ASO Visual Abstract: Predictive Value of Preoperative Cardiopulmonary Exercise Testing for Complications and Mortality After Esophagectomy: A Meta-analysis.

The association between preoperative cardiopulmonary exercise–test variables and short-term morbidity after esophagectomy: A hospital-based cohort study

Cause for scepticism regarding preoperative cardiopulmonary exercise testing

Indications for surgical pulmonary valve replacement (PVR) after repair of tetralogy of Fallot have recently been broadened to include asymptomatic patients. The outcomes of PVR in adults after repair of tetralogy of Fallot at a single tertiary center were retrospectively studied. Preoperative cardiopulmonary exercise testing was included. Mortality was the primary outcome measure. In total, 221 PVRs were performed in 220 patients (130 male patients; median age, 32 years; range, 16-64 years). Homografts were used in 117 patients, xenografts in 103 patients, and a mechanical valve in 1 patient. Early (30-day) mortality was 2%. Overall survival was 97% at 1 year, 96% at 3 years, and 92% at 10 years. Survival after PVR in the later era (2005-2010; n=156) was significantly better compared with survival in the earlier era (1993-2004; n=65; 99% versus 94% at 1 year and 98% versus 92% at 3 years, respectively; P=0.019). Earlier era patients were more symptomatic preoperatively (P=0.036) with a lower preoperative peak oxygen consumption (peak Vo₂; P<0.001). Freedom from redo surgical or transcatheter PVR was 98% at 5 years and 96% at 10 years for the whole cohort. Peak Vo₂, E/CO2 slope (ratio of minute ventilation to carbon dioxide production), and heart rate reserve during cardiopulmonary exercise testing predicted risk of early mortality when analyzed with logistic regression analysis; peak Vo₂ emerged as the strongest predictor on multivariable analysis (odds ratio, 0.65 per 1 mL·kg⁻¹·min⁻¹; P=0.041). PVR after repair of tetralogy of Fallot has a low and improving mortality, with a low need for reintervention. Preoperative cardiopulmonary exercise testing predicts surgical outcome and should therefore be included in the routine assessment of these patients.

Fit for surgery? Perspectives on preoperative exercise testing and training

Bowel cancer is the third most common cancer in the UK 1. Many of these patients will present for surgical treatment. The 2017 Annual Report of the National Bowel Cancer Audit describes data collected from over 30,000 patients diagnosed with bowel cancer between April 2015 and March 2016 in England and Wales 2. This national audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England and Wales. The audit is carried out by the Clinical Effectiveness Unit of the Royal College of Surgeons of England in partnership with the Association of Coloproctology of Great Britain and Ireland and NHS Digital. Sixty-three percent of these patients had undergone a major surgical resection 2. Centres in the UK are increasingly using pre-operative cardiopulmonary exercise testing (CPET) to risk stratify patients before major surgery. Within the same period, the National Bowel Cancer Audit conducted an organisational survey to determine the availability of on-site services including CPET for the objective evaluation of cardiopulmonary fitness and peri-operative risk at each NHS site 3. Cardiopulmonary exercise testing-derived metrics have the potential to predict morbidity and mortality after major abdominal surgery 4. It may also allow individualised risk assessment; inform shared decision making; identify requirement for postoperative critical care; and assesses and identifiy scope for optimisation of comorbidities and prehabilitation 5. The latest survey of CPET in the UK identified increasing utilisation with over 30,000 tests performed annually 6. National Bowel Cancer Audit data are publicly available online under the Open Government Licence via NHS Digital. We analysed the two latest datasets 2, 3 to determine if there were any differences between the clinical outcomes of patients who underwent surgery in centres with and without CPET. We compared 90-day mortality between hospitals that provided CPET and those that did not. Statistical analysis was conducted using MedCalc Statistical Software version 16.4.3 (MedCalc Software bvba, Ostend, Belgium; 2016). Patients were pooled for sites with and without CPET facilities. Relative risk (RR) was calculated for patients treated at sites with and without CPET. In centres that had onsite CPET facilities, 10,694/17,986 (59%) patients had major surgery. This was associated with an 18% reduction (RR 0.82, 95%CI 0.70–0.96, p = 0.0157) in 90-day mortality in centres that had CPET. There was no significant difference in disease severity (patients with distant metastases at the time of surgery) between centres with and without CPET (RR 0.99, 95%CI 0.90–1.09, p = 0.7947) or in the volume of patients in each centre on a curative major resection treatment pathway (RR 1.01, 95%CI 0.98–1.05, p = 0.53). Although there were more patients recorded as ASA status 1 in centres with CPET (RR 1.1, 95%CI 1.02–1.20, P = 0.0159), there was no difference in patients recorded as ASA physical status 2, 3 or 4/5 between centres with and without CPET (ASA 2 RR 0.97, 95%CI 0.95–1.0, p = 0.067; ASA 3 RR 0.96, 95%CI 0.91–1.01, p = 0.090; ASA 4/5 RR 0.87, 95%CI 0.73–1.04, p = 0.126). National Bowel Cancer Audit data are real-world data that are freely available for analysis and characterises routine clinical practice. Our analysis of this dataset suggests an association between better outcomes and centres that have CPET, which warrants further scrutiny. Exercise-oncology research is expanding and CPET-based prehabilitation has potential to improve outcomes after cancer surgery. Current data submission to the National Bowel cancer Audit includes patient-level CPET data and we would encourage the auditors to describe and refine further any correlation between CPET and outcomes after major colorectal cancer surgery in future reports.

