Preliminary evidence for physical activity following pelvic exenteration: a pilot longitudinal cohort study

Implementing a physiotherapy-led prehabilitation service and improving inpatient rehabilitation for people with complex colorectal cancer: a service evaluation project

Background/Aims

Prehabilitation improves pre-operative functional status which improves post-operative outcomes. There is limited evidence on the role prehabilitation for people with locally advanced or recurrent colorectal cancer and because of the complex nature of the surgery, patients have particular need for optimisation and specialist rehabilitation. A service evaluation was implemented to evaluate the impact of prehabilitation and increased post-operative rehabilitation in those with locally advanced or recurrent colorectal cancer.

Methods

Exercise-based prehabilitation and an increase in inpatient rehabilitation was implemented for those referred to the complex colorectal cancer clinic (n=59). Hospital length of stay and number of inpatient physiotherapy contacts (therapy sessions) were collected between May 2021 and May 2022 and compared to retrospective data of 44 people who underwent surgery between 2018 and 2019 to help evaluate this project. A range of secondary outcome measures were also collected to assess the impact of prehabilitation, including the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core-30, 30-Second Sit-to-Stand Test, Duke Activity Status Index and a patient questionnaire. Paired sample t-tests were performed to compare the total hospital length of stay for all patients in the retrospective 2018–2019 data group with the prehabilitation data group from 2021–2022.

Results

A total of 59 patients entered the service between May 2021 and May 2022. A significant difference between the length of stay in the two groups was found (P<0.05, t=0.731). Improvements in the Sit-to-Stand Test and Duke Activity Status Index were demonstrated (P<0.001). Data from the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core-30 showed small but not significant reductions in the severity of physical, fatigue, pain and appetite functioning scales. For the more complex patients, average weekly inpatient physiotherapy contacts per person increased from three in 2018–2019 to seven in 2021–2022. Patient compliance and satisfaction was high following implementation of the service development project.

Conclusions

Prehabilitation improves pre-operative functional status and combined with effective inpatient rehabilitation, may reduce hospital length of stay for those undergoing complex colorectal cancer surgery.

Implications for practice

Services that offer surgery for locally advanced or recurrent colorectal cancer should consider implementing a prehabilitation programme to improve pre-operative functional status. For those undergoing more complex surgeries, increased post-operative rehabilitation provision should be considered, as combined with prehabilitation, it may reduce hospital length of stay.

A patient-designed integrative oncology intervention for stage IV locally recurrent rectal cancer: A case report

INTRODUCTION

Stage IV colorectal cancer is a highly challenging condition to treat, with 5-year survival rates of 13% in Australia, improving to 40% for those patients with locally recurrent rectal cancer who are suitable for total neoadjuvant therapy and pelvic exenterative surgery. This study reports a unique case of a patient with Stage IV locally recurrent rectal cancer (LRRC), who designed and implemented a holistic integrative oncology intervention.

CASE PRESENTATION

The patient was 59-years-old when diagnosed with Stage IV locally recurrent rectal cancer, and referred to a highly specialised centre for colorectal cancer care at a tertiary teaching hospital in Sydney, Australia. Treatment included chemo/radiotherapy, liver resection and posterior pelvic exenteration surgery. The patient's background as a health researcher and clinician optimised her ability to design and implement an integrative oncology model of care, including yoga, mindfulness, Buddhist meditation and study, social connection, exercise, psychotherapeutic and nutritional support. This paper describes these mind-body practices and lifestyle modifications and outlines her experiences and outcomes at each stage of her extensive and radical treatment.

CONCLUSION

This case provides a unique perspective into how the integration of mind-body practices and lifestyle modifications with conventional treatment can support those living with colorectal cancer.

Is preoperative sarcopenia associated with postoperative complications after pelvic exenteration surgery?

PURPOSE

Pelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery.

METHODS

This retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3.

RESULTS

In total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis.

CONCLUSION

Sarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.

Utilising quality of life outcome trajectories to aid patient decision making in pelvic exenteration

BACKGROUND

Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst addressing and valuing the patient priorities. Communicating patient-centred information on quality of life (QoL) and functional outcomes is an essential component of this. The aim of this systematic review was to understand the impact of pelvic exenteration on QoL PROs over a longitudinal period and to develop QoL trajectories to support decision-making in this context.

METHODS

MEDLINE, Embase and Web of Science databases were searched between 1^st January 2000 and 20^th December 2021 Studies reporting on PROs, including QoL, in adults undergoing pelvic exenteration were included. Risk of bias was assessed using the ROBINS-I assessment tool. Data from studies reporting QoL using the same outcome measure at the same candidate timepoint were extracted and synthesised to develop a longitudinal QoL trajectory.

