Recent Submissions

  • Molecular mechanisms underpinning favourable physiological adaptations to exercise prehabilitation for urological cancer surgery

    Blackwell, James; Williams, John; Lund, Jonathan
    BACKGROUND: Surgery for urological cancers is associated with high complication rates and survivors commonly experience fatigue, reduced physical ability and quality of life. High-intensity interval training (HIIT) as surgical prehabilitation has been proven effective for improving the cardiorespiratory fitness (CRF) of urological cancer patients, however the mechanistic basis of this favourable adaptation is undefined. Thus, we aimed to assess the mechanisms of physiological responses to HIIT as surgical prehabilitation for urological cancer. METHODS: Nineteen male patients scheduled for major urological surgery were randomised to complete 4-weeks HIIT prehabilitation (71.6 ± 0.75 years, BMI: 27.7 ± 0.9 kg·m2) or a no-intervention control (71.8 ± 1.1 years, BMI: 26.9 ± 1.3 kg·m2). Before and after the intervention period, patients underwent m. vastus lateralis biopsies to quantify the impact of HIIT on mitochondrial oxidative phosphorylation (OXPHOS) capacity, cumulative myofibrillar muscle protein synthesis (MPS) and anabolic, catabolic and insulin-related signalling. RESULTS: OXPHOS capacity increased with HIIT, with increased expression of electron transport chain protein complexes (C)-II (p = 0.010) and III (p = 0.045); and a significant correlation between changes in C-I (r = 0.80, p = 0.003), C-IV (r = 0.75, p = 0.008) and C-V (r = 0.61, p = 0.046) and changes in CRF. Neither MPS (1.81 ± 0.12 to 2.04 ± 0.14%·day-1, p = 0.39) nor anabolic or catabolic proteins were upregulated by HIIT (p > 0.05). There was, however, an increase in phosphorylation of AS160Thr642 (p = 0.046) post-HIIT. CONCLUSIONS: A HIIT surgical prehabilitation regime, which improved the CRF of urological cancer patients, enhanced capacity for skeletal muscle OXPHOS; offering potential mechanistic explanation for this favourable adaptation. HIIT did not stimulate MPS, synonymous with the observed lack of hypertrophy. Larger trials pairing patient-centred and clinical endpoints with mechanistic investigations are required to determine the broader impacts of HIIT prehabilitation in this cohort, and to inform on future optimisation (i.e., to increase muscle mass).
  • Statistical primer: using prognostic models to predict the future: what cardiothoracic surgery can learn from Strictly Come Dancing

    Mawhinney, Jamie
    OBJECTIVES: Prognostic models are widely used across medicine and within cardiothoracic surgery, where predictive tools such as EuroSCORE are commonplace. Such models are a useful component of clinical assessment but may be misapplied. In this article, we demonstrate some of the major issues with risk scores by using the popular BBC television programme Strictly Come Dancing (known as Dancing with the Stars in many other countries) as an example. METHODS: We generated a multivariable prognostic model using data from the then-completed 19 series of Strictly Come Dancing to predict prospectively the results of the 20th series. RESULTS: The initial model based solely on demographic data was limited in its predictive value (0.25, 0.22; R2 and Spearman's rank correlation, respectively) but was substantially improved following the introduction of early judges' scores deemed representative of whether contestants could actually dance (0.40, 0.30). We then utilize our model to discuss the difficulties and pitfalls in using and interpreting prognostic models in cardiothoracic surgery and beyond, particularly where these do not adequately capture potentially important prognostic information. CONCLUSION: Researchers and clinicians alike should use prognostic models cautiously and not extrapolate conclusions from demographic data alone.
  • Guideline of guidelines: Postprostatectomy incontinence

    Pavithran, A
    The diagnosis of Postprostatectomy Incontinence (PPI) relies heavily on expert opinions. Challenges in assessing and treating PPI arise due to limited robust evidence and the absence of a concise definition, resulting in diverse reported incidence rates. In addition, unclear pathophysiological mechanisms, and lack of consensus on diagnostic work-up and treatment selection contribute to knowledge gaps. We aimed to provide a comprehensive review of guidelines from various professional organisations on the work-up and management of PPI. The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018). In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters (AUS) are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well. This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.
  • Ultrasound-guided percutaneous retrieval of non-radiopaque radial line using a microsnare

    Alaeddin, Hasan
    Radial arterial lines are inserted in critically ill patients admitted to hospital intensive care units for continuous monitoring of their blood pressure. On removal the line can rarely become transected, potentially leading to thrombosis of the radial artery. Retrieval of the broken fragment can be achieved by open surgery, however other retrieval methods using ultrasound-guidance have been performed as they are considered safer and less invasive. We describe our technique of ultrasound-guided percutaneous retrieval of a broken non-radioopaque radial line in one patient, which involved the use of a microsnare. Under local anaesthesia and ultrasound guidance, a 6 Fr 5.5 cm short brite tip sheath was introduced into the radial artery, followed by a microsnare which was used to capture the arterial line, track the line back into the sheath and remove it uneventfully. The use of a microsnare under ultrasound-guidance is only one method to retrieve transected radial lines, with other interventional methods described in the literature. It enables a minimally invasive and safer approach to this potentially critical challenge and can help affected patients avoid open surgery to achieve the same management outcome
  • The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure.

