Purpose Improving cardiopulmonary reserve, or peak oxygen consumption(trueV˙ O2peak), may reduce postoperative complications; however, this may be difficult to achieve between diagnosis and surgery. Our primary aim was to assess the efficacy of an approximate 14‐session, preoperative high‐intensity interval training(HIIT) program to increase trueV˙ O2peak by a clinically relevant 2 ml·kg−1·min−1. Our secondary aim was to document clinical outcomes. Methodology In this prospective study, participants aged 45–85 undergoing major abdominal surgery were randomized to standard care or 14 sessions of HIIT over 4 weeks. HIIT sessions involved approximately 30 min of stationary cycling. Interval training alternated 1 min of high (with the goal of reaching 90% max heart rate at least once during the session) and low/moderate‐intensity cycling. Cardiopulmonary exercise testing(CPET) measured the change in trueV˙ O2peak from baseline to surgery. Clinical outcomes included postoperative complications, length of stay(LOS), and Short Form 36 quality of life questionnaire(SF‐36). Results Of 63 participants, 46 completed both CPETs and 50 completed clinical follow‐up. There was a significant improvement in the HIIT group's mean ± SD trueV˙ O2peak (HIIT 2.87 ± 1.94 ml·kg1·min−1 vs standard care 0.15 ± 1.93, with an overall difference of 2.73 ml·kg1·min−1 95%CI [1.53, 3.93] p < 0.001). There were no statistically significant differences between groups for clinical outcomes, although the observed differences consistently favored the exercise group. This was most notable for total number of complications (0.64 v 1.16 per patient, p = 0.07), SF‐36 physical component score (p = 0.06), and LOS (mean 5.5 v 7.4 days, p = 0.07). Conclusions There was a significant improvement in trueV˙ O2peak with a four‐week preoperative HIIT program. Further appropriately powered work is required to explore the impact of preoperative HIIT on postoperative clinical outcomes.
IMPORTANCEThere are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial.OBJECTIVE To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes.DATA SOURCES Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021.STUDY SELECTION Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria.DATA EXTRACTION AND SYNTHESIS NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. MAIN OUTCOMES AND MEASURESPrimary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation.RESULTS A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes.CONCLUSIONS AND RELEVANCE This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.
Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p £ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.
Background Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery. Methods The Delphi methodology was implemented over three rounds of surveys distributed to prehabilitation experts from across multiple specialties, tumour streams and countries via a secure online platform. In the first round, participants were asked to provide baseline demographics and to identify five top prehabilitation research priorities. In successive rounds, participants were asked to rank research priorities on a 5-point Likert scale. Consensus was considered if > 70% of participants indicated agreement on each research priority. Results A total of 165 prehabilitation experts participated, including medical doctors, physiotherapists, dieticians, nurses, and academics across four continents. The first round identified 446 research priorities, collated within 75 unique research questions. Over two successive rounds, a list of 10 research priorities reached international consensus of importance. These included the efficacy of prehabilitation on varied postoperative outcomes, benefit to specific patient groups, ideal programme composition, cost efficacy, enhancing compliance and adherence, effect during neoadjuvant therapies, and modes of delivery. Conclusions This collaborative international study identified the top 10 research priorities in prehabilitation for patients undergoing cancer surgery. The identified priorities inform research strategies, provide future directions for prehabilitation research, support resource allocation and enhance the prehabilitation evidence base in cancer patients undergoing surgery.
We read with interest the article by Boereboom et al 1 in the Scandinavian Journal of Medicine Science in Sport. This well-performed study showed that a short (8 sessions over 19 days) pre-operative exercise training program increased exercise time and workload in the second cardiopulmonary exercise test (CPET), but did not lead to a change in participants' peak VO 2. We agree with the statement in the discussion that "Further work should be undertaken to explore exercise modality, training intensity, interval length and session frequency to try and determine an optimal HIIT protocol to improve the cardiorespiratory fitness (CRF) of preoperative patients in the short time-frame available." However, we feel that the title of the paper and the main conclusion that "short-term preoperative high-intensity interval training does not improve fitness of colorectal cancer patients" is potentially misleading.The main reason for our concern is related to the volume of intense exercise administered. This paper shows that a median intense exercise volume of 40 minutes (40 × 1 minute high-intensity exercise) does not improve peak VO 2 . This, therefore, makes an important contribution to the literature. Dunne et al showed an improvement of 2 mL/kg/min in peak VO 2 with 12 HIIT exercise sessions 2 before liver surgery. Each session was 40 minutes long, with 30 minutes spent alternating between low-and high-intensity exercise. It is not clear how many minutes of intense exercise were performed, but it was probably close to 120 minutes. We have recently completed a randomized trial 3,4 with a number of clinical similarities to this study. We demonstrated an improvement in peak VO 2 of 2.87 mL/kg/min. Our participants attended on average 12 sessions and on analysis performed 8 minutes of intense exercise per session, giving an approximate total of 100 minutes of intense exercise. This was associated with favorable trends in clinical outcomes.Future research should examine the number of sessions and the number of intense intervals needed to improve peak VO 2 over a period of 3-4 weeks. For example, while 40 minutes of high-intensity exercise is not enough to increase peak VO 2 , and 100 minutes of high-intensity is, we do not know what the impact of 80 minutes of high-intensity exercise (a volume that could be achieved in 8 sessions) will be. We have commenced a study to help define the dose-response curve between number of sessions of HIIT and change in peak VO 2 , in both average and high risk patients. Filling this gap in our current knowledge will help determine how best to prescribe HIIT in the context of variable surgical waiting times. We therefore believe that it is premature to conclude that "shortterm preoperative high-intensity interval training does not improve fitness of colorectal cancer patients." ORCID Kari Cliffordhttps://orcid.org/0000-0002-4908-7413 REFERENCES 1. Boereboom CL, Blackwell J, Williams JP, Phillips BE, Lund JN. Short-term pre-operative high-intensity interval training does not improve fitness of col...
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