RESULTS

Fourteen studies consisting of 1370 patients were included in this review. QoL trajectories were constructed in the domains of physical function, psychological function, role function, sexual function, body image and general and specific symptoms. Decision-making was only assessed by one study, with satisfaction with decision-making reported to be high. There is an initial decline in QoL scores in the domains of physical function, role function, sexual function, body image and general health and symptoms deteriorating during the first 3-6 months post-operatively. Psychological function is the only QoL domain that remains stable throughout the post-operative period.

CONCLUSION

Mapping QoL trajectories provides a visual representation of post-operative progress, highlighting the enduring impact of pelvic exenteration on patients and can be used to inform pre-operative shared decision-making.

PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL)

Background

Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients’ fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs.

Methods

This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs.

Discussion

The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery.

Trial registration

This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12621000617864) on 24th May 2021.

Preoperative functional capacity and postoperative outcomes following abdominal and pelvic cancer surgery: a systematic review and meta-analysis

BACKGROUND

There is clinical uncertainty regarding an association between preoperative functional capacity of cancer patients, and postoperative outcomes. The aim of this systematic review and meta-analysis is to investigate whether poor performance on preoperative six-minute walk test (6MWT) or five-times sit to stand test (5STS) is associated with worse postoperative complication rates and prolonged length of hospital stay (LOS) in cancer patients.

METHODS

An electronic search was performed from earliest available record to 26th February 2021 in MEDLINE, Embase and AMED. Studies investigating the association between preoperative physical function (measured using either 6MWT or 5STS) and postoperative outcomes (complications and LOS) in patients with gastrointestinal, abdominal and pelvic cancers were included. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Where possible, summary odds ratios (OR) or mean differences (MD), and 95% confidence intervals (CI) were calculated using random-effect models.

RESULTS

Five studies (379 patients) were included, of which none utilized the 5STS. Overall, studies were rated as having low to moderate risk of bias. Higher preoperative performance on the 6MWT (≥400 m) was associated with low grade postoperative complications (OR = 0.38; 95% CI = 0.15-0.95) but was not associated with a shorter LOS (MD = 3.29; 95%CI = -1.07-7.66).

CONCLUSION

The available evidence suggests that in cancer patients, a higher preoperative functional capacity may be associated with reduced postoperative complications. Conversely, there is no significant association between preoperative function and LOS. Further high-quality studies are needed in this area, including studies involving 5STS.

Functional outcomes following pelvic exenteration: results from a prospective cohort study

AIM

Postoperative functional outcomes following pelvic exenteration surgery for treatment of advanced or recurrent pelvic malignancies are poorly understood. The aim of this study was to determine the short-term functional outcomes following pelvic exenteration surgery using objective measures of physical function.

METHOD

Patients undergoing pelvic exenteration surgery between January 2017 and May 2020 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary measures were the 6-min walk test (6MWT) and the five times sit to stand (5STS) test. Data were collected at baseline (preoperatively), 10 days postoperatively and at discharge from hospital, and were analysed according to tumour type, extent of exenteration, sacrectomy, length of hospital stay, major nerve resection and postoperative complications.

RESULTS

The cohort of patients that participated in functional assessments consisted of 135 patients, with a median age of 61 years. Pelvic exenteration patients had a reduced 6MWT distance preoperatively compared to the general population (P < 0.001). Following surgery, we observed a further decrease in 6MWT distance (P < 0.001) and an increase in time to complete 5STS (P < 0.001) at postoperative day 10 compared to baseline, with a slight improvement at discharge. There were no differences in 6MWT and 5STS outcomes between patients based on comparisons of surgical and oncological factors.

CONCLUSION

Pelvic exenteration patients are functionally impaired in the preoperative period compared to the general population. Surgery causes a further reduction in physical function in the short term; however, functional outcomes are not impacted by tumour type, extent of exenteration, sacrectomy or nerve resection.

Changes in 24-Hour Physical Activity Patterns and Walking Gait Biomechanics After Primary Total Hip Arthroplasty: A 2-Year Follow-up Study

BACKGROUND

Despite marked improvements in self-reported pain, perceived functional ability, and gait function following primary total hip arthroplasty (THA), it remains unclear whether these improvements translate into improved physical activity and sleep behaviors. The aim of this study was to determine the change in 24-hour activity profile (waking activities and sleep) and laboratory-based gait function from preoperatively to 2 years following the THA.

METHODS

Fifty-one patients undergoing primary THA at a single public hospital were recruited. All THAs were performed using a posterior surgical approach with the same prosthesis type. A wrist-worn accelerometer was used to capture 24-hour activity profiles preoperatively and at 1 and 2 years postoperatively. Three-dimensional gait analysis was performed to determine changes in temporospatial and kinematic parameters of the hip and pelvis.

