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A cross-sectional survey of Australian anesthetists’ and surgeons’ perceptions of preoperative risk stratification and prehabilitation

  • Michael H.-G. LiEmail author
  • Vladimir Bolshinsky
  • Hilmy Ismail
  • Kate Burbury
  • Kwok M. Ho
  • Babak Amin
  • Alexander Heriot
  • Bernhard Riedel
Reports of Original Investigations
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Abstract

Purpose

Preoperative fitness training has been listed as a top ten research priority in anesthesia. We aimed to capture the current practice patterns and perspectives of anesthetists and colorectal surgeons in Australia and New Zealand regarding preoperative risk stratification and prehabilitation to provide a basis for implementation research.

Methods

During 2016, we separately surveyed fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) and members of the Colorectal Society of Surgeons in Australia and New Zealand (CSSANZ). Our outcome measures investigated the responders’ demographics, practice patterns, and perspectives. Practice patterns examined preoperative assessment and prehabilitation utilizing exercise, hematinic, and nutrition optimization.

Results

We received 155 responses from anesthetists and 71 responses from colorectal surgeons. We found that both specialty groups recognized that functional capacity was linked to postoperative outcome; however, fewer agreed that robust evidence exists for prehabilitation. Prehabilitation in routine practice remains low, with significant potential for expansion. The majority of anesthetists do not believe their patients are adequately risk stratified before surgery, and most of their colorectal colleagues are amenable to delaying surgery for at least an additional two weeks. Two-thirds of anesthetists did not use cardiopulmonary exercise testing as they lacked access. Hematinic and nutritional assessment and optimization is less frequently performed by anesthetists compared with their colorectal colleagues.

Conclusions

An unrecognized potential window for prehabilitation exists in the two to four weeks following cancer diagnosis. Early referral, larger multi-centre studies focusing on long-term outcomes, and further implementation research are required.

Un sondage transversal examinant les perceptions des anesthésiologistes et des chirurgiens australiens concernant la stratification préopératoire du risque et la préhabilitation

Résumé

Objectif

Le conditionnement physique préopératoire a été cité dans les dix priorités de recherche les plus importantes en anesthésie. Notre objectif était de déterminer quels étaient les habitudes actuelles de pratique ainsi que les perspectives des anesthésistes et des chirurgiens colorectaux en Australie et en Nouvelle-Zélande concernant la stratification préopératoire du risque et la préhabilitation afin de proposer un point de départ pour la recherche sur sa mise en œuvre.

Méthode

Au cours de l’année 2016, nous avons soumis un questionnaire séparé aux membres du Collège australien et néozélandais des anesthésistes (ANZCA - Australian and New Zealand College of Anaesthetists) et aux membres de la Société colorectale des chirurgiens australiens et néozélandais (CSSANZ - Colorectal Society of Surgeons in Australia and New Zealand). Nos critères d’évaluation portaient sur les données démographiques, les habitudes de pratique et les perspectives des répondants. Les questions sur les habitudes de pratique touchaient à l’évaluation préopératoire et la préhabilitation fondée sur l’exercice physique et l’optimisation antianémique et nutritionnelle.

Résultats

Nous avons reçu 155 réponses d’anesthésistes et 71 réponses de chirurgiens colorectaux. Notre questionnaire a révélé que les deux spécialités reconnaissaient que la capacité fonctionnelle est liée au pronostic postopératoire; toutefois, moins de répondants étaient d’avis qu’il existe des données probantes fiables concernant la préhabilitation. Dans la pratique de routine, la préhabilitation demeure peu courante mais a le potentiel de prendre plus d’ampleur. La plupart des anesthésistes estiment que leurs patients ne sont pas stratifiés adéquatement en fonction de leur risque avant leur chirurgie, et la plupart de leurs collègues colorectaux sont ouverts à l’idée de retarder la chirurgie d’au moins deux semaines supplémentaires. Deux tiers des anesthésiologistes n’ont pas eu recours à un test d’effort cardiopulmonaire par manque d’accès à ce type d’examen. L’évaluation et l’optimisation antianémique et nutritionnelle sont moins fréquemment réalisées par les anesthésistes comparativement à leurs collègues colorectaux.