    Lund, Jonathan
    AIM: The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology. METHODS: The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using 'grade'. RESULTS: This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG. CONCLUSION: This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.
  • A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease.

    Bunce, J
    AIM: The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD. METHODS: A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries. RESULTS: It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission. CONCLUSION: To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.
  • Outcomes of Concurrent Hiatus Hernia Repair with Different Bariatric Surgery Procedures: a Systematic Review and Meta-analysis.

    Idris, Iskandar
    BACKGROUND: Hiatus hernia (HH) is prevalent among patients with obesity. Concurrent repair is often performed during metabolic and bariatric surgery (MBS), but a consensus on the safety and effectiveness of concurrent HH repair (HHR) and MBS remains unclear. We performed a systematic review of the safety and effectiveness of concurrent HHR and MBS through the measurement of multiple postoperative outcomes. METHOD: Seventeen studies relating to concurrent MBS and HHR were identified. MBS procedures included laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), and adjustable gastric banding (LAGB). Studies with pre- and postoperative measurements and outcomes were extracted. RESULTS: For LSG, 9 of 11 studies concluded concurrent procedures to be safe and effective with no increase in mortality. Reoperation and readmission rates however were increased with HHR, whilst GORD rates were seen to improve, therefore providing a solution to the predominant issue with LSG. For LRYGB, in all 5 studies, concurrent procedures were concluded to be safe and effective, with no increase in mortality, length of stay, readmission and reoperation rates. Higher complication rates were observed compared to LSG with HHR. Among LAGB studies, all 4 studies were concluded to be safe and effective with no adverse outcomes on mortality and length of stay. GORD rates were seen to decrease, and reoperation rates from pouch dilatation and gastric prolapse were observed to significantly decrease. CONCLUSION: Concurrent HHR with MBS appears to be safe and effective. Assessment of MBS warrants the consideration of concurrent HHR depending on specific patient case and the surgeon's preference.
  • Malnutrition Following One-Anastomosis Gastric Bypass: a Systematic Review.

    Potluri, Sudha; Bandlamudi, Nanda; Holt, Guy; Madhok, Brijesh
    Severe malnutrition following one-anastomosis gastric bypass (OAGB) remains a concern. Fifty studies involving 49,991 patients were included in this review. In-hospital treatment for severe malnutrition was needed for 0.9% (n = 446) of patients. Biliopancreatic limb (BPL) length was 150 cm in five (1.1%) patients, > 150 cm in 151 (33.9%), and not reported in 290 (65%) patients. OAGB was revised to normal anatomy in 126 (28.2%), sleeve gastrectomy in 46 (10.3%), Roux-en-Y gastric bypass in 41 (9.2%), and shortening of BPL length in 17 (3.8%) patients. One hundred fifty-one (33.8%) patients responded to treatment; ten (2.2%) did not respond and was not reported in 285 (63.9%) patients. Eight (0.02%) deaths were reported. Standardisation of the OAGB technique along with robust prospective data collection is required to understand this serious problem.
  • A Systematic Review and Meta-Analysis: Do We Still Need Microscope Surgery in Hepatic Artery Anastomosis to Decrease the Incidence of Complications in Living Donor Liver Transplantation?

    Ebeidallah, Guirgis
    Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation (LT). Moreover, in comparison to deceased donor liver transplantation (DDLT), hepatic artery (HA) anastomosis is more challenging in living donor liver transplantation (LDLT) with a lot of controversial topics about the use of microscopic surgery. We aimed to compare the use of microscopic and loupe surgery in HA anastomosis in adult and pediatric LDLT to decrease the incidence of vascular complications. We searched PubMed, Scopes, Web of Science, and Cochrane Library for eligible studies from inception to April 2023 and a systematic review and a meta-analysis were done. According to our eligibility criteria, 10 studies with a total of 1939 patients were included. In comparison to microscopic surgery, loupe anastomosis has a similar incidence of HAT (thrombosis, risk ratio (RR) = 0.96, 95% CI = 0.26-3.48, P = 0.95). In addition to that, no significant difference was detected between the two types in terms of stenosis, decreased blood flow and hospital stay (decreased blood flow, RR = 0.68, 95% CI = 0.01-86.65, P = 0.88), (stenosis, RR = 1.81, 95% CI = 0.19-17.21, P = 0.60), (hospital stay, mean deviation (MD) = 1.16, 95% CI = -3.79-6.11, P = 0.65). However, the anastomotic time was longer in the case of microscopic surgery (anastomotic time, MD = 24.09, 95% CI = 7.79-40.39, P = 0.004). With an equal incidence of complications and longer anastomotic time, there is no added benefit of the routine use of microscopic surgery in HA anastomosis in LDLT.
  • Urology boot camp for medical students: Using virtual technology to enhance undergraduate education.

