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Sivakumar J, Forshaw MJ, Lam S, Peters CJ, Allum WH, Whibley J, Sinclair RCF, Snowden CP, Hii MW, Sivakumar H, Read M. Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data. Dis Esophagus 2022; 35:6524743. [PMID: 35138383 DOI: 10.1093/dote/doac005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/28/2021] [Indexed: 12/11/2022]
Abstract
Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.
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Affiliation(s)
- Jonathan Sivakumar
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Matthew J Forshaw
- Department of Upper Gastrointestinal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Stephen Lam
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Christopher J Peters
- Department of Surgery and Cancer, Imperial College London of St Mary's Hospital, London, UK
| | | | - Jessica Whibley
- Department of Physiotherapy, Royal Marsden Hospital, London, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - Michael W Hii
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Harry Sivakumar
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
| | - Matthew Read
- Department of Surgery, The University of Melbourne, Melbourne, Australia.,Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia
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Daza JF, Cuthbertson BH, Myles PS, Shulman MA, Wijeysundera DN, Wijeysundera DN, Pearse RM, Myles PS, Abbott TEF, Shulman MA, Torres E, Ambosta A, Melo M, Mamdani M, Thorpe KE, Wallace S, Farrington C, Croal BL, Granton JT, Oh P, Thompson B, Hillis G, Beattie WS, Wijeysundera HC, Ellis M, Borg B, Kerridge RK, Douglas J, Brannan J, Pretto J, Godsall MG, Beauchamp N, Allen S, Kennedy A, Wright E, Malherbe J, Ismail H, Riedel B, Melville A, Sivakumar H, Murmane A, Kenchington K, Kirabiyik Y, Gurunathan U, Stonell C, Brunello K, Steele K, Tronstad O, Masel P, Dent A, Smith E, Bodger A, Abolfathi M, Sivalingam P, Hall A, Painter TW, Macklin S, Elliott A, Carrera AM, Terblanche NCS, Pitt S, Samuels J, Wilde C, Leslie K, MacCormick A, Bramley D, Southcott AM, Grant J, Taylor H, Bates S, Towns M, Tippett A, Marshall F, McCartney CJL, Choi S, Somascanthan P, Flores K, Karkouti K, Clarke HA, Jerath A, McCluskey SA, Wasowicz M, Day L, Pazmino-Canizares J, Belliard R, Lee L, Dobson K, Stanbrook M, Hagen K, Campbell D, Short T, Van Der Westhuizen J, Higgie K, Lindsay H, Jang R, Wong C, McAllister D, Ali M, Kumar J, Waymouth E, Kim C, Dimech J, Lorimer M, Tai J, Miller R, Sara R, Collingwood A, Olliff S, Gabriel S, Houston H, Dalley P, Hurford S, Hunt A, Andrews L, Navarra L, Jason-Smith A, Thompson H, McMillan N, Back G. Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery. Br J Surg 2022; 109:968-976. [PMID: 35929065 DOI: 10.1093/bjs/znac263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/17/2022] [Accepted: 07/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort. METHODS Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups. RESULTS The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status. CONCLUSION The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.
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Affiliation(s)
- Julian F Daza
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brian H Cuthbertson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Mark A Shulman
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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Sivakumar J, Sivakumar H, Read M, Sinclair RCF, Snowden CP, Hii MW. The Role of Cardiopulmonary Exercise Testing as a Risk Assessment Tool in Patients Undergoing Oesophagectomy: A Systematic Review and Meta-analysis. Ann Surg Oncol 2020; 27:3783-3796. [DOI: 10.1245/s10434-020-08638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 02/06/2023]
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Sivakumar J, Sivakumar H, Hii MW. ASO Author Reflections: What is the Role of Cardiopulmonary Exercise Testing Prior to Oesophagectomy? Ann Surg Oncol 2020; 27:3797-3798. [PMID: 32451944 DOI: 10.1245/s10434-020-08643-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan Sivakumar
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia. .,Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Australia.
