgesia in patients undergoing upper abdominal J-shaped incision surgery, reducing opioid consumption and analgesic requirements, and improving the quality of recovery. It may be considered as part of a multimodal analgesic regimen following upper abdominal surgery.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Testing Center (ID: ChiCTR2300076653, 10.13.2023).

Prehabilitation in Major Surgery: An Evaluation of Cost Savings in a Tertiary Hospital

(1) Background: Prehabilitation programs improve patients' functional capacity before surgery by enhancing physical activity, nutrition, and psychological well-being, thereby reducing postoperative complications, hospital stays, and readmissions. We propose a centralized model led by an advanced practice nurse and internist to minimize consultations and reduce costs. (2) Methods: We studied 211 patients in a tertiary hospital in Madrid, with 135 enrolled in the centralized prehabilitation program and 76 in standard care (control). We compared complications, hospital stays, blood transfusions, and consultations, estimating costs using public pricing from Madrid's healthcare authorities. (3) Results: The centralized model significantly reduced blood transfusions (p = 0.014), postoperative complications (p < 0.001), and hospital stays (p = 0.004), leading to annual savings of EUR 593,453.00. (4) Conclusions: A centralized surgical prehabilitation model decreases complications, hospital stays, readmissions, and consultations compared to standard care, significantly reducing healthcare costs.

Outcomes of Incentive Spirometry for Patients Undergoing Coronary Artery Bypass Surgery: A Randomised Controlled Trial

BACKGROUND

Incentive spirometry is used in addition to care, especially in reducing pulmonary complications after surgery. Complications in the cardiovascular and pulmonary systems can basically be determined by blood values and vital signs, which are important objective data of haemodynamics.

AIM

This study aimed to test the hypothesis that the use of incentive spirometry in conjunction with postoperative pulmonary rehabilitation care has a notable impact on arterial blood gas, oxygen saturation (SpO2) and vital signs.

METHODS

This randomised, controlled trial used repeated-measures design. It was conducted between 2021 and 2022, and data from 58 patients who underwent coronary artery bypass graft surgery at the cardiovascular surgery clinic of a university hospital were analysed. All patients received pulmonary rehabilitation, and incentive spirometry was added for the experimental group.

RESULTS

In the experimental group, on post-op day 3, the arterial partial pressure of oxygen (PaO2) (p = 0.01), arterial oxygen saturation (SaO2) (p = 0.002) and oxygen saturation (SpO2) (p < 0.001) values were statistically significantly higher. Additionally, on post-op day 3 the experimental group had significantly lower systolic blood pressure (p = 0.03), diastolic blood pressure (p = 0.004) and respiratory rate (p < 0.001).

CONCLUSION

Incentive spirometry after coronary artery bypass graft surgery improves oxygen levels and vital signs.

Outcomes of open versus minimally invasive oesophagectomy in an Australian quaternary referral centre: a historical case-matched study

BACKGROUND

Oesophagectomy for surgical management of oesophageal carcinoma has previously been performed via an open approach (OE), with a change in recent years to a minimally invasive technique (MIO). We performed a retrospective study to compare the rates of post-operative complications between OE and MIO patients at our institution. Secondary outcomes included nodal yield and ICU LOS.

METHODS

This is a retrospective, observational, case-matched single centre study of 2-stage oesophagectomies for carcinoma from January 2011 to December 2021. Fourty-four MIO patients were matched by age to 44 OE patients. Post-operative pulmonary, cardiac and surgical complications were defined using the Esophagectomy Complications Consensus Group (ECCG) guidelines.

RESULTS

Baseline characteristics were similar for the two groups, with a higher ASA grade for patients undergoing MIO. There was no significant difference in post-operative pulmonary complication rates between the OE versus MIO groups (41% versus 55%, P = 0.29). There were more cardiac arrhythmias in the MIO group however this was not statistically significant (9.1% versus 22.7%, P = 0.08). Rate of re-operation was equal between the groups with no difference between rates of other surgical complications, ICU LOS or hospital LOS. Significantly higher nodal yield was achieved in the MIO group. Overall rate of Clavien-Dindo graded complications were similar (55% versus 66%, P = 0.28).

CONCLUSIONS

MIO was associated with higher lymph node yield, and comparable complication rates when compared to OE and does not significantly alter time spent in hospital.

Patient Education on Exercise Prehabilitation Among Patients Receiving Neoadjuvant Therapy for Cancer Surgery in China: A Mixed-Methods Study

Background/Objectives: Patients undergoing neoadjuvant therapy have ample time to engage in exercise prehabilitation. This study aimed to describe the current status, facilitators, and barriers of exercise prehabilitation among this population. Methods: This sequential explanatory mixed-methods evaluation was conducted at a general tertiary hospital in Beijing. It included a quantitative survey of patients who received neoadjuvant therapy before cancer surgery and qualitative semi-structured interviews with both patients and physicians. Thematic analysis was conducted using the Capability, Opportunity, and Motivation Behavior model. Results: A total of 269 patients participated in the survey, with a completion rate of 99.6%. Only 52.6% and 1.1% of patients met the standards for aerobic and muscle-strengthening activities, respectively. Fewer than 40% of patients reported learning about exercise prehabilitation from physicians. Patients' knowledge was associated with meeting aerobic activity standards after adjusting for confounders (Level 1: odds ratio [OR] of 2.06, 95% confidence interval [CI] of 1.02-4.22; Level 2: OR of 2.56, 95% CI of 1.25-5.36). In total, 28 participants were interviewed. Facilitators of patient education on exercise prehabilitation included the surgeon's ability to gain trust and patients' prior commitment to exercise. Barriers included physicians' lack of awareness of exercise benefits, insufficient knowledge or time for patient education, concerns about patients' exercise ability, lack of referrals to rehabilitation clinics, challenges in follow-up, conflicts with cultural beliefs, and inadequate insurance coverage. Conclusions: This study revealed a lack of physician-led patient education on exercise prehabilitation. Efforts are needed to enhance physician education, implement collaborative clinics, and provide remote supervision.

Interventions Provided by Physiotherapists to Prevent Complications After Major Gastrointestinal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Major surgery for gastrointestinal cancer carries a 50% risk of postoperative complications. Physiotherapists commonly provide interventions to patients undergoing gastrointestinal surgery for cancer with the intent of preventing complications and improving recovery. However, the evidence is unclear if physiotherapy is effective compared to providing no physiotherapy, nor if timing of service delivery during the perioperative pathway influences outcomes. The objective of this review is to evaluate and synthesise the evidence examining the effects of perioperative physiotherapy interventions delivered with prophylactic intent on postoperative outcomes compared to no treatment or early mobilisation alone.

METHODS

A protocol was prospectively registered with PROSPERO and a systematic review performed of four databases. Randomised controlled trials examining prophylactic physiotherapy interventions in adults undergoing gastrointestinal surgery for cancer were eligible for inclusion.