Correlation between preoperative cardiopulmonary exercise testing and six-minute walk test, five-times sit to stand test and Short Form-36 physical component score in patients undergoing cytoreductive surgery

Ventilation as a function of elimination of CO2 during incremental exercise (VE/VCO2 slope) has been shown to be a valuable predictor of complications and death after major non-cardiac surgery. VE/VCO2 slope and partial pressure of end-tidal carbon dioxide (PetCO2) are both affected by ventilation/perfusion mismatch, but research on the utility of PetCO2 for risk stratification in major abdominal surgery is limited. We aimed to determine the correlation between VE/VCO2 slope and PetCO2 measured during preoperative cardiopulmonary exercise testing (CPET) and its association with major cardiopulmonary complications (MCPCs) or death following oesophageal and other major abdominal cancer surgeries. In a retrospective cohort of 116 patients undergoing preoperative CPET 2008-2023, VE/VCO2 slope and PetCO2 (kPa) were recorded. The main outcome was MCPC during hospitalisation or death ≤90 days of surgery. We determined threshold values for each measure, corresponding to 90% specificity, using receiver operating characteristics analysis. A strong negative correlation was found between PetCO2 after a 5-minute warm-up and VE/VCO2 slope (Pearson r = -.88). In oesophagus cancer, VE/VCO2 slope >38 and PetCO2 < 4.1 kPa (30.8 mmHg) were both significant thresholds for the main outcome. For other major abdominal surgery patients, threshold analyses were non-significant. The area under the curve to predict outcome was similar using VE/VCO2 slope (0.70, 95% confidence interval 0.51-0.89) as compared to PetCO2 (0.71, 0.53-0-90). Both preoperative VE/VCO2 slope and PetCO2 could identify subjects with a very high risk of complications following oesophageal resection, with similar prognostic utility. PetCO2 can be measured with simpler equipment and could therefore be useful when CPET is not available.

e15072 Background: Pancreaticoduodenectomy is the standard of care for tumours confined to the head of pancreas and can be undertaken with low operative mortality. However, the procedure has a high morbidity, particularly in older patient populations with pre-existing co-morbidities. Many of the currently available methods for assessment of pre-operative risk rely on either scoring systems or indirect measures of cardiopulmonary function. In contrast, pre-operative cardiopulmonary exercise testing (CPET) provides a direct functional assessment of integrated cardiac and respiratory performance. This study evaluates the role of pre-operative cardiopulmonary exercise testing (CPET) for prediction of post-operative morbidity and outcome after pancreaticoduodenectomy. Methods: In a prospective cohort undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with co-morbidity) were categorized as high-risk and underwent preoperative assessment by CPET according to pre-defined protocol. Data were collected on functional status, postoperative complications and survival. The predictive potential of CPET-derived markers was assessed. Results: 143 patients underwent preoperative assessment of whom 50 were deemed low-risk for surgery per protocol. Of 93 high-risk patients 64 proceeded to surgery after preoperative CPET. CPET-derived ventilatory equivalent of carbon dioxide (VE/VCO2) at anaerobic threshold (AT) was a predictive marker of postoperative mortality with an AUC of 0.85 (95% CI 0.63 to 1.07, p = 0.020); a threshold of 41 was 75% sensitive and 94.6% specific (PPV 50%, NPV 98.1%). Above this threshold, raised VE/VCO2 was a predictor of poor long-term survival (HR 1.90, 95%CI: 1.02 to 3.57, p = 0.045). Conclusions: CPET is a useful adjunctive test for predicting post-operative outcome in patients being assessed for pancreaticoduodenectomy. CPET-derived VE/VCO2 above a threshold of 41 predicts early post-operative death and poor long-term survival. CPET should be considered in the pre-operative work-up prior to pancreaticoduodenectomy.