Conclusion

Il existe une fenêtre potentielle mais non reconnue pour la mise en œuvre d’une préhabilitation au cours des deux à quatre semaines suivant l’annonce d’un diagnostic de cancer. Une prise en charge précoce par des spécialistes, des études multicentriques plus importantes s’intéressant aux pronostics à long terme et des travaux de recherche supplémentaires sur la mise en œuvre sont nécessaires.

Notes

Acknowledgements

We would like to thank the ANZCA CTN and the CSSANZ secretariat for vetting and facilitating the survey’s distribution. We also acknowledge Prof Linda Denehy, A/Prof Prue Cormie, Mr Satish Warrier, Ms Belinda Steer, and Ms Fiona Wiseman for feedback regarding the surveys. Dr Ho would like to thank WA Health and Raine Medical Research Foundation for their support through the Raine Clinical Research Fellowship.

Conflict of interest

Dr. Ho is funded by WA Health and Raine Medical Research Foundation through the Raine Clinical Research Fellowship. The funding agencies have no influence on the choice of the subject matter, design of the study, data analyses, the decision to publish the results, and the final content of the manuscript. The other authors have not received any funding.

Author contributions

Michael H.-G. Li and Vladimir Bolshinsky contributed substantially to all aspects of this manuscript, including conception and design; acquisition, analysis, and interpretation of data, and drafting the article. Kate Burbury, Hilmy Ismail, Alexander Heriot, and Bernhard Riedel contributed substantially to the conception and design of the manuscript, and drafting the article. Babak Amin contributed substantially to the analysis of data and drafting of the article. Kwok M. Ho contributed substantially to the analysis of data, interpretation of data, and drafting the article.

Editorial responsibility

This submission was handled by Dr. Gregory L. Bryson, Deputy Editor-in-Chief, Canadian Journal of Anesthesia.