| | - Harry Sivakumar
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Australia.,Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Australia
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Shulman M, Cuthbertson B, Wijeysundera D, Pearse R, Thompson B, Torres E, Ambosta A, Wallace S, Farrington C, Myles P, Wallace S, Thompson B, Ellis M, Borg B, Kerridge R, Douglas J, Brannan J, Pretto J, Godsall M, Beauchamp N, Allen S, Kennedy A, Wright E, Malherbe J, Ismail H, Riedel B, Melville A, Sivakumar H, Murmane A, Kenchington K, Gurunathan U, Stonell C, Brunello K, Steele K, Tronstad O, Masel P, Dent A, Smith E, Bodger A, Abolfathi M, Sivalingam P, Hall A, Painter T, Macklin S, Elliott A, Carrera A, Terblanche N, Pitt S, Samuels J, Wilde C, MacCormick A, Leslie K, Bramley D, Southcott A, Grant J, Taylor H, Bates S, Towns M, Tippett A, Marshall F, McCartney C, Choi S, Somascanthan P, Flores K, Beattie W, Karkouti K, Clarke H, Jerath A, McCluskey S, Wasowicz M, Granton J, Day L, Pazmino-Canizares J, Hagen K, Campbell D, Short T, Van Der Westhuizen J, Higgie K, Lindsay H, Jang R, Wong C, Mcallister D, Ali M, Kumar J, Waymouth E, Kim C, Dimech J, Lorimer M, Tai J, Miller R, Sara R, Collingwood A, Olliff S, Gabriel S, Houston H, Dalley P, Hurford S, Hunt A, Andrews L, Navarra L, Jason-Smith A, Thompson H, McMillan N, Back G, Melo M, Mamdani M, Hillis G, Wijeysundera H. Using the 6-minute walk test to predict disability-free survival after major surgery. Br J Anaesth 2019; 122:111-119. [DOI: 10.1016/j.bja.2018.08.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 11/16/2022] Open
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Sivakumar H, Peyton P. Poor agreement in significant findings between meta-analyses and subsequent large randomized trials in perioperative medicine. Br J Anaesth 2016; 117:431-441. [DOI: 10.1093/bja/aew170] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Szental JA, Webb A, Weeraratne C, Campbell A, Sivakumar H, Leong S. Postoperative pain after laparoscopic cholecystectomy is not reduced by intraoperative analgesia guided by analgesia nociception index (ANI®) monitoring: a randomized clinical trial. Br J Anaesth 2014; 114:640-5. [PMID: 25540069 DOI: 10.1093/bja/aeu411] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy frequently results in significant immediate postoperative pain. A new pain monitor, analgesic nociception index (ANI®), based on heart rate variability, has recently been approved for intraoperative nociception monitoring. We designed a single-blind, parallel-group, randomized control trial to test the hypothesis that protocol-driven intraoperative analgesia guided by ANI during laparoscopic cholecystectomy would improve titration of intraoperative analgesics leading to decreased postoperative pain. METHODS One hundred and twenty consecutive adult participants presenting for elective laparoscopic cholecystectomy were recruited. Participants were randomly allocated by sealed envelope to receive intraoperative morphine either guided by ANI via a protocol (intervention group) or guided by the anaesthetist with ANI concealed (control group). All participants received paracetamol, parecoxib, fentanyl at induction, and local anaesthetic to port sites. The primary endpoint was the presence of moderate/severe pain (visual analogue scale ≥50 mm) at any of the four time points in the first postoperative hour. Secondary endpoints included postoperative rescue morphine. RESULTS Sixty participants were randomized to each group, and all but one drop-out from the intervention group were analysed. The usage of ANI guidance did not result in a decrease in the rate of moderate/severe pain (50.8% vs 45.0%: difference of -5.8%, 95% confidence interval, -23.7% to 12.1%, P=0.58), or the use of postoperative rescue analgesia. CONCLUSIONS This randomized control trial of intraoperative ANI-guided morphine administration in elective laparoscopic cholecystectomy failed to show any advantage over the current standard of care, and demonstrated a high level of postoperative pain, despite the use of multimodal analgesia. CLINICAL TRIAL REGISTRATION ANZCTR Reference ACTRN12612000953831 (URL: http://www.anzctr.org.au/trial_view.aspx?ID=362949).
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Affiliation(s)
- J A Szental
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
| | - A Webb
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
| | - C Weeraratne
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
| | - A Campbell
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
| | - H Sivakumar
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
| | - S Leong
- Peninsula Health, Hastings Road, Frankston, VIC 3199 Australia
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Sivakumar H, Cameron J, Mottram P. Echocardiographic Markers of Hypertensive Heart Disease in Young and Middle-aged Hypertensive Patients. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kumar AR, Borcar JM, Sivakumar H. TRACHEAL STENOSIS: A Case Report. Med J Armed Forces India 1996; 52:197-199. [PMID: 28769387 DOI: 10.1016/s0377-1237(17)30803-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- A Ravi Kumar
- Reader, Department of ENT, Armed Forces Medical College, Pune 411040
| | - J M Borcar
- Senior Adviser, Cardio Thoracic Surgery, Military Hospital (CTC), Pune 411040
| | - H Sivakumar
- PG Student, Department of ENT, Armed Forces Medical College, Pune 411040
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