ObjectiveWe aimed to evaluate whether or not using the slope of the increase in minute ventilation in relation to carbon dioxide (VE/VCo2-slope), with a cutoff value of 35, could improve risk stratification for major pulmonary complications or death following lobectomy in lung cancer patients at moderate risk (Vo2peak = 10-20 mL/kg/min). MethodsSingle center, retrospective analysis of 146 patients with lung cancer who underwent lobectomy and preoperative cardiopulmonary exercise testing in 2008-2020. The main outcome was any major pulmonary complication or death within 30 days of surgery. Patients were categorized based on their preoperative cardiopulmonary exercise testing as: low-risk group, peak oxygen uptake >20 mL/kg/min; low-moderate risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope <35; and moderate-high risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope ≥35. The frequency of complications between groups was compared using χ2 test. Logistic regression was used to calculate the odds ratio with 95% CI for the main outcome based on the cardiopulmonary exercise testing group. ResultsOverall, 25 patients (17%) experienced a major pulmonary complication or died (2 deaths). The frequency of complications differed between the cardiopulmonary exercise testing groups: 29%, 13%, and 8% in the moderate-high, low-moderate, and low-risk group, respectively (P = .023). Using the low-risk group as reference, the adjusted odds ratio for the low-moderate risk group was 3.44 (95% CI, 0.66-17.90), whereas the odds ratio for the moderate-high risk group was 8.87 (95% CI, 1.86-42.39). ConclusionsUsing the VE/VCo2-slope with a cutoff value of 35 improved risk stratification for major pulmonary complications following lobectomy in lung cancer patients with moderate risk based on a peak oxygen uptake of 10 to 20 mL/kg/min. This suggests that the VE/VCo2-slope can be used for preoperative risk evaluation in lung cancer lobectomy.

Fit for surgery? Evidence supporting prehabilitation programs

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are the standard treatment for selected patients with peritoneal malignancy. The optimal means of assessing risk prior to these complex operations is not known. This study explored the associations between preoperative cardiopulmonary exercise testing (CPET) variables and postoperative outcomes following elective CRS and HIPEC. This study included patients who underwent routine preoperative CPET prior to elective CRS and HIPEC at Royal Prince Alfred Hospital in Sydney between July 2017 and July 2020. CPET was performed using a cycle ergometer and measured peak oxygen uptake (VO2 peak) and anaerobic threshold (AT). Outcomes included in-hospital morbidity, length of intensive care unit (ICU) stay and hospital stay. The associations between preoperative CPET variables and postoperative morbidity were assessed using univariate and multivariate analyses. A total of 129 patients were included. Mean age was 56 years (standard deviation (SD) 12.5 years), and colorectal cancer was the most common indication for CRS and HIPEC. The overall complication rate was 69%, and two (1.6%) patients died in hospital. Patients who did not develop any postoperative complication had slightly higher preoperative AT and VO2 peak and shorter length of hospital stay. Data in this study support the role of CPET prior to CRS and HIPEC as an adjunct to improve risk assessment.