RESULTS

Nine publications from eight randomised controlled trials were included with a total sample of 1418 participants. Due to inconsistent reporting of other perioperative complications, meta-analysis of the effect of physiotherapy was only possible specific to postoperative pulmonary complications (PPCs). This found an estimated 59% reduction in risk with exposure to physiotherapy interventions (RR 0.41, 95%CI 0.23 to 0.73, p < 0.001). Sub-group analysis demonstrated that timing of delivery may be important, with physiotherapy delivered only in the preoperative phase or combined with a postoperative service significantly reducing PPC risk (RR 0.32, 95%CI 0.17 to 0.60, p < 0.001) and hospital length of stay (MD-1.4 days, 95%CI -2.24 to -0.58, p = 0.01), whilst the effect of postoperative physiotherapy alone was less certain.

CONCLUSIONS

Preoperative-alone and perioperative physiotherapy is likely to minimise the risk of PPCs in patients undergoing gastrointestinal surgery for cancer. This challenges current traditional paradigms of providing physiotherapy only in the postoperative phase of surgery. A review with broader scope and component network analysis is required to confirm this.

Short- and long-term outcomes following perioperative ERAS management in patients undergoing minimally invasive radical gastrectomy after neoadjuvant chemotherapy: A single-center retrospective propensity score matching study

INTRODUCTION

Gastric cancer patients receiving neoadjuvant chemotherapy (NACT) are more vulnerable to perioperative stress. Enhanced recovery after surgery (ERAS) is widely used in surgical patients aiming at reducing stress responses. However, whether this approach is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT remained determined. So, the objective of this study is to investigate the effects of ERAS for this special group of gastric cancer patients.

MATERIAL AND METHODS

The data of gastric cancer patients who underwent minimally invasive radical gastrectomy after NACT were collected. Patients were divided into an ERAS group and a conventional group based on whether they received perioperative ERAS management. Propensity score matching was conducted to eliminate bias. Pre- and postoperative inflammatory and nutritional marker levels, postoperative complications, recovery indices and 3-year OS and RFS were observed.

RESULTS

A total of 252 patients were analyzed after 1:1 PSM, including 126 patients in the ERAS group and 126 in the conventional group. The results showed that the implementation of ERAS significantly reduced the levels of novel inflammatory indicators, improve nutritional status and accelerate postoperative recovery. We found that the 3-year OS (72.2 % vs. 66.7 %) and RFS (67.5 % vs. 61.9 %) in the ERAS group showed an improvement trend compared to those in the traditional group, especially for stage III patients, although these differences were not significant.

CONCLUSION

The perioperative ERAS program is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT.

Comprehensive Strategies for Preoperative Pulmonary Risk Evaluation and Management

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. PPC incidence varies widely, influenced by factors such as surgery type, patient age, smoking status, and comorbid conditions, including chronic obstructive pulmonary disease (COPD) and congestive heart failure. While preoperative pulmonary function tests and chest radiographs are crucial for lung resection surgery, their use should be judiciously tailored to individual risk profiles. Effective risk stratification models, such as the American Society of Anesthesiologists classification, Arozullah respiratory failure index, Gupta Calculators, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) model, play a key role in predicting PPCs. Key strategies to diminish PPCs include preoperative optimization of respiratory conditions, smoking cessation, and respiratory rehabilitation. In patients with COPD and asthma, it is crucial to maintain optimal disease control through inhaled therapies, systemic corticosteroids, and tailored preoperative respiratory exercises. Anemia and hypoalbuminemia are significant predictors of PPCs and require meticulous management. The choice and duration of anesthesia also notably influence PPC risk, with regional anesthesia being preferable to general anesthesia when possible. Comprehensive preoperative evaluations and tailored interventions are essential for enhancing surgical outcomes and reducing PPC incidence. Additional studies involving domestic patients are necessary to refine national guidelines for managing those at risk of PPCs.

Considerations for Anesthesia in Older Adults with Cannabis Use

Over the past decade, legislative changes occurred in the USA and the western world that were followed by a substantial increase in reported use of cannabis among the general population. Among patients undergoing anesthesia for surgery or interventional procedures, older patients-often defined as adults over 65 years-are one of the fastest-growing populations. Within this group, the prevalence of cannabis use almost tripled over the past decade. In addition to habitual cannabis use, recommendations for treatment of chronic pain with cannabinoids have become increasingly more common. The clinical relevance of cannabis use in older adults is supported by recent studies linking it to increased anesthetic requirements as well as respiratory, cardiovascular, and psychiatric complications following surgery. Still, evidence remains equivocal, as these associations may largely depend on the type, frequency, and route of cannabis administration, and current research is mostly limited to retrospective cohort studies. Multisystemic effects of cannabis can become especially relevant in patients of advanced age undergoing anesthesia, characterized by physiological and pharmacodynamic alterations as well as a higher risks of drug-to-drug interactions. Best-practice guidelines emphasize the need for detailed, systematic preoperative screening for habits of cannabis use, including the history, type, and frequency, to guide perioperative management in these patients. This review discusses considerations for anesthesia in older patients with habitual cannabis use while highlighting strategies and recommendations to ensure safe and effective anesthesia care.

Pancreaticoduodenectomy for octogenarians under postoperative rehabilitation enhanced ERAS protocol

BACKGROUND

Although pancreaticoduodenectomy (PD) for pancreatic or periampullary cancer is the gold standard treatment regardless of patient age, patients aged 80 years or older have poor postoperative short-term outcomes because of their poor functional status and many medical comorbidities. Postoperative rehabilitation in octogenarians could improve postoperative outcomes; however, its effect remains unclear.

METHODS

This retrospective study included patients who underwent PD at two institutions between January 2019 and December 2022. All patients were managed using the enhanced recovery after surgery (ERAS) protocol, and elderly patients or those with loss of muscle mass or frailty underwent additional perioperative rehabilitation. Postoperative short-term outcomes were compared between the octogenarians and non-octogenarians.

RESULTS

We reviewed 251 patients including 44 octogenarians (17.5%). Octogenarians had higher rates of comorbidity (78.9% vs. 55.1%, P = 0.049) and sarcopenia (31.8% vs. 16.4%, P = 0.018) and a more impaired nutritional status than non-octogenarians and received postoperative rehabilitation more frequently (86.4% vs. 44.0%, P < 0.001, respectively). Under the rehabilitation-enhanced ERAS protocol, the postoperative major complication rate (25.0% vs. 24.6%, P = 0.960), the length of hospital stay (LOS) (P = 0.435), and the length of functional recovery (LOFR) (P = 0.110) did not differ between the two groups. In the multivariate analysis, age ≥ 80 years was not determined as a risk factor for major complications.

CONCLUSIONS

Despite the poor functional and nutritional status of octogenarians, their postoperative major complication rates, LOS, and LOFR after PD were comparable with those of non-octogenarians under the rehabilitation-enhanced ERAS protocol.

Effect of preoperative inspiratory muscle training combined with preoperative education on postoperative pulmonary complications in high-risk patients with lung cancer: protocol for a randomised controlled trial

INTRODUCTION

Preoperative inspiratory muscle training (IMT) is recognised as an important component of the preoperative management of lung cancer, although there is limited evidence for the delivery of a home-based IMT programme combined with preoperative education. We developed a programme combining short-term home-based IMT and preoperative physiotherapy education ('the programme'). This study aims to evaluate the effectiveness of this programme in reducing postoperative pulmonary complications (PPCs) after lung cancer resection compared with standard care.