RESULTS

Patients showed improvements in all temporospatial and kinematic parameters with time. Preoperatively, patients were sedentary or asleep for a mean time (and standard deviation) of 19.5 ± 2.2 hours per day. This remained unchanged up to 2 years postoperatively (19.6 ± 1.3 hours per day). Sleep efficiency remained suboptimal (<85%) at all time points and was worse at 2 years (77% ± 10%) compared with preoperatively (84% ± 5%). More than one-quarter of the sample were sedentary for >11 hours per day at 1 year (32%) and 2 years (41%), which was greater than the preoperative percentage (21%). Patients accumulated their activity performing light activities; however, patients performed less light activity at 2 years compared with preoperative levels. No significant differences (p = 0.935) were observed for moderate or vigorous activity across time.

CONCLUSIONS

Together with improvements in self-reported pain and perceived physical function, patients had significantly improved gait function postoperatively. However, despite the opportunity for patients to be more physically active postoperatively, patients were more sedentary, slept worse, and performed less physical activity at 2 years compared with preoperative levels.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective Quantification of In-Hospital Patient Mobilization after Cardiac Surgery Using Accelerometers: Selection, Use, and Analysis

Cardiac surgery patients infrequently mobilize during their hospital stay. It is unclear for patients why mobilization is important, and exact progress of mobilization activities is not available. The aim of this study was to select and evaluate accelerometers for objective qualification of in-hospital mobilization after cardiac surgery. Six static and dynamic patient activities were defined to measure patient mobilization during the postoperative hospital stay. Device requirements were formulated, and the available devices reviewed. A triaxial accelerometer (AX3, Axivity) was selected for a clinical pilot in a heart surgery ward and placed on both the upper arm and upper leg. An artificial neural network algorithm was applied to classify lying in bed, sitting in a chair, standing, walking, cycling on an exercise bike, and walking the stairs. The primary endpoint was the daily amount of each activity performed between 7 a.m. and 11 p.m. The secondary endpoints were length of intensive care unit stay and surgical ward stay. A subgroup analysis for male and female patients was planned. In total, 29 patients were classified after cardiac surgery with an intensive care unit stay of 1 (1 to 2) night and surgical ward stay of 5 (3 to 6) nights. Patients spent 41 (20 to 62) min less time in bed for each consecutive hospital day, as determined by a mixed-model analysis (p < 0.001). Standing, walking, and walking the stairs increased during the hospital stay. No differences between men (n = 22) and women (n = 7) were observed for all endpoints in this study. The approach presented in this study is applicable for measuring all six activities and for monitoring postoperative recovery of cardiac surgery patients. A next step is to provide feedback to patients and healthcare professionals, to speed up recovery.

Feasibility and acceptability of a preoperative exercise program for patients undergoing major cancer surgery: results from a pilot randomized controlled trial

Objective

To establish the feasibility and acceptability of a preoperative exercise program, and to obtain pilot data on the likely difference in key surgical outcomes to inform the sample size calculation for a full-scale trial.

Design

Pilot randomized controlled trial.

Setting

Royal Prince Alfred Hospital, Sydney, Australia.

Subjects

We included patients undergoing elective pelvic exenteration or cytoreductive surgery aged 18 to 80 years, who presented to the participating gastrointestinal surgeon at least 2 weeks prior to surgery. Patients presenting cognitive impairment, co-morbidity preventing participation in exercise, inadequate English language, currently participating in an exercise program or unable to attend the exercise program sessions were excluded.

Methods

Participants were randomized to a 2–6 weeks preoperative, face-to-face, individualised exercise program or to usual care. Feasibility was assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the preoperative exercise program. Acceptability of the exercise program was assessed with a semi-structured questionnaire exploring the advice received and the amount, duration and intensity of the exercise program. In addition, postoperative complication rates (Clavien-Dindo), length of hospital stay and self-reported measures of health-related quality of life (SF-36v2) were collected at baseline, day before surgery and in-hospital up to discharge from hospital.

Results

Of 122 patients screened, 26 (21%) were eligible and 22 (85%) accepted to participate in the trial and were randomized to the intervention (11; 50%) or control group (11; 50%). The median age of the include participants was 63 years. Adherence to the preoperative exercise sessions was 92.7%, with all participants either satisfied (33%) or extremely satisfied (67%) with the overall design of the preoperative exercise program. No significant differences in outcomes were found between groups.

Conclusions

The results of our pilot trial demonstrate that a preoperative exercise program is feasible and acceptable to patients undergoing major abdominal cancer surgery. There is an urgent need for a definite trial investigating the effectiveness of a preoperative exercise program on postoperative outcomes in patients undergoing major abdominal cancer surgery. This could potentially reduce postoperative complication rates, length of hospital stay and subsequently overall health care costs.

Trial registration

ACTRN12617001129370. Registered on August 1, 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373396&showOriginal=true&isReview=true

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00765-8.