    Fonseka, Thomas; Henry, Mei-Ling; Gowda, Arjun; Ellis, Ricky
    OBJECTIVES: The study aims to describe the methodology of converting the urology boot camp for medical students into a virtual course with key take home points for a successful conversion and to present quantitative and qualitative data demonstrating the impact of the boot camp on improving delegates' knowledge and clinical acumen. MATERIALS AND METHODS: The face-to-face boot camp was converted to a virtual format employing a variety of techniques including; utilizing an online platform to deliver live screened lectures, using online polling software to foster an interactive learning environment and displaying pre-recorded videos to teach practical skills. Validated Multiple Choice Questionnaires (MCQs) were used prior to and after the course. This enabled the assessment of delegates' knowledge of urology according to the national undergraduate curriculum, and paired t tests were used to quantify the level of improvement. Thematic analysis was carried out on post-course delegate feedback to identify highlights of the course and ways of improving future iterations. RESULTS: In total, 131 delegates took part in the pilot virtual course. Of these, 105 delegates completed the pre- and post-course MCQs. There was a statistically significant improvement in the assessment following the course (p = <0.001) with mean score increasing from 47.5% pre-course to 65.8% post-course. All delegates who attended the most recent implementation of the virtual course (n = 31) felt it improved their knowledge and confidence in urology. Twenty delegates (64.5%) felt that it prepared them for both final year medical school examinations and working as a foundation year doctor. Positive themes in feedback were identified, which included the interactive nature of the course, the quality of teaching, the level and content of information provided and the high yield, concise organization of the teaching schedule. CONCLUSION: Using virtual technology and innovative educational frameworks, we have demonstrated the successful conversion of the urology boot camp for medical students to a virtual format. At a national level, with support from the British Association of Urological Surgeons, the face-to-face component of the course will continue to run in parallel with the virtual course with the aim of standardizing and improving UK undergraduate urological education. The virtual course has been implemented on an international scale, and this has already shown promising results.
  • An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study.

    Nanayakkara, K D L; Viswanath, Gokhare; Madhok, Brijesh
    INTRODUCTION: The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair. METHODS: A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC). RESULTS: A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia. CONCLUSION: This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.
  • Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models.

    Hardy, Katie
    BACKGROUND: Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk. METHODS: Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively. RESULTS: The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits. CONCLUSIONS: The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.
  • Proteomic features of skeletal muscle adaptation to resistance exercise training as a function of age.

    Williams, John P
    Resistance exercise training (RET) can counteract negative features of muscle ageing but older age associates with reduced adaptive capacity to RET. Altered muscle protein networks likely contribute to ageing RET adaptation; therefore, associated proteome-wide responses warrant exploration. We employed quantitative sarcoplasmic proteomics to compare age-related proteome and phosphoproteome responses to RET. Thigh muscle biopsies were collected from eight young (25 ± 1.1 years) and eight older (67.5 ± 2.6 years) adults before and after 20 weeks supervised RET. Muscle sarcoplasmic fractions were pooled for each condition and analysed using Isobaric Tags for Relative and Absolute Quantification (iTRAQ) labelling, tandem mass spectrometry and network-based hub protein identification. Older adults displayed impaired RET-induced adaptations in whole-body lean mass, body fat percentage and thigh lean mass (P > 0.05). iTRAQ identified 73 differentially expressed proteins with age and/or RET. Despite possible proteomic stochasticity, RET improved ageing profiles for mitochondrial function and glucose metabolism (top hub; PYK (pyruvate kinase)) but failed to correct altered ageing expression of cytoskeletal proteins (top hub; YWHAZ (14-3-3 protein zeta/delta)). These ageing RET proteomic profiles were generally unchanged or oppositely regulated post-RET in younger muscle. Similarly, RET corrected expression of 10 phosphoproteins altered in ageing, but these responses were again different vs. younger adults. Older muscle is characterised by RET-induced metabolic protein profiles that, whilst not present in younger muscle, improve untrained age-related proteomic deficits. Combined with impaired cytoskeletal adhesion responses, these results provide a proteomic framework for understanding and optimising ageing muscle RET adaptation.
  • The Impact of Surgeon Speciality Interest on Outcomes of Emergency Laparotomy in IBD.