METHODS AND ANALYSIS

In this randomised controlled trial, 114 participants scheduled for lung cancer surgery at the First Affiliated Hospital of Fujian Medical University will be randomly assigned (1:1) to either receive usual care (information booklet) or usual care combined with the programme, which consist of short-term home-based IMT and preoperative physiotherapy education. The primary outcome measure will be PPCs using the Melbourne Group Score. Secondary outcomes will include health-related quality of life, maximal inspiratory pressure, 6 min walk distance, length of hospital stay, anxiety and depression levels, and hospital costs.

ETHICS AND DISSEMINATION

The study has received ethics approval from the ethics committee of the first affiliated hospital of Fujian Medical University (approval no: MRCTA, ECFAH of MFU [2021]569). Participants will be required to provide written informed consent. The results of the study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300067464.

Impact and effect of preoperative short-term preoperative pulmonary-related training on patients with gastric cancer: a randomized controlled single center trial

PURPOSE

This study aimed is to evaluate the impact of pre- and postoperative pulmonary-related training, including respiratory and aerobic training, on postoperative pulmonary complications (PPCs) after radical resection of gastric cancer (GC).

METHODS

We conducted a randomized controlled trial of 121 participants who received a systematic, comprehensive, high-intensity pulmonary exercise regimen for 5 days preoperatively and at least 5 days postoperatively. The control group received standard preoperative care. We analyzed the occurrence of PPCs in both groups as the primary outcome RESULTS: A total of 43 of 121 participants (35.5%) were diagnosed as having PPCs, and the incidence of PPCs was markedly lower in the training group than in the control group (26.2% [16 of 61] vs 45.0% [27 of 60]; P = .031). Moreover, the duration of the postoperative hospital stay was shorter in the training group (8.69 ± 1.92 days) than the control group (9.57 ± 2.16 days; P = .020) and reduced hospitalization costs, amounting to €9605.1 ± €2556.26 in the training group and €10,594.6 ± €2560.7 in the control group (P = .035).

CONCLUSION

Our study established that a perioperative pulmonary-related training notably diminishes the incidence of PPCs, curtails the duration of hospitalization, and mitigates hospitalization expenses for patients undergoing GC surgery.

Evaluation and Management of Perioperative Pulmonary Complications

Pulmonary complications are very common after noncardiac surgery and can be easily overlooked. If not properly screened for or evaluated these can in many instances lead to postoperative respiratory failure or even death. Decisions regarding ambulatory versus inpatient surgery, modality of anesthesia, protective ventilation and method of weaning, type of analgesia, and postoperative monitoring can be crucial to avoid such complications.

An Updated Systematic Review and Meta-Analysis of Unimodal Prehabilitation with Exercise Intervention to Enhance Postoperative Outcomes in Cancer Surgery

BACKGROUND

The objective of this systematic review and meta-analysis was to update the body of evidence on the efficacy of prehabilitation with exercise interventions, in reducing postoperative complications and length of hospital stay after cancer surgery.

METHODS

A comprehensive literature search was conducted on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED, and PsycINFO to identify randomized controlled trials investigating the impact of prehabilitation with exercise interventions for patients undergoing cancer surgery. Primary and secondary outcomes assessed were postoperative complications and length of hospital stay, respectively. Risk of bias was evaluated using the Cochrane risk of bias tool, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was used to determine the strength of evidence. Relative risk and mean difference were calculated using random-effects meta-analysis.

RESULTS

In this updated review, 32 trials (n = 2304 participants) were identified, with 5 trials focused on patients undergoing surgery for genitourinary cancer (n = 422 participants), 9 for lower gastrointestinal cancer (n = 639 participants), 6 for upper gastrointestinal cancer (n = 526), and 11 for lung cancer (n = 717 participants). The majority of included trials exhibited some risk of bias. Evidence of low-to-moderate quality indicated that prehabilitation with preoperative exercise significantly reduced postoperative complication rates by approximately 50% and decreased the length of hospital stay by 2.5 days in patients undergoing lung resection. Preoperative exercise did not demonstrate effectiveness in reducing postoperative complications or length of hospital stay for other cancer populations.

CONCLUSIONS

Evidence supports the efficacy of prehabilitation with exercise in reducing postoperative complications and length of hospital stay in patients undergoing lung cancer surgery. Further research is warranted to establish the efficacy of unimodal prehabilitation with exercise in genitourinary, lower gastrointestinal, and upper gastrointestinal cancer populations having cancer surgery.

Physiotherapy provided for patients undergoing thoracic surgery in Sweden - a national survey of practice

INTRODUCTION

Patients undergoing thoracic surgery commonly receive perioperative physio-therapy, typically consisting of education, mobilization, breathing exercises, and mobility exercises. To date, no study has described physiotherapy practice for patients undergoing thoracic surgery in Sweden.

PURPOSE

To investigate physiotherapy interventions for patients undergoing thoracic surgery in Sweden.

METHODS

All physiotherapists currently working in thoracic surgery units in Sweden (n = 8) were eligible to participate. A survey was e-mailed to the physiotherapists, to determine physiotherapy interventions offered to patients undergoing thoracoscopy or open thoracic surgery. Of 21 physiotherapists, 13 (62%) responded, representing seven hospitals.

RESULTS

Physiotherapists reported routinely providing preoperative education and postoperative treatment for all patients undergoing thoracic surgery. Breathing exercises and mobilization were usually initiated on the day of surgery or the first postoperative day. Common treatments were deep breathing exercises, with or without positive expiratory pressure, and airway clearance techniques. Upper limb and shoulder exercises were typically initiated on the first or second day after surgery. The most important factor reported to influence treatment choice was personal experience of the attending physiotherapist. No routine post-discharge rehabilitation was provided.

CONCLUSION

Physiotherapists in Sweden reported routinely treating patients scheduled for thoracic surgery, both pre and postoperatively. Prehabilitation or post-discharge rehabilitation was not routinely provided.

Early mobilization after pancreatic surgery: A randomized controlled trial

BACKGROUND

Pancreatic surgery has long been burdened with high postoperative morbidity. Early mobilization has been advocated to prevent complications and improve functional capacity. However, there is a lack of high-quality evidence supporting how to implement early mobilization and its independent impact on postoperative outcomes. The aim of this study was to investigate the effectiveness of implementing early mobilization in reducing postoperative complications and enhancing recovery in patients undergoing pancreatic surgery.

METHODS

We conducted a single-blind, randomized trial in patients who underwent pancreatic surgery in a tertiary hospital in China. Eligible participants were randomly assigned to either the control group or the intervention group. Patients in the control group received usual care, whereas those in the intervention group received the early enforced mobilization protocol. The protocol consisted of 2 key components: professional assistance with the first ambulation on postoperative day 1 and family-involved supervision to achieve daily walking goals. The primary outcome was postoperative complications within 30 days, measured by the Comprehensive Complication Index. Secondary outcomes were postoperative mobilization, time to recovery of gastrointestinal function, postoperative pulmonary complications, pancreatic surgery-specific complications, patient-reported outcome measures, and 30-day readmission and mortality.

