Effect of a Preoperative Intervention on Preoperative and Postoperative Outcomes in Low-Risk Patients Awaiting Elective Coronary Artery Bypass Graft Surgery Does preoperative hip rehabilitation advice improve recovery and patient satisfaction? A preoperative education intervention to reduce anxiety and improve recovery among Chinese cardiac patients: a randomized controlled trial. Does Minimally Invasive Total Knee Arthroplasty Improve Isokinetic Torque? Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies Shrinking preoperative fast time with maltodextrin and protein hydrolysate in gastrointestinal resections due to cancer. Short‐Term Preoperative High‐Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS) Depression predicts perioperative outcomes following coronary artery bypass graft surgery Preoperative albumin and surgical site identify surgical risk for major postoperative complications. Pre- and Postoperative Cardiopulmonary Rehabilitation in Hospitalized Patients Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial Non-invasive hemodynamic optimization in major abdominal surgery: a feasibility study. Unilateral versus bilateral pedicle screw instrumentation for single-level minimally invasive transforaminal lumbar interbody fusion Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? The future of fast‐track surgery Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Preoperative supraphysiological testosterone in older men undergoing knee replacement surgery. Enhanced recovery after liver surgery. The effect of tobacco consumption and body mass index on complications and hospital stay after inguinal hernia surgery Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE study): study protocol for a randomized controlled trial
In Ontario , Canada , the discrepancy between the high dem and for  coronary artery bypass graft surgery ( CABG )  and the low immediate supply results in waiting lists . In 1990 , a consensus panel of cardiologists and surgeons developed criteria to ensure that high-risk patients were given priority for this procedure ( 1 ) . Each patient receives an acuity score that corresponds to a recommended maximum delay . Aggregated acuity scores of 4 , 5 , 6 , and 7 indicate elective status and represent a waiting time ranging from greater than 14 days to a maximum of 6 months . The mortality rate for patients awaiting CABG  has been shown to be remarkably stableapproximately 0.5 % to 0.6 % per year over the past 10 years ( 2 ) . Despite this , however , evidence shows that patients ' functional and psychological status can deteriorate during the wait for surgery ( 3 - 5 ) . Through its effects on the autonomic nervous system , emotional stress also influences catecholamines , myocardial oxygen dem and , and platelet aggregation ; this may affect morbidity during the waiting period ( 6 - 8 ) . Such factors as preoperative anxiety and little social support have adverse psychological effects during extended preoperative waiting periods and , in addition , have been found to predict poor physical recovery from heart surgery ( 9 ) . Therefore , psychological factors and physical deconditioning , both of which occur during the waiting period ( 10 - 12 ) , may negatively affect patients ' in-hospital course , including length of stay . Because waiting for health services will probably continue to be a reality in publicly funded health care systems that value universal access , careful study of simple , affordable methods to improve patient outcomes during the waiting period is warranted . We examined the effect of a minimum 8-week , multidimensional , preoperative intervention on the presurgery and postsurgery outcomes of patients awaiting elective CABG . We hypothesized that a combination of exercise training , education , and social support would affect patients ' physical and psychological readiness for surgery and thereby reduce postoperative length of hospital stay . We further hypothesized that the effectiveness of the preoperative intervention would be sustained into the first 6 months of the postoperative period . Methods Patients Patients were recruited from the waiting lists of all seven cardiovascular surgeons operating in the Hamilton Health Sciences Corporation surgical center , Hamilton , Ontario , Canada . Each year , approximately 1300 open-heart surgeries are performed in this center . Roughly 60 % of patients awaiting CABG have elective status and are placed on the waiting list . During the time of our study , elective waiting times ranged from 3 weeks to greater than 20 weeks . Approximately 40 % of elective patients are usually awaiting first-time  CABG ( nonvalve replacement ) . Only patients awaiting a first CABG whose surgery date s were at least 10 weeks away were approached to participate in our study . Patients were excluded if they were having combined CABG and valve surgery , if their ejection fractions were less than 0.40 , if they could not attend the exercise classes because of geographic inaccessibility , or if they were unable to participate because of physical limitations . After these inclusion and exclusion criteria were applied , our pool of potential participants was approximately 250 patients per year . We intended to select low-risk patients because it is not common to test an exercise intervention in patients awaiting CABG . Design We design ed a two-group r and omized , controlled trial . Eligible patients were r and omly assigned to 8 weeks of multidimensional