Enhanced recovery after surgery protocols emphasize the importance of early postoperative mobilization. However, literature quantifying actual physical activity after major abdominal cancer surgery is scarce and inconclusive.
Introduction Patients with end-stage liver disease awaiting orthotopic liver transplantation (OLT) are generally classified as frail due to disease-related malnutrition and a progressive decline in musculoskeletal and aerobic fitness, which is associated with poor pre-OLT, peri-OLT and post-OLT outcomes. However, frailty in these patients may be reversable with adequate exercise and nutritional interventions. Methods and analysis Non-randomised clinical trial evaluating the effect of a home-based bimodal lifestyle programme in unfit patients with a preoperative oxygen uptake (VO 2 ) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO 2 at peak exercise ≤18 mL/kg/min listed for OLT at the University Medical Center Groningen (UMCG). The programme is patient tailored and comprises high-intensity interval and endurance training, and functional exercises three times per week, combined with nutritional support. Patients will go through two training periods, each lasting 6 weeks. The primary outcome of this study is the impact of the programme on patients’ aerobic fitness after the first study period. Secondary outcomes include aerobic capacity after the second study period, changes in sarcopenia, anthropometry, functional mobility, perceived quality of life and fatigue, incidence of hepatic encephalopathy and microbiome composition. Moreover, number and reasons of intercurrent hospitalisations during the study and postoperative outcomes up to 12 months post OLT will be recorded. Finally, feasibility of the programme will be assessed by monitoring the participation rate and reasons for non-participation, number and severity of adverse events, and dropout rate and reasons for dropout. Ethics and dissemination This study was approved by the Medical Research Ethics Committee of the UMCG (registration number NL83612.042.23, August 2023) and is registered in the Clinicaltrials.gov register ( NCT05853484 ). Good Clinical Practice guidelines and the principles of the Declaration of Helsinki will be applied. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals. Trial registration number NCT05853484 .
Abstract Background Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level. Methods Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either ‘node-picking’ (the removal of an individual LLN) or ‘partial regional node dissection’ (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those undergoing only rectal resection. Results Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking ( n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND ( n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery ( n = 48) or rectal resection alone ( n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7–3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2–2.5, p = 0.874). Conclusion Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.
Neoadjuvant short-course radiotherapy was routinely applied for nonlocally advanced rectal cancer (cT1-3N0-1M0 with >1 mm distance to the mesorectal fascia) in the Netherlands following the Dutch total mesorectal excision trial. This policy has shifted toward selective application after guideline revision in 2014.
Introduction Short-term exercise prehabilitation programmes have demonstrated promising results in improving aerobic capacity of unfit patients prior to major abdominal surgery. However, little is known about the cardiac and skeletal muscle adaptations explaining the improvement in aerobic capacity following short-term exercise prehabilitation. Methods and analysis In this single-centre study with a pretest–post-test design, 12 unfit patients with a preoperative oxygen uptake (VO 2 ) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO 2 at peak exercise ≤18 mL/kg/min, who are scheduled to undergo hepatopancreatobiliary surgery at the University Medical Center Groningen (UMCG), the Netherlands, will be recruited. As part of standard care, unfit patients are advised to participate in a home-based exercise prehabilitation programme, comprising high-intensity interval training and functional exercises three times per week, combined with nutritional support, during a 4-week period. Pre-intervention and post-intervention, patients will complete a cardiopulmonary exercise test. Next to this, study participants will perform additional in-vivo exercise cardiac magnetic resonance (MR) imaging and phosphorus 31-MR spectroscopy of the quadriceps femoris muscle before and after the intervention to assess the effect on respectively cardiac and skeletal muscle function. Ethics and dissemination This study was approved in May 2023 by the Medical Research Ethics Committee of the UMCG (registration number NL83611.042.23, March 2023) and is registered in the ClinicalTrials.gov register. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals. Trial registration number NCT05772819 .