RESULTS

A total of 135 patients were enrolled: 67 in the intervention group and 68 in the control group. The median Comprehensive Complication Index was not statistically significant between groups (mean difference -1.7; 95% confidence interval -8.7 to 0). Patients in the intervention group had earlier first ambulation postoperatively, walked greater distances on postoperative days 1-7, and had earlier time to first defecation. Trends for improvement in patient-reported outcomes showed that scores of Quality of Recovery 15 at postoperative day 3, physical function of Quality of Life Questionnaire C30 at postoperative day 7, and global quality of life at postoperative day 30 were significantly greater in the intervention group. There was no between-group difference in other domains of the Quality of Life Questionnaire C30 or other secondary outcome measures.

CONCLUSION

Early enforced mobilization intervention did not reduce postoperative complications of patients undergoing pancreatic surgery, but it can enhance postoperative mobilization and improve the recovery of gastrointestinal function and patient-perceived quality of recovery.

Postoperative Complications and Mobilization Following Major Abdominal Surgery With Versus Without Fitness Tracker-based Feedback (EXPELLIARMUS): A Student-led Multicenter Randomized Controlled Clinical Trial of the CHIR-Net SIGMA Study Group

OBJECTIVE

To determine whether daily postoperative step goals and feedback through a fitness tracker (FT) reduce the rate of postoperative complications after surgery.

BACKGROUND

Early and enhanced postoperative mobilization has been advocated to reduce postoperative complications, but it is unknown whether FT alone can reduce morbidity.

METHODS

EXPELLIARMUS was performed at 11 University Hospitals across Germany by the student-led clinical trial network SIGMA. Patients undergoing major abdominal surgery were enrolled, equipped with an FT, and randomly assigned to the experimental (visible screen) or control intervention (blackened screen). The experimental group received daily step goals and feedback through the FT. The primary end point was postoperative morbidity within 30 days using the Comprehensive Complication Index (CCI). All trial visits were performed by medical students in the hospital with the opportunity to consult a surgeon-facilitator who also obtained informed consent. After discharge, medical students performed the 30-day postoperative visit through telephone and electronic questionnaires.

RESULTS

A total of 347 patients were enrolled. Baseline characteristics were comparable between the 2 groups. The mean age of patients was 58 years, and 71% underwent surgery for malignant disease, with the most frequent indications being pancreatic, colorectal, and hepatobiliary malignancies. Roughly one-third of patients underwent laparoscopic surgery. No imputation for the primary end point was necessary as data completeness was 100%. There was no significant difference in the CCI between the 2 groups in the intention-to-treat analysis (mean±SD CCI experimental group: 23±24 vs. control: 22±22; 95% CI: -6.1, 3.7; P=0.628). All secondary outcomes, including quality of recovery, 6-minute walking test, length of hospital stay, and step count until postoperative day 7 were comparable between the 2 groups.

CONCLUSIONS

Daily step goals combined with FT-based feedback had no effect on postoperative morbidity. The EXPELLIARMUS shows that medical students can successfully conduct randomized controlled trials in surgery.

Multimodal prehabilitation and postoperative outcomes in upper abdominal surgery: systematic review and meta-analysis

The impact of multimodal prehabilitation on postoperative complications in upper abdominal surgeries is understudied. This review analyzes randomized trials on multimodal prehabilitation with patient and hospital outcomes. MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched for trials on prehabilitation before elective (non-emergency) abdominal surgery. Two reviewers independently screened studies, extracted data, and assessed study quality. Primary outcomes of interest were postoperative pulmonary complications (PPCs) and all-cause complications; secondary outcomes included hospital and intensive care length of stay. A meta-analysis with random-effect models was performed, and heterogeneity was evaluated with I-square and Cochran's Q test. Dichotomous variables were reported in log-odds ratio and continuous variables were presented as mean difference. Ten studies (total 1503 patients) were included. Odds of developing complications after prehabilitation were significantly lower compared to various control groups (- 0.38 [- 0.75- - 0.004], P = 0.048). Five studies described PPCs, and participants with prehabilitation had decreased odds of PPC (- 0.96 [- 1.38- - 0.54], P < 0.001). Prehabilitation did not significantly reduce length of stay, unless exercise was implemented; with exercise, hospital stay decreased significantly (- 0.91 [- 1.67- - 0.14], P = 0.02). Multimodal prehabilitation may decrease complications in upper abdominal surgery, but not necessarily length of stay; research should address heterogeneity in the literature.

Preoperative physiotherapy prevents postoperative pulmonary complications after major abdominal surgery: a meta-analysis of individual patient data

QUESTIONS

Among patients having elective abdominal surgery, how much does preoperative physiotherapy education with breathing exercise training reduce the incidence of postoperative pulmonary complications (PPCs), hospital length of stay and 12-month mortality? How stable are the treatment effects across different PPC definitions, including pneumonia? How much do the treatment effects on PPC, hospital length of stay and mortality vary within clinically relevant subgroups?

DESIGN

Individual participant-level meta-analysis (n = 800) from two randomised controlled trials analysed with multivariable regression.

PARTICIPANTS

Adults undergoing major elective abdominal surgery.

INTERVENTIONS

Experimental participants received a single preoperative session with a physiotherapist within 4 weeks of surgery and educated on PPC prevention with breathing exercises and early mobilisation. They were taught breathing exercises and instructed to start them immediately on waking from surgery. The control group received no preoperative or postoperative physiotherapy, or early ambulation alone.

OUTCOME MEASURES

PPC, hospital length of stay and 12-month mortality.

RESULTS

Participants who received preoperative physiotherapy had 47% lower odds of developing a PPC (adjusted OR 0.53, 95% CI 0.34 to 0.85). This effect was stable regardless of PPC definition. Effects were greatest in participants who smoked, were aged ≤ 45 years, had abnormal body weight, had multiple comorbidities, or were undergoing bariatric or upper gastrointestinal surgery. Participants having operations ≤ 3 hours in duration were least responsive to preoperative physiotherapy. Participants with multiple comorbidities were more likely to have a shorter hospital stay if provided with preoperative physiotherapy (adjusted MD -3.2 days, 95% CI -6.2 to -0.3). Effects on mortality were uncertain.

CONCLUSION

There is strong evidence to support preoperative physiotherapy in preventing PPCs after elective abdominal surgery.

Enhancement of Pulmonary Function and Reduction of Complications Through EIT-Guided Yoga Breathing Exercise After Esophagectomy

BACKGROUND This study aimed to investigate the impact of EIT-guided yoga breathing training on postoperative pulmonary complications (PPCs) for esophageal cancer patients. MATERIAL AND METHODS Total of 62 patients underwent radical resections of esophageal cancer. Esophageal cancer patients were randomized to the standard care group, or the intervention group receiving an additional complete breathing exercise under the guidance of EIT in AICU. Following extubation after the esophagectomy, pulmonary functions were evaluated by EIT with center of ventilation (CoV), dependent silent spaces (DSS), and non-dependent silent spaces (NSS). RESULTS Sixty-one older esophageal cancer patients (31 in the Control group and 30 in the EIT group) were included in the final analysis. Forty-four patients experienced pulmonary complications after esophagectomy, 27 (87.1%) in the Control group and 17 (36.7%) in the EIT group (RR, 0.42 (95% CI: 0.26, 0.69). The most common pulmonary complication was pleural effusion, with an incidence of 30% in the EIT group and 74.2% in the Control group, with RR of 0.40 (95% CI: 0.23, 0.73). Time for the first pulmonary complication was significantly longer in the EIT group than in the Control group (hazard ratio, HR, 0.43; 95% CI 0.21 to 0.87; P=0.019). Patients in the EIT group had significantly higher scores in CoV, DSS, and NSS than in the Control group. CONCLUSIONS Guided by EIT, the addition of the postoperative breathing exercise to the standardized care during AICU could further improve pulmonary function, and reduce postoperative pulmonary complications after esophagectomy.