preoperative intervention or to usual care . Those assigned to usual care were followed by their primary care physicians , cardiologists , or surgeons . During the waiting period , the intervention group received individualized , prescribed exercise training twice per week in a supervised environment ; education and reinforcement ; and monthly nurse-initiated telephone calls to answer questions and provide reassurance . After surgery , patients in both the treatment and control groups were given the opportunity to join the existing cardiac rehabilitation program ( Appendix ) . Outcomes The primary outcome was postoperative length of hospital stay . Secondary outcomes were peak exercise performance , health-related quality of life , social support , anxiety , and utilization of health care services . Measurements were taken at baseline , 1 week before surgery , 6 to 8 weeks after surgery , and 6 months after surgery . All of the secondary outcome variables were measured at baseline and 1 week before surgery . At 6 weeks and 6 months after surgery , only exercise performance , quality of life , and social support were measured . Determination of Sample Size Sample size was determined by using 19941995 data on length of stay in our surgical center . According to a r and om sample of 20 patients undergoing elective CABG , the mean total length of stay SD was 9.4 3.5 days . On the basis of these data , and accounting for a loss of 10 % to 15 % of patients , we determined that a sample size of 125 patients per group had sufficient power ( 0.8 ) to detect a 1-day reduction in hospital stay ( = 0.05 ) . Procedures The Research Ethics Board of McMaster University ( Hamilton , Ontario ) and the study hospital approved the study . On a weekly basis , staff at each of the surgeon 's offices supplied the names of patients who were scheduled to wait at least 10 weeks for surgery . Patients were telephoned , and the study was explained to them . The recruitment officer was completely c and i d about the r and om assignment and the treatments that would be offered to each group . Within 1 week after giving verbal consent , patients came to the clinic to provide written informed consent . At this visit , we collected complete baseline data and patients underwent an exercise test . Baseline data included demographic information ( age , sex , socioeconomic status , living arrangements , education , and employment status ) ; medical history ; past and present smoking status ; and history of myocardial infa rct ion , angina , congestive heart failure , and diabetes . Baseline data were also collected on anxiety , health-related quality of life , utilization of health care services , and social support . Data later obtained from medical records included total length of hospital stay , length of postoperative stay , number of hours spent in the intensive care unit ( ICU ) before receiving a discharge order , and actual hours spent in the ICU . R and omization and Blinding The study coordinator r and omly assigned patients to study groups by using a concealed r and omization process . A consultant prepared the r and omization schedule , and assignments were sealed in opaque envelopes that were opened in sequence after consent and baseline data were obtained . Patients were not blinded to their group assignments . However , the patients ' physicians ( cardiologists , surgeons , and general practitioners ) were blinded to group assignment and were not informed of it at any point in the study by patients or health care staff . Persons involved in offering the intervention ( nurses , kinesiologists , dietitians ) were aware of the patients ' group assignments but had no role in determining the patients ' readiness for discharge from the ICU or from the hospital ; therefore , they did not directly affect the primary outcome . Assessment of Outcomes Data on length of stay were collected by individual chart review . Total length of stay and total length of ICU stay were easily determined by using admission and discharge date s. However , after discussion with the cardiovascular surgeons before the study began , we realized that total length of ICU stay would misrepresent patients ' postoperative progress . On many occasions , the patient is ready for discharge from the ICU but bed or staffing issues substantially delay his or her actual departure . Therefore , we collected data on length of ICU stay in hours and , more particularly , in hours until order for ICU discharge . This required detailed chart review to locate time in and time out information as well as the time that the physician 's discharge order was given . Although the physicians often did not record the times of their orders , these data were found in nurses ' ICU notes . In approximately 5 % of cases , the data were not retrievable and the mean time until order for discharge was imputed . Exercise performance was measured by using a symptom-limited , upright-cycle ergometer exercise test .  General health-related quality of life was measured by using the Medical Outcomes Study 36-item Short Form Survey ( SF-36 ) ( 13 ) .  