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The pre-and postoperative course of functional status of patients with esophageal cancer undergoing esophagectomy

Developing an evidence-based and theory informed intervention to involve families in patients care after surgery

Objectives: In the post-surgical setting, active involvement of family caregivers has the potential to improve patient outcomes by prevention of surgical complications that are sensitive to fundamental care. This paper describes the development of a theoretically grounded program to enhance the active involvement of family caregivers in fundamental care for post-surgical patients. Methods: We used a quality improvement project following a multi-phase design. In Phase 1, an iterative method was used to combine evidence from a narrative review and professionals’ preferences. In Phase 2, the logic model underlying the program was developed guided by four steps: (1) confirm situation, intervention aim, and target population; (2) documented expected outcomes, and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Results: Phase 1 identified a minimum set of family involvement activities that were both supported by staff and the narrative review. In Phase 2, the logic model was developed and includes (1) the inputs (e.g. educational- and environmental support), (2) the ultimate outcomes (e.g. reduction of postoperative complications), (3) the intermediate outcomes (e.g. behavioural changes), and (4) immediate outcomes (e.g. improved knowledge, skills and attitude). Conclusions: We demonstrated how we aimed to change our practice to an environment in which family caregivers were stimulated to be actively involved in postoperative care on surgical wards, and how we took different factors into account. The description of this program may provide a solid basis for professionals to implement the family involvement program in their own setting.

Activating Relatives to Get Involved in Care After Surgery: Protocol for a Prospective Cohort Study

Background:Postoperative complications and readmissions to hospital are factors known to negatively influence the short- and long-term quality of life of patients with gastrointestinal cancer. Active family involvement in activities, such as fundamental care activities, has the potential to improve the quality of health care. However, there is a lack of evidence regarding the relationship between active family involvement and outcomes in patients with gastrointestinal cancer after surgery.Objective:This protocol aims to evaluate the effect of a family involvement program (FIP) on unplanned readmissions of adult patients undergoing surgery for malignant gastrointestinal tumors. Furthermore, the study aims to evaluate the effect of the FIP on family caregiver (FC) burden and their well-being and the fidelity of the FIP.Methods:This cohort study will be conducted in 2 academic hospitals in the Netherlands. The FIP will be offered to adult patients and their FCs. Patients are scheduled for oncological gastrointestinal surgery and have an expected hospital stay of at least 5 days after surgery. FCs must be willing to participate in fundamental care activities during hospitalization and after discharge. Consenting patients and their families will choose to either participate in the FIP or be included in the usual care group. According to the power calculation, we will recruit 150 patients and families in the FIP group and 150 in the usual care group. The intervention group will receive the FIP that consists of information, shared goal setting, task-oriented training, participation in fundamental care, presence of FCs during ward rounds, and rooming-in for at least 8 hours a day. Patients in the comparison group will receive usual postoperative care. The primary outcome measure is the number of unplanned readmissions up to 30 days after surgery. Several secondary outcomes will be collected, that is, total number of complications (sensitive to fundamental care activities) at 30 and 90 days after surgery, emergency department visits, intensive care unit admissions up to 30 and 90 days after surgery, hospital length of stay, patients’ quality of life, and the amount of home care needed after discharge. FC outcomes are caregiver burden and well-being up to 90 days after participating in the FIP. To evaluate fidelity, we will check whether the FIP is executed as intended. Univariable regression and multivariable regression analyses will be conducted.Results:The first participant was enrolled in April 2019. The follow-up period of the last participant ended in May 2022. The study was funded by an unrestricted grant of the University hospital in 2018. We aim to publish the results in 2023.Conclusions:This study will provide evidence on outcomes from a FIP and will provide health care professionals practical tools for family involvement in the oncological surgical care setting.

Preoperative functional status is not associated with postoperative surgical complications in low risk patients undergoing esophagectomy

Physiotherapy With Telerehabilitation in Patients With Complicated Postoperative Recovery After Esophageal Cancer Surgery: Feasibility Study

Background: Improvement of functional status with physiotherapy is an important goal for patients with postoperative complications and an increased length of hospital stay (LoS) after esophagectomy. Supervised physiotherapy with telerehabilitation instead of conventional face-to-face care could be an alternative to treat these patients in their home environment after hospital discharge (T0), but its feasibility has not yet been investigated in detail. Objective: The aim of this study was to investigate the feasibility of a 12-week supervised postoperative physiotherapy intervention with telerehabilitation for patients with esophageal cancer who underwent esophagectomy and had postoperative complications or who had an increased LoS. The secondary objective was to investigate the preliminary effectiveness of telerehabilitation on functional recovery compared with usual care. Methods: A prospective feasibility study with a matched historical comparison group was performed. Feasibility outcomes included willingness and adherence to participate, refusal rate, treatment duration, occurrence of adverse events, and patient satisfaction. Secondary outcome measures were measurements of musculoskeletal and cardiovascular functions and activities according to the domains of the International Classification of Functioning, Disability and Health. Results: A total of 22 patients with esophageal cancer who underwent esophagectomy and had postoperative complications or an increased LoS were included. The mean age at surgery was 64.55 (SD 6.72) years, and 77% (17/22) of patients were male. Moreover, 15 patients completed the intervention. Patient adherence was 99.8% in the first 6 weeks and dropped to 75.6% in the following 6 weeks, with a mean difference of -24.3% (95% CI 1.3 to 47.2; P=.04). At 3 months post operation, no differences in functional status were found between the intervention group and the matched historical comparison group. Conclusions: This study showed that a postoperative physiotherapeutic intervention with telerehabilitation is feasible for patients with postoperative complications or an increased LoS after esophageal cancer surgery up to 6 weeks after T0.

The Association Between Preoperative Inspiratory Muscle Training Variables and Postoperative Pulmonary Complications in Subjects With Esophageal Cancer

Background: Preoperative inspiratory muscle training (IMT) is frequently used in patients waiting for major surgery to improve respiratory muscle function and to reduce the risk of postoperative pulmonary complications (PPCs). Currently, the mechanism of action of IMT in reducing PPCs is still unclear. Therefore, we investigated the associations between preoperative IMT variables and the occurrence of PPCs in patients with esophageal cancer. Methods: A multi-center cohort study was conducted in subjects scheduled for esophagectomy, who followed IMT as part of a prehabilitation program. IMT variables included maximum inspiratory pressure (PImax) before and after IMT and IMT intensity variables including training load, frequency, and duration. Associations between PImax and IMT intensity variables and PPCs were analyzed using independent samples t tests and logistic regression analyses, corrected for age and pulmonary comorbidities and stratified for the occurrence of anastomotic leakages. Results: Eighty-seven subjects were included (69 males; mean age 66.7 ± 7.3 y). A higher PImax (odds ratio 1.016, P = .07) or increase in PImax during IMT (odds ratio 1.020, P = .066) was not associated with a reduced risk of PPCs after esophagectomy. Intensity variables of IMT were also not associated (P ranging from .16 to .95) with PPCs after esophagectomy. Analyses stratified for the occurrence of anastomotic leakages showed no associations between IMT variables and PPCs. Conclusions: This study shows that an improvement in preoperative inspiratory muscle strength during IMT and training intensity of IMT were not associated with a reduced risk on PPCs after esophagectomy. Further research is needed to investigate other possible factors explaining the mechanism of action of preoperative IMT in patients undergoing major surgery, such as the awareness of patients related to respiratory muscle function and a diaphragmatic breathing pattern.