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery: An Abridged Version of the Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Outcome after coronary artery bypass grafting is usually evaluated by exercise stress testing. Increased exercise capacity and reduced angina pectoris have been equated with improved quality of life, but this represents a limited view. To prospectively evaluate the effects of coronary artery bypass grafting on quality of life and exercise capacity and their interrelationship. In a consecutive series of patients (N = 2365) who underwent coronary artery bypass grafting, we administered a questionnaire to assess quality of life before and 2 years after surgery. A standardized exercise test was performed during the year before surgery and 2 years after. A preoperative exercise test was performed by 726 patients. Among these patients, 462 completed a quality-of-life questionnaire preoperatively and 578 did so postoperatively. Preoperative and postoperative exercise tests were obtained from 362 patients. The improvement in quality of life was related to the severity of preoperative angina (P < .001) and female sex (P = .004) and was inversely related to preoperative exercise performance (P = .04). The improvement in exercise capacity was greater among men (P < .001) and was inversely related to preoperative exercise capacity (P < .001). The greatest improvement in quality of life after coronary artery bypass grafting appeared in those patients with the most impaired exercise capacity, those with the most severe angina pectoris, and women. Improvement in exercise capacity was greatest in patients with the poorest preoperative exercise capacity and in men. These findings indicate that exercise testing is of limited value as a measure of quality of life and that assessment by a questionnaire has a complementary place.

The field of urological oncology is rapidly changing. For example, robotic surgery, targeted therapy, and ablation techniques are oncological options that were in their infancy 10 years ago and are now mainstream in many areas of the world. Additionally, immunotherapy has recently become a promising avenue in multiple urological cancers. As we move forward, expect to see a larger presence of urological oncology literature obtained via social media, which BJUI has initiated and subsequently set the standard for the field. Related to this, this month's edition of BJUI includes four online ‘Articles of the Week’, with each focusing on urological oncology. Using data from the pro-PSA Multicentric European Study (PROMEtheuS) project, Abrate et al. 1 evaluated the utility of the Prostate Health Index (PHI) in 142 obese (body mass index BMI >30 kg/m2) men who underwent a prostate biopsy for an abnormal DRE or elevated PSA level. Among the 142 patients, 65 (45.8%) were found to harbour prostate cancer. Using the PHI threshold of 35.7, the authors determined that 46 (32.4%) negative biopsies could have been avoided while six (9.2%) cancers would have been missed. Related to this, Salami et al. 2 compared the cancer detection rates of MRI fusion biopsy vs standard 12-core TRUS-guided biopsy in 140 men with a previous negative prostate biopsy and a lesion appreciated on a multiparametric MRI. While the cancer detection rates were similar overall, the MRI fusion biopsy was more likely to detect clinically significant prostate cancer (48% vs 31%), defined as Gleason ≥7 or Gleason 6 with a lesion volume of >0.2 mL on MRI. In an era where over-diagnosis of prostate cancer is commonplace, data to better stratify patients who need (or do not need) a prostate biopsy and enhanced ways to identify clinically significant prostate cancers are of paramount importance. Soares et al. 3 report their results among 1 138 contemporary laparoscopic radical prostatectomy patients who had at least 5 years of follow-up. Only one case required an open conversion and the transfusion rate was merely 0.5%. At last follow-up, 85% of patients had an undetectable PSA level, 94% of patients were continent, and 77% of non-diabetic men aged <70 years retained potency. These impressive single-surgeon results further suggest that the morbidity of prostate cancer surgery has diminished with increasing time and experience. Additionally, Tolchard et al. 4 prospectively evaluated 105 patients with bladder cancer with preoperative cardiopulmonary exercise testing prior to radical cystectomy. Patients who received neoadjuvant chemotherapy were excluded and there was a 6% perioperative death rate with 90 days of follow-up. The results suggest that patients with poor cardiopulmonary reserve along with hypertension are at higher risk of perioperative complications and prolonged hospital stay; median length of stay was 22 and 9 days for patients with and without a complication. Furthermore, while only 2% of patients had a preoperative diagnosis of heart failure, there were a significant proportion of patients (50% in this study) found to have moderate-to-severe heart failure based on preoperative cardiopulmonary exercise testing. These provocative results suggest that the urological community should further investigate the utility of routine cardiopulmonary exercise testing in patients undergoing radical cystectomy along with the optimal incorporation of such testing in patients receiving neoadjuvant chemotherapy. None declared.

BackgroundsThere is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.MethodsA search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.ResultsFifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26–3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49–2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend.ConclusionsThis systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-10251-3.