Social support was measured by using the  Interpersonal Support Evaluation List  ( 14 ) , and the total scale score was used in analysis . Anxiety was measured with the Spielberger StateTrait Anxiety Inventory ( 15 ) , from which both a trait score and a state anxiety score were computed . The total score from the Health Services Utilization Question naire ( 16 ) was computed and used in the analysis ( Appendix ) . Statistical Analysis All analyses were performed by using the SPSS statistical package ( 17 ) , versions 6.0 and 8.0 ( SPSS , Inc. , Chicago , Illinois ) . We analyzed data on patients whose status was elective from study entry until 1 week before surgery ( n = 220 ) . Data were complete for the primary outcome variables . When a measurement tool did not supply an approach for dealing with missing data , we used an imputation strategy , the hot deck approach ( 18 ) , in which the score from a matched patient in the same group is substituted for the missing score . The defining characteristics for matching patients were age , sex , and number of bypasses required . At the measurement point 6 months after surgery , 78 % of patients returned for all final assessment s. Follow-up to establish vital status was complete for all patients . Data on length of stay are usually positively skewed . Therefore , we selected the MannWhitney test for The goal of the current study was to investigate whether preoperative rehabilitation advice reinforced by a patient information booklet can aid recovery after total hip arthroplasty in terms of pain , function , satisfaction , and quality of life .  Thirty-five patients awaiting primary total hip arthroplasty were recruited into this study and r and omly allocated before admission to receive either the st and ard pathway of care or the rehabilitation program and booklet . All patients showed increases in function and psychological variables with time . The preoperative class and booklet , however , seemed to have the greatest impact on length of hospital stay , reducing the hospital stay by 3 days , and therapy input required , significantly influencing the cost of the procedure ( the rehabilitation class led to a cost saving of 587 British pounds ; approximately 810 dollars , per patient ) . In addition , patients attending the class reported higher levels of satisfaction ( 99 % satisfied in the preoperative rehabilitation class compared with 80 % in the control group 3 months postoperatively ) and had more realistic expectations of surgery BACKGROUND Patients awaiting cardiac surgery typically experience significant physical and psychological stress . However , although there is evidence that preoperative education interventions can lead to positive postoperative outcomes for surgical patients in general , less is known about the effectiveness among patients undergoing cardiac surgery , especially Chinese cardiac patients . OBJECTIVES To determine whether a preoperative education intervention design ed for Chinese cardiac patients can reduce anxiety and improve recovery . DESIGN R and omized controlled trial . SETTING S Cardiac surgical wards of two public hospitals in Luoyang , China . METHODS 153 adult patients undergoing cardiac surgery were r and omized into the trial , 77 to a usual care control group and 76 to preoperative education group comprising usual care plus an information leaflet and verbal advice . Measurement was conducted before r and omization and at seven days following surgery . The primary outcome was change in anxiety measured by the Hospital Anxiety and Depression Scale ( HADS ) . Secondary outcomes were change in depression ( HADS ) , change in pain as measured by subscales of the Brief Pain Inventory-short form ( BPI-sf ) , length of Intensive Care Unit stay and postoperative hospital stay . RESULTS Of 153 participants r and omized , 135 ( 88.2 % ) completed the trial . Participants who received preoperative education experienced a greater decrease in anxiety score ( mean difference -3.6 points , 95 % confidence interval -4.62 to -2.57 ; P<0.001 ) and a greater decrease in depression score ( mean difference -2.1 points , 95 % CI -3.19 to -0.92 ; P<0.001 ) compared with those who did not . There was no difference between groups in average pain , current pain , and interference in general activity , mood and walking ability . Patients r and omized to the preoperative education group reported less interference from pain in sleeping ( mean difference -0.9 points , 95 % CI -1.63 to -0.16 ; P=0.02 ) . There was some evidence to suggest a reduced number of hours spent in the Intensive Care Unit among preoperative education patients ( P=0.05 ) but no difference in length of postoperative hospital stay ( P=0.17 ) . CONCLUSIONS This form of preoperative education is effective in reducing anxiety and depression among Chinese cardiac surgery patients . Based upon existing evidence and international practice , preoperative education should be incorporated into routine practice to prepare Chinese cardiac patients for surgery Background Less invasive dissection of the extensor apparatus , one of the aspects of minimally invasive surgical ( MIS ) TKA , might result in less reduction of postoperative quadriceps strength . However , it is unclear whether MIS is associated with less strength reduction . Questions / purpose sWe asked whether knee strength ( extensor or flexor torque ) would be greater in patients having a MIS TKA  compared with patients having a st and ard TKA  and whether knee scores , alignment , ROM , tourniquet and operating times , and hospital length of stay were improved . Methods We prospect ively recruited 52 patients awaiting MIS or st and ard TKA , matched for age , weight , height , BMI , sex , and surgically treated side , but not r and omized .  