Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery – A Randomized Clinical Trial
JAMA Surg. online Sept 5, 2018. doi:10.1001/jamasurg.2018.1645
Enrico M. Minnella, MD1; Rashami Awasthi, MSc1; Sarah-Eve Loiselle, PDt1; et al Ramanakumar V. Agnihotram, PhD2; Lorenzo E. Ferri, MD, PhD3; Francesco Carli, MD, MPhil1
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Major surgery is like running a marathon—and both require training
The impact of surgery leads to significant homeostatic disturbance.1 The surgical stress response is characterised by catabolism and increased oxygen demand. The extent and duration of the stress response is proportionate to the magnitude of surgery and the associated risk of developing postoperative complications.2
Patients who experience postoperative complications within 30 days of surgery have a reduced long term survival rate.3 Even in the absence of complications there is a 20-40% reduction in postoperative physical function and a significant deterioration in quality of life after major surgery.4
- Critically ill children with low vitamin D: 2.5 X more likely to die or stay 2 days longer - meta-analysis Nov 2017
- Children stayed in ICU 3.5 days longer if low vitamin D – Dec 2015
- Low Vitamin D when entering ICU is deadly (acute kidney injury in this case) – Aug 2017
- Chance of dying in hospital cut in half by just 10 ng higher level of Vitamin D – April 2016
- All ICU patients with good vitamin D level survived, none who died had a good level – April 2018
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(Not statistically significant improvements (not expected for such a small trial)
- Question What is the effect of a structured preoperative exercise and nutrition conditioning program (prehabilitation) on functional capacity after esophagogastric surgery?
- Findings In this randomized clinical trial (26 prehabilitation participants vs 25 control participants), prehabilitation significantly improved functional capacity before and after surgery.
- Meaning Prehabilitation may be considered for optimizing physical fitness during esophagogastric cancer care.
Importance Preserving functional capacity is a key element in the care continuum for patients with esophagogastric cancer. Prehabilitation, a preoperative conditioning intervention aiming to optimize physical status, has not been tested in upper gastrointestinal surgery to date.
Objective To investigate whether prehabilitation is effective in improving functional status in patients undergoing esophagogastric cancer resection.
Design, Setting, and Participants A randomized clinical trial (available-case analysis based on completed assessments) was conducted at McGill University Health Centre (Montreal, Quebec, Canada) comparing prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. The study dates were February 13, 2013, to February 10, 2017.
Main Outcomes and Measures The primary outcome was change in functional capacity, measured with absolute change in 6-minute walk distance (6MWD). Preoperative (end of the prehabilitation period) and postoperative (from 4 to 8 weeks after surgery) data were compared between groups.
Results Sixty-eight patients were randomized, and 51 were included in the primary analysis. The control group were a mean (SD) age, 68.0 (11.6) years and 20 (80%) men. Patients in the prehabilitation group were a mean (SD) age, 67.3 (7.4) years and 18 (69%) men. Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean [SD] 6MWD change, 36.9 [51.4] vs −22.8 [52.5] m; P < .001) and after surgery (mean [SD] 6MWD change, 15.4 [65.6] vs −81.8 [87.0] m; P < .001).
Conclusions and Relevance Prehabilitation improves perioperative functional capacity in esophagogastric surgery. Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum.
Trial Registration ClinicalTrials.gov Identifier: NCT01666158
At baseline, all patients had an evaluation of their fitness level and functional ability in terms of walking and endurance, strength, joint mobility, and posture. A physician (E.M.M.) prescribed an individualized, home-based exercise training program 4 times per week according to guidelines provided by the American College of Sports Medicine.25 Participants received an individual session with a kinesiologist, who demonstrated the complete training program and provided corrective feedback as necessary.26 Aerobic exercise consisted of 30 minutes (including 5-minute warm-up and 5-minute cooldown) of moderate continuous training 3 days per week. Exercise modalities were brisk walk, jogging, or cycling depending on personal physical level and attitude. Patients were instructed by the kinesiologist to self-select the intensity to reach 12 to 13 on rated perceived exertion (range, 6-20 on the Borg Rating of Perceived Exertion Scale).27,28 Strengthening activity, prescribed 1 day per week, consisted of 30 minutes (including 5-minute flexibility and 5-minute stretching) of 3 sets of 8 to 12 repetitions for 8 muscle groups using an elastic band as resistance (TheraBand). Resistance level was selected by the kinesiologist to reach a moderate-intensity effort, rated as 5 to 6 on a 10-point scale.29 Participants were provided with a logbook to record all activities. The kinesiologist monitored the adherence and addressed issues or doubts by weekly telephone calls.
At the time of enrollment, participants completed a 3-day estimated food record of 2 weekdays and 1 weekend day. A dietitian (S.-E.L.) assessed dietary habits and anthropometric data to create a comprehensive status evaluation and to estimate the required amount and relative proportion of macronutrients.30 Metabolic requirement was adjusted to meet the increased nutritional demand due to the stress associated with their upcoming surgery.31,32 Food-based dietary advice was given, and whey protein supplement (Immunocal; Immunotec Inc) was prescribed to guarantee a daily protein intake of 1.2 to 1.5 g/kg of ideal body weight (or approximately 20% of total energy requirements).33 These supplements, if needed, were consumed every morning after breakfast or immediately after exercise during training days. Nutrition therapy was given to all participants in the intervention group, even in the absence of malnutrition.34 Participants were provided with a logbook, and the nutritionist monitored the adherence and addressed issues or doubts by weekly telephone calls.