Clinical covariates that improve surgical risk prediction and guide targeted prehabilitation: an exploratory, retrospective cohort study of major colorectal cancer surgery patients evaluated with preoperative cardiopulmonary exercise testing

Abstract

Background Preoperative risk stratification is used to derive an optimal treatment plan for patients requiring cancer surgery. Patients with reversible risk factors are candidates for prehabilitation programmes. This pilot study explores the impact of preoperative covariates of comorbid disease (Charlson Co-morbidity Index), preoperative serum biomarkers, and traditional cardiopulmonary exercise testing (CPET)-derived parameters of functional capacity on postoperative outcomes after major colorectal cancer surgery. Methods Consecutive patients who underwent CPET prior to colorectal cancer surgery over a 2-year period were identified and a minimum of 2-year postoperative follow-up was performed. Postoperative assessment included: Clavien-Dindo complication score, Comprehensive Complication Index, Days at Home within 90 days (DAH-90) after surgery, and overall survival. Results The Charlson Co-morbidity Index did not discriminate postoperative complications, or overall survival. In contrast, low preoperative haemoglobin, low albumin, or high neutrophil count were associated with postoperative complications and reduced overall survival. CPET-derived parameters predictive of postoperative complications, DAH-90, and reduced overall survival included measures of VCO2 kinetics at anaerobic threshold (AT), peakVO2 (corrected to body surface area), and VO2 kinetics during the post-exercise recovery phase. Inflammatory parameters and CO2 kinetics added significant predictive value to peakVO2 within bi-variable models for postoperative complications and overall survival (P < 0.0001). Conclusion Consideration of modifiable ‘triple low’ preoperative risk (anaemia, malnutrition, deconditioning) factors and inflammation will improve surgical risk prediction and guide prehabilitation. Gas exchange parameters that focus on VCO2 kinetics at AT and correcting peakVO2 to body surface area (rather than absolute weight) may improve CPET-derived preoperative risk assessment.

Evaluation of postoperative results after a presurgical optimisation programme

“…It has been shown that surgical patients with anaemia carry an increased risk of postoperative complications and have a higher mortality rate than those without this condition (Bolshinsky et al 2022 ). Treating anaemia before surgery reduces the number of postoperative complications and blood transfusions (Blum et al 2022 )(Froessler et al 2016 ) and accelerates the recuperation of mobility [s39].…”

Exercise capacity prior to major cancer surgery: A cross‐sectional observational study of the validity of the 6‐minute walk and 30‐second sit‐to‐stand tests

“…The Measurement of Exercise Tolerance before Surgery (METS) trial ( n = 1400) reported no added prognostic value of VO 2peak in predicting 30‐day mortality or myocardial infarction 42 . In major colorectal cancer surgery variables derived from CPET, in addition to VO 2peak , (VCO 2 kinetics) added significantly to the prediction of poorer postoperative outcomes 48 . With the aim of reducing burden for patients, clinicians, researchers, and the health care system, the 6MWT and 30STS are both valid and feasible measures of exercise capacity in populations with cancer and could be used either in lieu of having access to CPET or as initial screening to determine if an individual is high risk and requires further assessment using CPET.…”

“…42 In major colorectal cancer surgery variables derived from CPET, in addition to VO 2peak , (VCO 2 kinetics) added significantly to the prediction of poorer postoperative outcomes. 48 With the aim of reducing burden for patients, clinicians, researchers, and the health care system, the 6MWT and 30STS are both valid and feasible measures of exercise capacity in populations with cancer and could be used either in lieu of having access to CPET or as initial screening to determine if an individual is high risk and requires further assessment using CPET. Further evidence is required to establish concurrent validity given correlations between these measures and CPET variables were only fair to moderate.…”

Post-operative Anaemia Independently Predicts Prolonged Hospital Length of Stay After Upper Gastrointestinal Cancer Surgery

“…[6][7][8][9][10][11][12][13][14] There are increasing evidence demonstrating multidisciplinary prehabilitation programs that improve functional capacity before surgery may reduce hospital LOS after cancer surgery. [15][16][17][18][19] Prolonged length of stay (LOS) occurs in approximately 10% of patients undergoing major upper GI surgery and is associated with higher risks of readmission, postoperative complications, and mortality.…”