Abstract Background : Morbidity rates in pancreatic surgery are high, and especially frail patients with low aerobic capacity are at risk of complications and require specialized prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes. In this study we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale. Methods : In this multicenter study adult patients scheduled for elective pancreatic surgery, with a preoperative oxygen uptake (VO 2 ) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or a VO 2 at peak exercise (VO 2 peak) ≤18 mL/kg/min will be recruited. The study will be conducted in a pretest-posttest design. A total of 30 patients will be included in the four-week home-based, partly supervised exercise prehabilitation program on an advanced cycle ergometer. The program comprises 30-minute high-intensity interval training three times a week. Training intensity will be based on a steep ramp test (i.e., an abbreviated maximum exercise test on the advanced ergometer) performance, aiming to improve aerobic fitness. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. Every week, a steep ramp test will be repeated, and training intensity will be adjusted accordingly. Next to assessing feasibility (participation rate, reasons for non-participation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this exercise prehabilitation program, we will evaluate individual patient’s responses to prehabilitation on aerobic capacity, functional mobility, body composition, perceived fatigue, quality of life, muscle function, and immune system factors. Discussion : Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery. Trial registration : This study was approved by the Medical Research Ethics Committee of the Maastricht University Medical Center+ (METC azM/UM), the Netherlands (registration number METC20-090, NL75340.068.20, September 2021) and is registered in the Clinicaltrials.gov register (NCT05496777).
Objectives: A significant proportion of patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC) are anemic at the time of resection. In these patients, blood transfusions are omitted due to their potential negative impact on oncological outcomes. The aim of the present study was to determine the prognostic value of preoperative anemia in resected PDAC patients, irrespective of blood transfusion status. Methods: In this retrospective two-center cohort study patients who underwent resection for histologically confirmed PDAC between 2013 and 2022 were included. The prognostic role of preoperative anemia was investigated using Cox proportional-hazard regression analysis. A subgroup analysis was performed in which PDAC patients who received a perioperative blood transfusion were excluded. Results: Among the 280 PDAC patients who were included, 110 (39%) were found to have anemia prior to surgery. Preoperative anemia was associated with increased use of blood transfusions, with a total of 44 patients (16%) requiring transfusion perioperatively. In the whole cohort, preoperative anemia was found to be an independent predictor of lower disease-free survival (DFS) (HR=1.518; 95% CI 1.103-2.090; P =0.011), but not overall survival (OS). However, when patients who received a perioperative blood transfusion were excluded from the analysis, preoperative anemia was independently associated with both lower DFS (HR=1.636; 95% CI 1.113-2.404; P =0.012) and OS (HR=1.484; 95% CI 1.036-2.127; P =0.031). Conclusions: Preoperative anemia was shown to be an independent risk factor for inferior oncological survival after resection for PDAC. These results support the need for increased awareness regarding the potential adverse effects of preoperative anemia on oncological outcomes in PDAC.
Objectives Patients with pancreatic disease(s) have a high risk of developing diabetes mellitus (DM). Diabetes mellitus is associated with adverse postoperative outcomes. This study aimed to investigate the prevalence and effects of DM on postoperative outcomes in pancreatic surgery. Methods Subgroup analysis of a prospective cohort study conducted at an academic hospital. Patients undergoing pancreatoduodenectomy between January 2019 and November 2022 were included and screened for DM preoperatively using glycated hemoglobin (HbA1c). New-onset DM was diagnosed based on HbA1c ≥ 6.5% (48 mmol/mol). Postoperative outcomes were compared between patients with and without DM. Results From 117 patients, 29 (24.8%) were given a diagnosis of DM, and of those, 5 (17.2%) were diagnosed with new-onset DM, and 15 (51.8%) displayed poorly controlled preoperative DM (HbA 1c ≥ 7% [53 mmol/mol]). The incidence of surgical site infections (48.3% vs 27.3% in the non-DM group; P = 0.04) was higher for patients with DM. This association remained significant after adjusting for confounders (odds ratio, 2.60 [95% confidence interval, 1.03–6.66]; P = 0.04). Conclusions One-quarter of the patients scheduled for pancreatoduodenectomy had DM; over half of them had poor glycemic control. The association between DM status and surgical site infections revealed in this study emphasizes the importance of adequate preoperative glycemic control.
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