Combining Spirometry and the ARISCAT Respiratory Risk Assessment Can Improve Postoperative Outcomes and Reduce Mortality Risk in Mexico

Introduction

Although a major goal of preoperative evaluation is to identify risk factors and improve postoperative outcomes, current clinical guidelines in Mexico indicate that preoperative spirometry should only be performed on patients with pulmonary disease. The aim of this study was to compare the incidence of postoperative complications (POC), mortality, and risk factors among adults who did or did not undergo preoperative spirometry, based on their Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk level.

Material and methods

An observational, retrospective and comparative study design was used to identify 2059 patients from the General Hospital of Mexico who had an ARISCAT assessment during 2013-2017. Patients were classified in two groups: ARISCAT with spirometry (n = 1306) and ARISCAT without spirometry (n = 753). Chi-square, Fisher's exact test and the Student's t-tests were used to compare groups. Logistic regression was used to identify factors associated with an increased risk of POC and mortality.

Results

In the ARISCAT with spirometry group, 11% of patients had POC, compared with 48% of patients in the ARISCAT without spirometry group. High-risk ARISCAT patients who did not receive spirometry had higher mortality (18%), than those who underwent spirometry (0.4%). Logistic regression results indicate that not performing preoperative spirometry increases the probability of POC and mortality.

Conclusions

Our findings suggest that the combined use of preoperative spirometry and ARISCAT is associated with reduced POC and mortality. Future clinical guidelines should recommend the use of preoperative spirometry for patients with a moderate or high ARISCAT level in Mexico.

Smooth Return to Work Through Early Rehabilitation and Interdisciplinary Collaboration After Ostomy: A Case Report of a Japanese Patient

A male patient in his 40s was diagnosed with rectal cancer and underwent abdominoperineal resection (APR) with permanent end colostomy as surgical treatment. He wanted to return to work as soon as possible after discharge. A physical therapist (PT) was involved in the preoperative consultation, and both the PT and occupational therapist started bed rest and activities of daily living (ADL) practice the day after surgery. On the third postoperative day, lightweight trunk exercises were initiated with a gradual increase in load. Stoma management was supervised by a nurse and progress was monitored. The patient's progress in ADLs, postoperative complications, and return to work were evaluated two weeks after discharge. Consequently, the patient was able to continue rehabilitation without early complications related to postoperative stoma. He could lift 20 kg and return to carpentry two weeks after discharge. The stoma quality of life improved from 61 points at two weeks after surgery to 74 points at two weeks after discharge. Early rehabilitation for social reintegration after ostomy creation can be safely performed under PT supervision, and a comprehensive interprofessional collaboration can contribute to smooth social reintegration.

Experiences of Patients with Breast Cancer Participating in a Prehabilitation Program: A Qualitative Study

Background: Breast cancer (BC) is the most prevalent cancer diagnosis among women worldwide. Several randomized controlled trials and systematic reviews have shown the benefits of exercise before, during, and after cancer treatment to manage side effects related to cancer and its therapies. However, these are poorly implemented across the disease-span, specifically, during the preoperative setting. Methods: Patients diagnosed with BC and participating in a randomized controlled trial on the effects of a prehabilitation program based on Nordic walking, muscle strengthening, and therapeutic education were invited to participate in this qualitative substudy. Two groups of eight patients each were recorded, transcript and analyzed using a specialized software (Atlas-Ti®, version 24). Results: During the axial codification phase, 22 unique codes and 6 main themes were identified related to their experience with the program, namely, (1) information received prior to participating; (2) motivation to participate; (3) barriers; (4) facilitators; (5) perceived degree of support from healthcare workers as well as peers; and (6) satisfaction with the characteristics of the prehabilitation program. Conclusions: Patients interviewed showed great interest in prehabilitation as a way to prepare both physically and mentally for surgery. In order to implement these interventions, healthcare systems need to acknowledge barriers and facilitators as well as the need for these programs to be supervised and monitored to avoid adverse events.

Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BACKGROUND

Preserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD).

METHODS

This study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses.

RESULTS

PRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30-4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80-5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group.

CONCLUSION

Our study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer

BACKGROUND

Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC.

RESULTS

Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740.

CONCLUSION

In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach

BACKGROUND

Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes.

METHODS

A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia.

RESULTS

The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27).

CONCLUSIONS

Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.

Impact of Preoperative Nutritional Support on Surgical Outcomes in Gastrointestinal Surgeries: A Systematic Review

Malnutrition presents a significant risk to patients undergoing gastrointestinal surgery, with direct consequences on postoperative complication rates, recovery times, and mortality. Our systematic review, guided by PRISMA protocols, examined the impact of preoperative nutritional support on these surgical outcomes. We scrutinized publications from PubMed, Medline, Embase, and the Cochrane Library up to April 2023, including randomized controlled trials, cohort studies, and systematic reviews. The stringent selection process narrowed to 10 studies demonstrating the efficacy of preoperative nutritional support, from oral supplements to enteral and parenteral nutrition, in reducing postoperative complications and length of hospital stays while enhancing recovery rates. The benefits varied, indicating a pressing need for customized nutritional regimens based on patient demographics and surgical specifics. Our findings advocate incorporating individualized nutritional strategies into preoperative care, enhancing patient outcomes. Future research should aim to refine these strategies, focusing on the optimal timing, duration, and type of nutritional support.

Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.

Preoperative physical activity is associated with prognosis in patients with esophageal cancer undergoing thoracoscopic-laparoscopic esophagectomy after neoadjuvant chemotherapy

OBJECTIVE

This study examined the association between a single preoperative physiotherapy session during neoadjuvant chemotherapy and physical function and that between preoperative physical activity and prognosis.

METHODS

In this retrospective, single-center, observational study, we evaluated data from 234 patients scheduled for neoadjuvant chemotherapy and thoracoscopic-laparoscopic esophagectomy who underwent a single preoperative physiotherapy session. The five-repetition sit-to-stand test was performed before and after neoadjuvant chemotherapy. After neoadjuvant chemotherapy, patients were classified into high- and low-physical activity groups based on preoperative physical activity. To examine the association between preoperative physiotherapy and changes in physical function, a multivariate regression analysis was performed. The Cox proportional hazards model was used to investigate the association between preoperative physical activity and overall survival.

RESULTS

The median percentage change in the five-repetition sit-to-stand test score was - 3.36%. In the multivariate regression analysis, the regression coefficient of the constant term was - 23.93 (95% confidence interval - 45.31 to - 2.56; P = 0.028). Low physical activity was significantly associated with overall survival after adjustment for confounding factors (P = 0.040).