References

  1. 1.
    Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16: 1193-224.CrossRefGoogle Scholar
  2. 2.
    Bainbridge D, Martin J, Arango M, Cheng D; Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012; 380: 1075-81.Google Scholar
  3. 3.
    Nathan H, Atoria CL, Bach PB, Elkin EB. Hospital volume, complications, and cost of cancer surgery in the elderly. J Clin Oncol 2015; 33: 107-14.CrossRefGoogle Scholar
  4. 4.
    Findlay GP, Goodwin AP, Protopapa K, Smith NC, Mason M. Knowing the risk: a review of the peri-operative care of surgical patients. London: National Confidential Enquiry into Patient Outcome and Death; 2011.Google Scholar
  5. 5.
    Independent Hospital Pricing Authority. National Hospital Cost Data Collection - Australian Public Hospitals Cost Report 2013-2014, Round 18. Canberra: Department of Health; 2016.Google Scholar
  6. 6.
    Bailey JG, Davis PJ, Levy AR, Molinari M, Johnson PM. The impact of adverse events on health care costs for older adults undergoing nonelective abdominal surgery. Can J Surg 2016; 59: 172-9.CrossRefGoogle Scholar
  7. 7.
    Grocott MP, Pearse RM. Perioperative medicine: the future of anaesthesia? Br J Anaesth 2012; 108: 723-6.CrossRefGoogle Scholar
  8. 8.
    Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 2013; 92: 715-27.CrossRefGoogle Scholar
  9. 9.
    West MA, Loughney L, Barben CP, et al. The effects of neoadjuvant chemoradiotherapy on physical fitness and morbidity in rectal cancer surgery patients. Eur J Surg Oncol 2014; 40: 1421-8.CrossRefGoogle Scholar
  10. 10.
    Barberan-Garcia A, Ubre M, Roca J, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg 2018; 267: 50-6.CrossRefGoogle Scholar
  11. 11.
    Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018; 360: j5916.CrossRefGoogle Scholar
  12. 12.
    Barakat HM, Shahin Y, Khan JA, McCollum PT, Chetter IC. Preoperative supervised exercise improves outcomes after elective abdominal aortic aneurysm repair: a randomized controlled trial. Ann Surg 2016; 264: 47-53.CrossRefGoogle Scholar
  13. 13.
    Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncologica 2017; 56: 128-33.CrossRefGoogle Scholar
  14. 14.
    Bolshinsky V, Li MH, Ismail H, Burbury K, Riedel B, Heriot A. Multimodal prehabilitation programs as a bundle of care in gastrointestinal cancer surgery: a systematic review. Dis Colon Rectum 2018; 61: 124-38.CrossRefGoogle Scholar
  15. 15.
    Lane-Fall MB, Cobb BT, Cene CW, Beidas RS. Implementation science in perioperative care. Anesthesiol Clin 2018; 36: 1-15.CrossRefGoogle Scholar
  16. 16.
    Boereboom CL, Williams JP, Leighton P, Lund JN; Exercise Prehabilitation in Colorectal Cancer Delphi Study Group. Forming a consensus opinion on exercise prehabilitation in elderly colorectal cancer patients: a Delphi study. Tech Coloproctol 2015; 19: 347-54.Google Scholar
  17. 17.
    Nagamatsu Y, Shima I, Yamana H, Fujita H, Shirouzu K, Ishitake T. Preoperative evaluation of cardiopulmonary reserve with the use of expired gas analysis during exercise testing in patients with squamous cell carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg 2001; 121: 1064-8.CrossRefGoogle Scholar
  18. 18.
    West MA, Parry MG, Lythgoe D, et al. Cardiopulmonary exercise testing for the prediction of morbidity risk after rectal cancer surgery. Br J Surg 2014; 101: 1166-72.CrossRefGoogle Scholar
  19. 19.
    Moran J, Wilson F, Guinan E, McCormick P, Hussey J, Moriarty J. Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review. Br J Anaesth 2016; 116: 177-91.CrossRefGoogle Scholar
  20. 20.
    Singh F, Newton RU, Galvao DA, Spry N, Baker MK. A systematic review of pre-surgical exercise intervention studies with cancer patients. Surg Oncol 2013; 22: 92-104.CrossRefGoogle Scholar
  21. 21.
    Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest 1999; 116: 355-62.CrossRefGoogle Scholar
  22. 22.
    Levett DZ, Grocott MP. Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS). Can J Anesth 2015; 62: 131-42.CrossRefGoogle Scholar
  23. 23.
    Guazzi M, Adams V, Conraads V, et al. EACPR/AHA Joint Scientific Statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 2012; 33: 2917–27.Google Scholar
