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.
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Introduction: This study evaluates the course of physical fitness and nutritional status during curative therapy for esophageal cancer, after implementation of a prehabilitation program. Additionally, the impact of baseline physical fitness level and severe postoperative complications on the course of individual patients were explored. Materials and methods: This multicenter, observational cohort study included patients with esophageal cancer following curative treatment. Prehabilitation, consisting of supervised exercise training and nutritional counseling was offered as standard care to patients after neoadjuvant therapy, prior to surgery. Primary outcome measures included change of exercise capacity, hand grip strength, self-reported physical functioning, Body Mass Index, and malnutrition risk from diagnosis to 2–6 months postoperatively. Analyses over time were performed using linear mixed models, and linear mixed regression models to investigate the impact of baseline level and severe postoperative complications. Results: Hundred sixty-eight patients were included (mean age 65.9 ± 8.6 years; 78.0 % male). All parameters (except for malnutrition risk) showed a decline during neoadjuvant therapy (p < .05), an improvement during prehabilitation (p < .005) and a decline postoperatively (p < .001), with a high heterogeneity between patients. Change in the outcomes from baseline to postoperatively was not different for patients with or without a severe complication. Better baseline physical fitness and nutritional status were significantly associated with a greater decline postoperatively (p < .001). Conclusion: This study demonstrates a notable decline during neoadjuvant therapy, that fully recovers during prehabilitation, and a subsequent long lasting decline postoperatively. The heterogeneity in the course of physical fitness and nutritional status underlines the importance of individualized monitoring.
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Surgery aims to improve a patient’s medical condition. However, surgery is a major life event with the risk of negative consequences, like peri- and postoperative complications, prolonged hospitalization and delayed recovery of physical functioning. One of the major common side effects, functional decline, before (in the “waiting” period), during and after hospitalization is impressive, especially in frail people. Preoperative screening aims to identify frail, highrisk patients at an early stage, and advice these high-risk patients to start supervised preoperative home-based exercise training (prehabilitation) as soon as possible. Depending on the health status of the patient and his/her outcomes during the screening and the type of surgery, prehabilitation should focus on respiratory, cardiovascular and/or musculoskeletal parameters to prepare the patient for surgery. By improving preoperative physical fitness, a patient is able to better with stand the impact of major surgery and this will lead to a both reduced risk of negative side effects and better short term outcomes as a result. Besides prehabilitation hospital culture and infrastructure should be inherently activating so that patients stay as active as can be, socially, mentally and physically. In the first part of this chapter the concept of prehabilitation and different parameters that should be trained will be described. The second part focuses on the “Better in, Better out” (BiBo™) strategy, which aims to optimize patient’s pre-, peri- and postoperative physical fitness. Prehabilitation should comprise “shared decisions” between patient and physical therapist regarding experience and evidence based best options for rehabilitation goals, needs, and potential of the individual patient and his/her (in) formal support-system. Next, a case will describe the preoperative care pathway. This chapter will close with conclusions about how moving people before and after surgery will improve their outcomes.
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