CONCLUSIONS

This study demonstrated that a single preoperative physiotherapy session during neoadjuvant chemotherapy improves physical function, and preoperative physical activity is significantly associated with prognosis.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

The Influence of Patient Provider Educational Interactions and Associated Preoperative Variables on Outcomes in the Hip Dysplasia Population

Background

Patient provider interactions influence patient treatment adherence, clinical outcomes, patient satisfaction, and an overall patient's engagement in healthcare decisions. The purpose of this study was to examine the effectiveness of patient provider educational interactions and associated variables on patient reported outcomes in the hip dysplasia population.

Methods

A secondary data analysis was completed with 6-month postoperative survey data from participants, who had undergone periacetabular osteotomy. Data analysis including demographic variables, patient reported outcome results, and pre-operative knowledge retention.

Results

A significant difference was found between participants' expectations of crutch use and physical therapy care with actual performance (p<0.001 and p=0.01) and with engagement in pre-operative support based on mental health history (p=0.02).

Conclusion

Pre-operative interactions with a provider team and prior patients (pre-operative support) can influence a patient's educational experience. Providers should review educational interventions and offer pre-operative support to patients. Level of Evidence: VI.

Analysis of postoperative pulmonary complications after gastrectomy for gastric cancer: development and validation of a nomogram

Background

Postoperative pulmonary complications (PPCs) are common in gastric cancer patients after gastrectomy. The aim of our study was to investigate the perioperative risk factors and to develop a nomogram to identify patients who are at significant risk of PPCs.

Methods

The clinical data of gastric cancer patients who underwent elective gastrectomy in the First Affiliated Hospital of Nanjing Medical University from 2017 to 2021 were retrospectively collected. All patients were randomly divided into a training and a validation cohort at a ratio of 7:3. Univariate and multivariate analysis were applied to identify the independent risk factors that might predict PPCs, and a nomogram was constructed. Both discrimination and calibration abilities were estimated by the area under a receiver operating characteristic curve (AUC) and calibration curves. The clinical effectiveness of the nomogram was further quantified with the decision curve analysis (DCA).

Results

Of 2,124 included patients, one hundred and fifty patients (7.1%) developed PPCs. Binary logistic analysis showed that age > 65 years, higher total cholesterol level, longer duration of surgery, total gastrectomy, and the dose of oxycodone > 5.5 mg were independent risk factors for the occurrence of PPCs, which were contained in the nomogram. The predictive nomogram showed good discrimination and calibration [an AUC of 0.735 (95% CI: 0.687-0.783) in a training cohort and 0.781 (95% CI: 0.715-0.847) in a validation cohort]. The calibration curve and decision curve analysis showed a good agreement between nomogram predictions and actual observations.

Conclusion

We developed a nomogram model based on age, total cholesterol, extent of resection, duration of surgery, and the dose of oxycodone to predict the risk of PPCs in gastric cancer patients after elective gastrectomy.

Protocol for the PORT study: short-term perioperative rehabilitation to improve outcomes in cardiac valvular surgery - a randomised control trial

INTRODUCTION

Perioperative rehabilitation (PORT) has shown a positive effect on patients undergoing cardiac surgery. However, there are minimal data on the impact of short-term PORT in cardiac surgery, which is associated with higher postoperative morbidity and mortality. The trial will assess the efficacy of short-term PORT in reducing in-hospital mortality, postoperative pulmonary complications and length of stay, compared with the usual care in cardiac surgical patients.

METHODS AND ANALYSIS

This is a single-centre prospective, randomised, open, controlled trial with a 1:1 ratio. Consecutive 800 adult patients undergoing elective valve surgery will be randomised to either usual care or in-hospital short-term PORT that consists of education, inspiratory muscle training, active cycle of breathing techniques and early mobilisation. The primary outcome of this study will be a composite of in-hospital all-cause mortality, incidence of postoperative pulmonary complications and the ratio of postoperative hospitalisation >7 days.

ETHICS AND DISSEMINATION

The PORT study was granted by the Medical Research Ethics Committee of Guangdong Provincial People's Hospital in August 2018. Findings will be disseminated to patients, clinicians and commissioning groups through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT03709511.

Influence of perioperative step volume on complication rate and length of hospital stay after colorectal cancer surgery (IPOS trial): study protocol for a randomised controlled single-centre trial at a German university hospital

BACKGROUND

Perioperative mobilisation and physical activity are critical components of postoperative rehabilitation. Physical inactivity is a significant risk factor for complications and prolonged hospitalisation. However, specific recommendations for preoperative and postoperative physical activity levels are currently lacking. Evidence suggests that daily step count before and after surgery may impact the length of hospital stay and complication rate.The goal of this study is to determine the effectiveness of perioperative step volume recommendations, measured by pedometers, in reducing the length of hospital stay and complication rate for patients undergoing colorectal cancer surgery.

METHODS

This study is a single-centre randomised controlled trial with two arms, allocated at a 1:1 ratio. The trial includes individuals undergoing colorectal surgery for either suspected or confirmed colorectal malignancy. A total of 222 patients will be randomly assigned to either an intervention or a control group. Step counts will be measured using a pedometer. Patients assigned to the intervention group will be given a predetermined preoperative and postoperative step count goal. The analysis will be conducted on preoperative and postoperative physical activity, quality of life, health, duration of hospitalisation, complication rate and bowel function, among other factors.

ETHICS AND DISSEMINATION

The trial was approved by the ethics committee of the Ludwig-Maximilians-University of Munich, Germany (reference number: 22-0758, protocol version 2022.02). Results will be published in peer-reviewed journals and shared at academic conferences. After the publication of the results, a fully anonymised data set and the statistical code can be made available on justified scientific request and after ethical approval has been granted.

TRIAL REGISTRATION NUMBER

DRKS00030017.

PHYSIO+++: protocol for a pilot randomised controlled trial assessing the feasibility of physiotherapist-led non-invasive ventilation for patients with hypoxaemia following abdominal surgery

INTRODUCTION

Few clinical trials have investigated physiotherapy interventions to treat hypoxaemia following abdominal surgery. The objective of this study is to determine the feasibility and safety of conducting a clinical trial of physiotherapist-led non-invasive ventilation (NIV).

METHODS AND ANALYSIS

This single-centre, 50-patient, parallel-group, assessor blinded, pilot feasibility randomised controlled trial with concealed allocation will enrol spontaneously ventilating adults with hypoxaemia within 72 hours of major abdominal surgery. Participants will receive either (1) usual care physiotherapy of a single education session (talk), daily walking of 10-15 min (walk) and four sessions of coached deep breathing and coughing (breathe) or (2) usual care physiotherapy plus four 30 min sessions of physiotherapist-led NIV delivered over 2 postoperative days. Primary feasibility and safety outcome measures are; number of eligible patients recruited per week, total time of NIV treatment delivered, acceptability of treatments to patients and clinicians and incidence of adverse events. Secondary feasibility outcomes include measures of recruitment and treatment adherence. Exploratory outcome measures include change in respiratory parameters, postoperative pulmonary complications, length of hospital stay, health-related quality of life, postoperative activity levels and mortality.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the relevant institution. Results will be published to inform future research.

TRIAL REGISTRATION NUMBER

ACTRN12622000839707.