  24. 24.
    Smith TP, Kinasewitz GT, Tucker WY, Spillers WP, George RB. Exercise capacity as a predictor of post-thoracotomy morbidity. Am Rev Respir Dis 1984; 129: 730-4.CrossRefGoogle Scholar
  25. 25.
    Bechard D, Wetstein L. Assessment of exercise oxygen consumption as preoperative criterion for lung resection. Ann Thorac Surg 1987; 44: 344-9.CrossRefGoogle Scholar
  26. 26.
    Win T, Jackson A, Sharples L, et al. Cardiopulmonary exercise tests and lung cancer surgical outcome. Chest 2005; 127: 1159-65.Google Scholar
  27. 27.
    Bolliger CT, Wyser C, Roser H, Soler M, Perruchoud AP. Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications. Chest 1995; 108: 341-8.CrossRefGoogle Scholar
  28. 28.
    Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143(5 Suppl): e166S-90S.CrossRefGoogle Scholar
  29. 29.
    Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391: 2631-40.CrossRefGoogle Scholar
  30. 30.
    Hightower CE, Riedel BJ, Feig BW, et al. A pilot study evaluating predictors of postoperative outcomes after major abdominal surgery: physiological capacity compared with the ASA physical status classification system. Br J Anaesth 2010; 104: 465-71.CrossRefGoogle Scholar
  31. 31.
    Ha D, Choi H, Zell K, et al. Association of impaired heart rate recovery with cardiopulmonary complications after lung cancer resection surgery. J Thorac Cardiovasc Surg 2015; 149(1168–73): e3.Google Scholar
  32. 32.
    Chandrabalan VV, McMillan DC, Carter R, et al. Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery. HPB (Oxford) 2013; 15: 899-907.CrossRefGoogle Scholar
  33. 33.
    Aloia TA, Zimmitti G, Conrad C, Gottumukalla V, Kopetz S, Vauthey JN. Return to intended oncologic treatment (RIOT): a novel metric for evaluating the quality of oncosurgical therapy for malignancy. J Surg Oncol 2014; 110: 107-14.CrossRefGoogle Scholar
  34. 34.
    Struthers R, Erasmus P, Holmes K, Warman P, Collingwood A, Sneyd JR. Assessing fitness for surgery: a comparison of questionnaire, incremental shuttle walk, and cardiopulmonary exercise testing in general surgical patients. Br J Anaesth 2008; 101: 774-80.CrossRefGoogle Scholar
  35. 35.
    Li MH, Bolshinsky V, Ismail H, Ho KM, Heriot A, Riedel B. Comparison of Duke Activity Status Index with cardiopulmonary exercise testing in cancer patients. J Anesth 2018; 32: 576-84.CrossRefGoogle Scholar
  36. 36.
    Santos BF, Souza HC, Miranda AP, Cipriano FG, Gastaldi AC. Performance in the 6-minute walk test and postoperative pulmonary complications in pulmonary surgery: an observational study. Braz J Phys Ther 2016; 20: 66-72.CrossRefGoogle Scholar
  37. 37.
    West MA, Loughney L, Lythgoe D, et al. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 2015; 114: 244-51.CrossRefGoogle Scholar
  38. 38.
    Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interactive Cardiovasc Thorac Surg 2016; 23: 486-97.CrossRefGoogle Scholar
  39. 39.
    Boereboom C, Doleman B, Lund JN, Williams JP. Systematic review of pre-operative exercise in colorectal cancer patients. Tech Coloproctol 2016; 20: 81-9.CrossRefGoogle Scholar
  40. 40.
    Gupta D, Vashi PG, Lammersfeld CA, Braun DP. Role of nutritional status in predicting the length of stay in cancer: a systematic review of the epidemiological literature. Ann Nutr Metab 2011; 59: 96-106.CrossRefGoogle Scholar
  41. 41.
    McClave SA, Kozar R, Martindale RG, et al. Summary points and consensus recommendations from the North American Surgical Nutrition Summit. JPEN J Parenter Enteral Nutr 2013; 37(5 Suppl): 99S-105S.CrossRefGoogle Scholar
  42. 42.
    Li C, Carli F, Lee L, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 2013; 27: 1072-82.CrossRefGoogle Scholar
  43. 43.
    Marik PE, Zaloga GP. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature. JPEN J Parenter Enteral Nutr 2010; 34: 378-86.CrossRefGoogle Scholar
  44. 44.
    Gillis C, Loiselle SE, Fiore JF Jr, et al. Prehabilitation with whey protein supplementation on perioperative functional exercise capacity in patients undergoing colorectal resection for cancer: a pilot double-blinded randomized placebo-controlled trial. J Acad Nutr Diet 2016; 116: 802-12.CrossRefGoogle Scholar
  45. 45.