    Bunce, J; Doleman, Brett; Lund, Jonathan; Tierney, Gillian
    INTRODUCTION: Emergency laparotomy may be required in patients with inflammatory bowel disease (IBD). NELA is the largest prospectively maintained database of adult emergency laparotomies in England and Wales and includes clinical urgency of the cases. The impact of surgeon subspeciality on outcomes after emergency laparotomy for IBD is unclear. We have investigated this association, according to the degree of urgency in IBD emergency laparotomy, including the effect of minimally invasive surgery (MIS). METHODS: Adults with IBD in the NELA database between 2013 and 2016 were included. Surgeon subspeciality was colorectal or non-colorectal. Urgencies are 'Immediate', '2-6 h', '6-18 h' and '18-24 h'. Logistic regression was used to investigate in-patient mortality and post-operative length of stay (LOS). RESULTS: There was significantly reduced mortality and LOS in IBD patients who were operated on by a colorectal surgeon in the least urgent category of emergency laparotomies; Mortality adjusted OR 2.99 (CI 1.2-7.8) P = 0.025, LOS IRR 1.18 (CI 1.02-1.4) P = 0.025. This association was not seen in more urgent categories. Colorectal surgeons were more likely to use MIS, P < 0.001, and MIS was associated with decreased LOS in the least urgent cohort, P < 0.001, but not in the other urgencies. CONCLUSIONS: We found improved outcomes in the least urgent cohort of IBD emergency laparotomies when operated on by a colorectal surgeon in comparison to a non-colorectal general surgeon. In the most urgent cases, there was no benefit in the operation being performed by a colorectal surgeon. Further work on characterising IBD emergencies by urgency would be of value.
  • A surgeon's trial success of curing pedal eumycetoma.

    Choudhry, Baseem
    Mycetoma is a chronic infection of underlying fungal (eumycetoma) or bacterial (actinomycetoma) origin. It is characterised by a clinical triad of tumour-like swelling, actively draining sinuses and macroscopic grains of characteristic colours. We the case of a 66-year-old woman on immunosuppressive therapy presenting with eumycetoma of the foot (Madura foot). The fungal organism cultured was Acrophialophora fusispora. This case was managed with a combination of extensive surgical debridement, and packing with calcium sulfate (Stimulan) beads impregnated with vancomycin and voriconazole. As far as the authors are aware, this is a novel adjunct to the surgical treatment of deep fungal infection in the foot. Eumycetoma treated with surgery and oral antifungal therapy leads to cure rates of 25%-35%. This novel treatment seems to bear further investigation for the potential to improve cure rates. At 8 months follow-up, our patient appears to be making good progress with no current signs of recurrence.
  • Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit.

    Doleman, Brett; Lund, Jonathan; Frisby, Jacky; Tierney, Gillian
    BACKGROUND: Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. METHODS: A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. RESULTS: Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85). CONCLUSIONS: Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.
  • A systematic review of the impact of postoperative aerobic exercise training in patients undergoing surgery for intra-abdominal cancers.

    Paul, M; Smart, Thomas; Doleman, Brett; Toft, Suzanne; Williams, J P; Lund, Jonathan
    INTRODUCTION: Enhanced recovery after surgery (ERAS) programmes which advocate early mobility after surgery have improved immediate clinical outcomes for patients undergoing abdominal cancer resections with curative intent. However, the impact of continued physical activity on patient-related outcomes and functional recovery is not well defined. The aim of this review was to assess the impact of postoperative aerobic exercise training, either alone or in conjunction with another exercise modality, on patients who have had surgery for intra-abdominal cancer. METHODS: A literature search was performed of electronic journal databases. Eligible papers needed to report an outcome of aerobic capacity in patients older than 18 years of age, who underwent cancer surgery with curative intent and participated in an exercise programme (not solely ERAS) that included an aerobic exercise component starting at any point in the postoperative pathway up to 12 weeks. RESULTS: Eleven studies were deemed eligible for inclusion consisting of two inpatient, one mixed inpatient/outpatient and eight outpatient studies. Meta-analysis of four outpatient studies, each reporting change in 6-min walk test (6MWT), showed a significant improvement in 6MWT with exercise (MD 74.92 m, 95% CI 48.52-101.31 m). The impact on health-related quality of life was variable across studies. CONCLUSION: Postoperative exercise confers benefits in improving aerobic function post surgery and can be safely delivered in various formats (home-based or group/supervised).

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