Evidence-based Practice Interventions for Reducing Postoperative Pulmonary Complications: A Narrative Review

Background

Specific surgical procedures, such as upper abdominal and thoracic surgery, are connected to an increased predisposition of postoperative pulmonary complications (PPCs). The incidence of PPCs could vary approximately between 20-90% with upper abdominal surgery, which can be minimized by using treatment procedures that increase lung capacity and encourage inspiration. This review aims to examine the effectiveness of already existing evidence-based interventions that promote lung expansion, thereby preventing PPCs.

Method

We mainly focused on the existing evidence of preoperative education on the incentive spirometer, early mobilization, directed coughing, deep breathing exercises, chest physiotherapy, and inspiratory muscle training (IMT) to prevent PPCs. The literature search was limited to experimental, observational studies, systemic reviews, and articles published in the last 15 years, January 2007- Dec. 2022, in PubMed and Google Scholar.

Result

This initial search yielded a total of 5301 articles. All articles with titles not related to the topic were eliminated. 1050 records were screened, and the final review was conducted with 22 articles, including 13 randomized controlled trials (RCTs), four systemic reviews, one retrospective review, three observational studies, and one non-experimental study. Our review reveals mixed evidence for individual interventions, including but not limited to incentive spirometry, inspiratory muscle training, early mobilization, cough, deep breathing, etc. Some studies maintain that intervention is effective; others imply there is no substantial difference in the choice of intervention.

Conclusion

The literature review concluded that patients who received multiple interventions showed significant improvement in pulmonary function postoperatively. However, definitive studies need to be conducted to solidify this conclusion.

Mismatch of populations between randomised controlled trials of perioperative interventions in major abdominal surgery and current clinical practice

BACKGROUND

Demographics of patients undergoing major abdominal surgery are changing. External validity of relevant RCTs may be limited by participants not resembling patients encountered in clinical practice. We aimed to characterise differences in age, weight, BMI, and ASA grade between participants in perioperative trials in major abdominal surgery and patients in a reference real-world clinical practice sample. The secondary aim was to investigate whether time since trial publication was associated with increasing mismatch between these groups.

METHODS

MEDLINE and Embase were searched for multicentre RCTs from inception to September 2022. Studies of perioperative interventions in adults were included. Studies that limited enrolment based on age, weight, BMI, or ASA status were excluded. We compared trial cohort age, weight, BMI, and ASA distribution to those of patients undergoing major abdominal surgery at our tertiary referral hospital during September 2021 to September 2022. We used a local, single-institution reference sample to reflect the reality of clinical practice (i.e. patients treated by a clinician in their own hospital, rather than averaged nationally). Mismatch was defined using comparison of summary characteristics and ad hoc criteria based on differences relevant to predicted mortality risk after surgery.

RESULTS

One-hundred and six trials (44,499 participants) were compared to a reference cohort of 2792 clinical practice patients. Trials were published a median (IQR [range]) 13.4 (5-20 [0-35]) years ago. A total of 94.3% of trials were mismatched on at least one characteristic (age, weight, BMI, ASA). Recruitment of ASA 3 + participants in trials increased over time, and recruitment of ASA 1 participants decreased over time (Spearman's Rho 0.58 and - 0.44, respectively).

CONCLUSIONS

Patients encountered in our current local clinical practice are significantly different from those in our defined set of perioperative RCTs. Older trials recruit more low-risk than high-risk participants-trials may thus 'expire' over time. These trials may not be generalisable to current patients undergoing major abdominal surgery, and meta-analyses or guidelines incorporating these trials may therefore be similarly non-applicable. Comparison to local, rather than national cohorts, is important for meaningful on-the-ground evidence-based decision-making.

An Accessible Pre-Rehabilitation Bundle for Patients Undergoing Elective Heart Valve Surgery with Limited Resources: The TIME Randomized Clinical Trial

Background

Despite gradually increasing evidence for pre-rehabilitation for heart valve surgery, it remains underused, especially in developing countries with limited resources. The study aimed to investigate the feasibility and effects of an innovative three-day pre-rehabilitation bundle for patients undergoing elective heart valve surgery.

Methods

This was a single-center, assessor-blind, randomized clinical trial. A total of 165 patients were randomly assigned to either usual care (control group, n = 83) or usual care with an additional 3-day pre-rehabilitation bundle (Three-day of Inspiratory muscle training, aerobic Muscle training, and Education (TIME) group, n = 82). The main outcome of the study was the incidence of postoperative pulmonary complications (PPCs). Secondary outcomes included the feasibility of the intervention, duration of the non-invasive ventilator, length of stay, and PPCs-related medical costs on discharge.

Results

Of 165 patients 53.94% were male, the mean age was 63.41 years, and PPCs were present in 26 of 82 patients in the TIME group and 44 of 83 in the control group (odds ratio (OR), 0.60; 95% CI, 0.41-0.87, p = 0.006). The feasibility of the pre-rehabilitation bundle was good, and no adverse events were observed. Treatment satisfaction and motivation scored on 10-point scales, were 9.1 ± 0.8 and 8.6 ± 1.4, respectively. The TIME group also had fewer additional PPCs-related medical costs compared to the control group (6.96 vs. 9.57 thousand CNY (1.01 vs. 1.39 thousand USD), p < 0.001).

Conclusions

The three-day accessible pre-rehabilitation bundle reduces the incidence of PPCs, length of stay, and PPCs-related medical costs in patients undergoing elective valve surgery. It may provide an accessible model for the expansion of pre-rehabilitation in countries and regions with limited medical resources.

Clinical Trial Registration

This trial was based on the Consolidated Standards of Reporting Trials (CONSORT) guidelines. This trial was registered in the Chinese Clinical Trial Registry (identifier ChiCTR2000039671).

Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis

BACKGROUND

Postoperative complications occur in up to 43% of patients after surgery, resulting in increased morbidity and economic burden. Prehabilitation has the potential to increase patients' preoperative health status and thereby improve postoperative outcomes. However, reported results of prehabilitation are contradictory. The objective of this systematic review is to evaluate the effects of prehabilitation on postoperative outcomes (postoperative complications, hospital length of stay, pain at postoperative day 1) in patients undergoing elective surgery.

METHODS

The authors performed a systematic review and meta-analysis of RCTs published between January 2006 and June 2023 comparing prehabilitation programmes lasting ≥14 days to 'standard of care' (SOC) and reporting postoperative complications according to the Clavien-Dindo classification. Database searches were conducted in PubMed, CINAHL, EMBASE, PsycINFO. The primary outcome examined was the effect of uni- or multimodal prehabilitation on 30-day complications. Secondary outcomes were length of ICU and hospital stay (LOS) and reported pain scores.

RESULTS

Twenty-five studies (including 2090 patients randomized in a 1:1 ratio) met the inclusion criteria. Average methodological study quality was moderate. There was no difference between prehabilitation and SOC groups in regard to occurrence of postoperative complications (OR = 1.02, 95% c.i. 0.93 to 1.13; P = 0.10; I2 = 34%), total hospital LOS (-0.13 days; 95% c.i. -0.56 to 0.28; P = 0.53; I2 = 21%) or reported postoperative pain. The ICU LOS was significantly shorter in the prehabilitation group (-0.57 days; 95% c.i. -1.10 to -0.04; P = 0.03; I2 = 46%). Separate comparison of uni- and multimodal prehabilitation showed no difference for either intervention.