    Ng O, Keeler B, Mishra A, et al. Iron therapy for pre-operative anaemia (protocol). The Cochrane Collaboration - 2015. Available from URL: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011588/epdf/full (accessed December 2018).
  46. 46.
    Koduru P, Abraham BP. The role of ferric carboxymaltose in the treatment of iron deficiency anemia in patients with gastrointestinal disease. Therap Adv Gastroenterol 2016; 9: 76-85.CrossRefGoogle Scholar
  47. 47.
    Okonko DO, Grzeslo A, Witkowski T, et al. Effect of intravenous iron sucrose on exercise tolerance in anemic and nonanemic patients with symptomatic chronic heart failure and iron deficiency FERRIC-HF: a randomized, controlled, observer-blinded trial. J Am Coll Cardiol 2008; 51: 103-12.CrossRefGoogle Scholar
  48. 48.
    Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth 2011; 55: 111-5.CrossRefGoogle Scholar
  49. 49.
    Wolters U, Wolf T, Stutzer H, Schroder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996; 77: 217-22.CrossRefGoogle Scholar
  50. 50.
    Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br 2005; 87: 844-50.CrossRefGoogle Scholar
  51. 51.
    Tang R, Chen HH, Wang YL, et al. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients. Ann Surg 2001; 234: 181-9.CrossRefGoogle Scholar
  52. 52.
    Rauh MA, Krackow KA. In-hospital deaths following elective total joint arthroplasty. Orthopedics 2004; 27: 407-11.Google Scholar
  53. 53.
    Sauvanet A, Mariette C, Thomas P, et al. Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors. J Am Coll Surg 2005; 201: 253-62.CrossRefGoogle Scholar
  54. 54.
    Prause G, Offner A, Ratzenhofer-Komenda B, Vicenzi M, Smolle J, Smolle-Juttner F. Comparison of two preoperative indices to predict perioperative mortality in non-cardiac thoracic surgery. Eur J Cardiothorac Surg 1997; 11: 670-5.CrossRefGoogle Scholar
  55. 55.
    Carey MS, Victory R, Stitt L, Tsang N. Factors that influence length of stay for in-patient gynaecology surgery: is the Case Mix Group (CMG) or type of procedure more important? J Obstet Gynaecol Can 2006; 28: 149-55.CrossRefGoogle Scholar
  56. 56.
    Aronson WL, McAuliffe MS, Miller K. Variability in the American Society of Anesthesiologists Physical Status Classification Scale. AANA J 2003; 71: 265-74.Google Scholar
  57. 57.
    Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aide and informed consent tool for patients and surgeons. J Am Coll Surg 2013; 217: 833-42.e1-3.Google Scholar
  58. 58.
    Cata JP, Wang H, Gottumukkala V, Reuben J, Sessler DI. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth 2013; 110: 690-701.CrossRefGoogle Scholar
  59. 59.
    Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 2009; 208: 931-7, 7.e1-2; discussion 938-9.Google Scholar
  60. 60.
    Kwag SJ, Kim JG, Kang WK, Lee JK, Oh ST. The nutritional risk is a independent factor for postoperative morbidity in surgery for colorectal cancer. Ann Surg Treat Res 2014; 86: 206-11.CrossRefGoogle Scholar
  61. 61.
    Boney O, Bell M, Bell N, et al. Identifying research priorities in anaesthesia and perioperative care: final report of the joint National Institute of Academic Anaesthesia/James Lind Alliance Research Priority Setting Partnership. BMJ Open 2015; 5: e010006.CrossRefGoogle Scholar
  62. 62.
    Canadian Medical Association. Anesthesiology Profile: Canadian Medical Association; 2014. Available from URL: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Anesthesiology-e.pdf (accessed December 2018).

Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  1. 1.Department of Cancer Anaesthesia, Perioperative and Pain MedicinePeter MacCallum Cancer CentreMelbourneAustralia
  2. 2.Department of Cancer SurgeryPeter MacCallum Cancer CentreMelbourneAustralia
  3. 3.Department of HaematologyPeter MacCallum Cancer CentreMelbourneAustralia
  4. 4.Department of SurgeryUniversity of MelbourneMelbourneAustralia
  5. 5.School of Population HealthUniversity of Western AustraliaPerthAustralia
  6. 6.School of Veterinary and Life SciencesMurdoch UniversityPerthAustralia
  7. 7.Department of Intensive Care MedicineRoyal Perth HospitalPerthAustralia

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