The Necessity of Chest Physical Therapy for Thoracoscopic Oesophagectomy

The influence of minimally invasive esophagectomy versus open esophagectomy on postoperative pulmonary function in esophageal cancer patients: a meta-analysis

OBJECTIVE

To compare the influence of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on postoperative pulmonary function in patients with esophageal cancer.

METHODS

Studies about the influence of MIE and OE on postoperative pulmonary function in esophageal cancer patients were searched from PubMed, EMBASE, the Cochrane Library, CNKI, Chinese Science and Technology Journal Database, CBM, and Wanfang Data from inception to March 18, 2021. Meta-analysis was performed using the RevMan 5.3.

RESULTS

This analysis included eight studies, enrolling 264 patients who underwent MIE and 257 patients who underwent OE. The meta-analysis results showed that the MIE group had a higher outcome regarding the percent predicted vital capacity (%VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and maximum voluntary ventilation (MVV) 1 month after surgery than the OE group. In addition, those who underwent MIE had lower ΔVC%, ΔFVC, and ΔFEV1 between pre-operation and 1 month after surgery than those who underwent OE. There is no statistical difference between the two groups in ΔMVV.

CONCLUSION

Compared with OE, MIE has a more protective effect on postoperative pulmonary function. However, due to the small number of included literature and all cohort studies, this finding needs to be validated with larger samples and higher quality RCT studies.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100049186.

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

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

Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis

The aim of this systematic review and pooled analysis is to determine the effect of enhanced recovery programs (ERP) on clinical outcome measures following esophagectomy. Medline, Embase, trial registries, conference proceedings, and reference lists were searched for trials comparing clinical outcome from esophagectomy followed by a conventional pathway with esophagectomy followed by an ERP. Primary outcomes were the incidence of postoperative mortality, anastomotic leak and pulmonary complications, and secondary outcomes were length of hospital stay and the incidence of 30-day readmission. Nine studies were included comprising 1240 patients, 661 patients underwent esophagectomy followed conventional pathway, and 579 patients underwent ERP. Utilization of ERP was associated with a reduction in the incidence of anastomotic leak (12.2-8.3%; pooled odds ratios = 0.61; 95% confidence interval = 0.39 to 0.96; P = 0.03) and pulmonary complications (29.1-19.6%; pooled odds ratios = 0.52; 95% confidence interval = 0.36 to 0.77; P = 0.001) and length of hospital stay, and no significant change in postoperative mortality or readmission rate. There was significant variation in the design of enhanced recovery protocols, surgical approach, and utilization of neoadjuvant therapies between the studies that are important confounding variables to be considered. This study suggests a benefit to the utilization of ERP following esophagectomy. The pathways provide a template for all medical personnel interacting with these patients in order to provide incremental changes in all aspects of clinical care that translates into global improvements seen in postoperative outcomes.

Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience

BACKGROUND

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures.

METHODS

The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques.

RESULTS

In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE.

CONCLUSIONS

The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

Esophagectomy without mortality: what can surgeons do?

INTRODUCTION

Surgical resection remains the mainstay treatment for patients with localized esophageal cancer. It is, however, a complex procedure. Mortality rate used to be high, but in recent years, death rate has been reduced to below 5% in specialized centers.

METHODS

Outcome of esophagectomy can be improved by paying attention to (1) appropriate patient section, (2) choice of surgical techniques and their execution, and (3) optimizing perioperative care. A volume-outcome relationship is also evident. Surgeons can perform esophagectomy without mortality, but a multi-disciplinary team management is essential to achieve this goal.

Randomized clinical trials in esophageal carcinoma

The treatment of esophageal cancer with curative intent remains highly controversial, with advocates of surgery alone, chemoradiotherapy alone, surgery with adjuvant therapy (including neoadjuvant and postoperative), and trimodality therapy each contributing prospective randomized controlled trials (PRCTs) to the body of scientific publications between 2000 and 2008. Any improvements in survival have been small in absolute percentage terms, and as such PRCTs published over the last decade have met the same primary obstacle encountered by the studies from the two prior decades, namely lack of power to detect small differences in outcome. Variations in staging methods, surgical technique, radiotherapy technique, and chemotherapy regime have in turn been the subject of PRCTs over the last nine years. In many cases primary end points have not been survival but rather rates of complication or response. As well as giving an overview of PRCTs, this article collates the level Ia evidence published to date.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Minimally invasive techniques for oesophageal cancer surgery

Innovative minimally invasive surgical (MIS) techniques have been explored for the purpose of oesophagectomy since the early 1990s, including various combinations of thoracoscopy, laparoscopy or laparoscopic-assisted methods, mediastinoscopy and open thoracotomy and laparotomy. The myriad of surgical approaches implies a lack of consensus on which is superior. Like open surgery, it is perhaps more important to have a tailored approach for the individual patient. MIS oesophagectomy has been shown to be feasible, and at least equivalent postoperative morbidity and mortality rates to open surgical resection have been demonstrated. Selected series have achieved less blood loss, reduction in some postoperative complications, decrease in intensive care and hospital stay, and better preservation of pulmonary function. Clear proof of superiority over conventional oesophagectomy methods however is not forthcoming since comparisons were often made with unmatched patient cohorts, and a well conducted randomized controlled trial has not been carried out. It is expected that with further improvements in instrumentation and experience, these difficult procedures may become more accessible and widely practised.

Endoscopic therapy for oesophageal cancer

Transthoracic surgery for oesophageal cancer is associated with a high incidence of respiratory complications. Recent development of minimally invasive oesophagectomy by the use of video-assisted thoracoscopic approach may have a potential to minimize morbidity and mortality. While results from earlier series were equivocal, recent reports have shown an encouraging trend. This article serves to review the recent literature evidence in relation to the surgical approach, safety, efficacy and potential problems of such a highly complex minimally invasive operation.