CONCLUSION

Prehabilitation reduces ICU LOS compared with SOC in elective surgery patients but has no effect on overall complication rates or total LOS, regardless of modality. Prehabilitation programs need standardization and specific targeting of those patients most likely to benefit.

Impact of Prehabilitation on Postoperative Mortality and the Need for Non-Home Discharge in High-Risk Surgical Patients

BACKGROUND

The preoperative period is an important target for interventions (eg Surgical Prehabilitation and Readiness [SPAR]) that can improve postoperative outcomes for older patients with comorbidities.

STUDY DESIGN

To determine whether a preoperative multidisciplinary prehabilitation program (SPAR) reduces postoperative 30-day mortality and the need for non-home discharge in high-risk surgical patients, surgical patients enrolled in a prehabilitation program targeting physical activity, pulmonary function, nutrition, and mindfulness were compared with historical control patients from 1 institution's American College of Surgeons (ACS) NSQIP database. SPAR patients were propensity score-matched 1:3 to pre-SPAR NSQIP patients, and their outcomes were compared. The ACS NSQIP Surgical Risk Calculator was used to compare observed-to-expected ratios for postoperative outcomes.

RESULTS

A total of 246 patients were enrolled in SPAR. A 6-month compliance audit revealed that overall patient adherence to the SPAR program was 89%. At the time of analysis, 118 SPAR patients underwent surgery with 30 days of follow-up. Compared with pre-SPAR NSQIP patients (n = 4,028), SPAR patients were significantly older with worse functional status and more comorbidities. Compared with propensity score-matched pre-SPAR NSQIP patients, SPAR patients had significantly decreased 30-day mortality (0% vs 4.1%, p = 0.036) and decreased need for discharge to postacute care facilities (6.5% vs 15.9%, p = 0.014). Similarly, SPAR patients exhibited decreased observed 30-day mortality (observed-to-expected ratio 0.41) and need for discharge to a facility (observed-to-expected ratio 0.56) compared with their expected outcomes using the ACS NSQIP Surgical Risk Calculator.

CONCLUSIONS

The SPAR program is safe and feasible and may reduce postoperative mortality and the need for discharge to postacute care facilities in high-risk surgical patients.

Surgery for primary malignant tumors of the abdominal wall: experiences of three African surgical oncology units and review of the literature

BACKGROUND AND OBJECTIVES

Tumors of the abdominal wall are uncommon but diverse. The surgical challenge is double. The tumor must be completely removed and the abdominal wall repaired. Our aim was to describe the indications, techniques, and results of surgery on these tumors in an African context.

METHODS

Retrospective, multicentric and descriptive study conducted in three West African surgical oncology units. We included all abdominal wall tumors followed up between January 2010 and October 2022. Histological type, size, surgical procedure, and method of abdominal wall repair were considered. Survival was calculated using the Kaplan-Meier method and comparisons of proportions were made using the Student t test.

RESULTS

We registered 62 tumors of the abdominal wall and we operated on 41 (66.1%). The mean size of the tumors was 14.3 ± 26 cm. Dermatofibrosarcoma and desmoid tumor were present in 33 and 3 cases respectively. In 31.7% of cases in addition to the tumour, the resections carried away the muscular aponeurotic plane. Parietal resections required the use of a two-sided prosthesis in 6 cases. In 13 cases, we used skin flaps. The resections margins were invaded in 5 cases and revision surgery was performed in all of them. Incisional hernia was noticed in 2 cases. The tumor recurrence rate was 12.2% with an average time of 13 months until occurrence. Overall survival at 3 years was 80%.

CONCLUSIONS

Surgery is the mainstay of treatment for abdominal wall tumors. It must combine tumor resections and parietal repair. Cancer surgeons need to be trained in abdominal wall repair.

A toolbox for a structured risk-based prehabilitation program in major surgical oncology

Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.

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.

Benefits of Prehabilitation before Complex Aortic Surgery

The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.

Effect of preoperative inspiratory muscle training on postoperative outcomes in patients undergoing cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Cardiovascular disease is the most prevalent disease worldwide and places a great burden on the health and economic welfare of patients. Cardiac surgery is an important way to treat cardiovascular disease, but it can prolong mechanical ventilation time, intensive care unit (ICU) stay, and postoperative hospitalization for patients. Previous studies have demonstrated that preoperative inspiratory muscle training could decrease the incidence of postoperative pulmonary complications.

AIM

To explore the effect of preoperative inspiratory muscle training on mechanical ventilation time, length of ICU stay, and duration of postoperative hospitalization after cardiac surgery.

METHODS

A literature search of PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure, WanFang, and the China Science and Technology journal VIP database was performed on April 13, 2022. The data was independently extracted by two authors. The inclusion criteria were: (1) Randomized controlled trial; (2) Accessible as a full paper; (3) Patients who received cardiac surgery; (4) Preoperative inspiratory muscle training was implemented in these patients; (5) The study reported at least one of the following: Mechanical ventilation time, length of ICU stay, and/or duration of postoperative hospitalization; and (6) In English language.

RESULTS

We analyzed six randomized controlled trials with a total of 925 participants. The pooled mean difference of mechanical ventilation time was -0.45 h [95% confidence interval (CI): -1.59-0.69], which was not statistically significant between the intervention group and the control group. The pooled mean difference of length of ICU stay was 0.44 h (95%CI: -0.58-1.45). The pooled mean difference of postoperative hospitalization was -1.77 d in the intervention group vs the control group [95%CI: -2.41-(-1.12)].

CONCLUSION

Preoperative inspiratory muscle training may decrease the duration of postoperative hospitalization for patients undergoing cardiac surgery. More high-quality studies are needed to confirm our conclusion.

Impact of Preemptive Postoperative Pressure Support Ventilation and Physiotherapy on Postoperative Pulmonary Complications after Major Cervicofacial Cancer Surgery: A before and after Study

Introduction: Complex cervicofacial cancer surgery with free flap reconstruction is known to have a high incidence of postoperative pulmonary complications (PPCs). We hypothesized that by implementing an optimized respiratory protocol, including preemptive postoperative pressure support ventilation, physiotherapy, and critical respiratory support and follow-up, we could decrease the incidence of PPCs. Patients and methods: We evaluated the incidence of PPCs over two periods in two groups of patients having a routine or optimized postoperative respiratory protocol: 156 adult patients undergoing major cervicofacial cancer surgery were assessed; 91 were in Group 1 (routine) and 65 were in Group 2 (optimized). In Group 1, no ventilatory support sessions were performed. The incidence of pulmonary complications in both groups was compared using a multivariate analysis. Mortality was also compared until one year postoperatively. Results: In Group 2 with an optimized protocol, the mean number of ventilatory support sessions was 3.7 ± 1 (minimum 2, maximum 6). The incidence of respiratory complications, which was 34% in Group 1 (routine), was reduced by 59% OR = 0.41 (0.16; 0.95), p = 0.043) to 21% for the optimized Group 2. No difference in mortality was found. Conclusions: The present retrospective study showed that using an optimized preemptive respiratory pressure support ventilation combined with physiotherapy after a major cervicofacial surgery could possibly help reduce the incidence of pulmonary complications. Prospective studies are needed to verify these findings.