Isokinetic tests  were performed preoperatively and postoperatively to obtain peak values of extensor and flexor torque . Postoperative-to-preoperative ratios and the extensor-flexor torque ratio also were calculated . Results Mean baseline extensor torques were 57 Nm and 53 Nm for MIS and st and ard TKAs , respectively . At 8 weeks postoperatively , absolute values of the mean postoperative knee extensor torque also were similar : 47 and 45 Nm for patients with MIS and st and ard TKAs , respectively . The postoperative-to-preoperative ratios were 0.8 for extensor and flexor torque in both groups . The extensor-flexor torque ratios were similar between groups . Conclusions Our data suggest a less invasive dissection of the extensor apparatus involved in MIS TKA does not enhance postoperative quadriceps strength . Level of Evidence Level III , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence This clinical study prospect ively compares the results of open surgery to minimally invasive fusion for degenerative lumbar spine pathologies . Eighty-two patients were studied ( 41 minimally invasive surgery [ MIS ] spinal fusion , 41 open surgical equivalent ) under a single surgeon ( R. J. Mobbs ) . The two groups were compared using the Oswestry Disability Index , the Short Form-12 version 1 , the Visual Analogue Scale score , the Patient Satisfaction Index , length of hospital stay , time to mobilise , postoperative medication and complications . The MIS cohort was found to have significantly less postoperative pain , and to have met the expectations of a significantly greater proportion of patients than conventional open surgery . The patients who underwent the MIS approach also had significantly shorter length of stay , time to mobilisation , lower opioid use and total complication rates . In our study MIS provided similar efficacy to the conventional open technique , and proved to be superior with regard to patient satisfaction , length of hospital stay , time to mobilise and complication rates OBJECTIVE Prolonged preoperative fasting increases postoperative hospital length of stay and current evidence recommends patients drink a carbohydrate-based liquid drink 2 h before surgery . The aim of this study was to investigate whether the addition of hydrolyzed protein to a carbohydrate-based drink would reduce both the inflammatory response and hospital length of stay . METHODS We evaluated 22 patients of both sexes , undergoing gastrointestinal resection due to cancer . Patients were r and omized into two groups : control group ( n = 12 ; 6 - 8 h fast ) and the intervention group ( n = 10 ; fasted to solids for 6 h ; and given a beverage containing 11 % pea protein hydrolysate and 89 % carbohydrates ( 79 % maltodextrin and 21 % sucrose ) , 400 mL the night before and 200 mL 3 h before surgery . Blood sample s were collected the morning before surgery and on postoperative day 2 . RESULTS Overall mortality was 4.5 % ( one case , control group ) . The duration of postoperative hospital stay was twofold longer in the control group ( P = 0.04 ) . A significant increase of serum C-reactive protein/albumin ratio was observed in controls compared with the intervention group ( P = 0.04 ) . CONCLUSION The abbreviation of preoperative fasting time to 3 h using a solution containing carbohydrates and hydrolyzed pea proteins reduces the acute-phase inflammatory response and decreases the postoperative length of stay in patients undergoing major surgery for a malignancy Introduction : Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications . In this r and omized controlled trial , we hypothesized that a high‐intensity interval training ( HIIT ) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications . Methods : Patients with operable lung cancer were r and omly assigned to usual care ( UC ) ( n = 77 ) or preoperative rehabilitation based on HIIT ( Rehab ) ( n = 74 ) .  Maximal cardiopulmonary exercise testing and the 6‐minute walk test were performed twice before surgery . The primary outcome measure was a composite of death and in‐hospital postoperative complications . Results : The groups were well balanced in terms of patient characteristics . During the preoperative waiting period ( median 25 days ) , the peak oxygen consumption and the 6‐minute walking distance increased ( median + 15 % , interquartile range , 25th to 75 percentile [ IQR25%–75 % , % ] = + 9 % to + 22 % , p = 0.003 and + 15 % , IQR25%–75 % = + 8 % to + 28 % , p < 0.001 , respectively ) in the Rehab group , whereas peak oxygen consumption declined in the UC group ( median –8 % , IQR25%–75 % = –16 % to 0 % ] , p = 0.005 ) . The primary end point did not differ significantly between the two groups : at least one postoperative complication developed in 27 of the 74 patients ( 35.5 % ) in the Rehab group and 39 of 77 patients ( 50.6 % ) in the UC group ( p = 0.080 ) . Notably , the incidence of pulmonary complications was lower in the Rehab compared with in the UC group ( 23 % versus 44 % , p = 0.018 ) , owing to a significant reduction in atelectasis ( 12.2 % versus 36.4 % , p < 0.001 ) , and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit ( median –7 hours , IQR25%–75 % = –4 to –10 ) . Conclusions : In this r and omized controlled trial , preoperative HIIT result ed in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection Background Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay . It is accepted that patients undergoing surgery on the bowel are at a higher risk . In the current era of minimally invasive colorectal surgery combined with enhanced recovery , reducing the incidence and severity of postoperative nausea and vomiting is particularly important . Dexamethasone is widely , but not universally used . It is known to improve appetite and gastric emptying , thus reduce vomiting . However , this benefit is not established in patients undergoing bowel surgery , and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery . Design DREAMS is a phase III , double-blind , multicenter , r and omized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections . DREAMS aims to r and omize 1,350 patients over 2.5 years . Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are r and omized between 8 mg intravenous dexamethasone and control ( no dexamethasone ) . All patients are given one additional antiemetic at the time of induction , prior to r and omization . Both the patient and their surgeon are blinded as to the treatment arm . Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone , including quicker return to oral diet and reduced length of stay . Health-related quality of life , fatigue and risks of infections will be investigated . Trial registration IS RCT Abstract Objectives . To assess preoperative depression in middle-aged men undergoing coronary artery bypass graft surgery ( CABG )  and to determine if depression is related to perioperative outcomes . Design . One hundred and nine middle-aged male patients were r and omly selected and assessed for depression one day before CABG using the Symptom Checklist-90 Revised ( SCL-90R ) . Perioperative outcomes were : ( 1 ) postoperative length of hospital stay , ( 2 ) the presence of any early complications ( at intensive care unit ) , and ( 3 ) the presence of any late complications ( at cardiac surgery unit ) . Results . Twenty-five ( 23 % ) patients had a high level of depression . Preoperative depression scores significantly predicted postoperative length of hospital stay ( p<0.001 ) and the incidence of late perioperative complications ( p<0.05 ) independently from biomedical and sociodemographic factors . Each increase in depression T score increased the odds of occurrence of late complications by 10 % ( p=0.018 , CI 95 % 1.02–1.19 ) . Conclusions . Depression is common in middle-aged men undergoing CABG and is an independent predictor of postoperative length of hospital stay and late perioperative complications BACKGROUND Although malnutrition contributes to morbidity , studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology . This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and re source use in patients who receive no preoperative nutrition support  and reinterprets the results of several conflicting r and omized , prospect i ve studies in this context . METHODS This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal , gastric , pancreaticoduodenal , or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not .  RESULTS Most medical records contained inadequate analysis of preoperative nutritional status , but preoperative albumin correlated inversely with complications , length of stay , postoperative stay , intensive care unit ( ICU ) stay , mortality , and resumption of oral intake .  Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels , whereas colonic surgery result ed in lower complication rates at the same albumin levels . Re source use ( eg , length of stay and ICU stay ) related to these complication rates ; esophageal and pancreatic procedures used the most re sources and colon procedures used the fewest at most albumin levels . This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several r and omized , prospect i ve nutritional studies and must be applied to the design and implementation of new studies . CONCLUSIONS Elective , non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition , but did not , result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient population s in trials should be stratified by operative site and by markers of nutritional status . Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support . Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated , unrecognized , and untreated in many hospitalized patients Herdy AH , Marcchi PLB , Vila A , Tavares C , Collaço J , Niebauer J , Ribeiro JP : Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery : a r and omized controlled trial . Am J Phys Med Rehabil 2008;87:714–719 . Objective : Patients who have to wait in the hospital for coronary artery bypass surgery ( CABG ) are exposed to the potential risks of immobilization . This clinical trial was conducted to evaluate the effects of an in-hospital cardiopulmonary rehabilitation program performed before and after CABG on postoperative outcomes . Design : Fifty-six patients who had to wait for CABG in-hospital were r and omly assigned to a cardiopulmonary rehabilitation ( Rehab ; n = 29 ) or to usual care ( Control ; n = 27 ) . In the Rehab group , intervention lasted for at least 5 days preoperatively until discharge . The program consisted of phase I cardiac rehabilitation associated with respiratory physical therapy . Outcomes were blindly evaluated . Results : By hospital discharge , Rehab patients presented a shorter time to endotracheal extubation ( 1054 ± 376 vs. 1340 ± 666 min , P = 0.05 ) , a reduction in the incidence of pleural effusion ( relative risk [ RR ] = 0.2 ; 95 % confidence interval [ CI ] : 0.5–0.8 ) , atelectasis ( RR = 0.15 ; 95 % CI : 0.03–0.8 ) , pneumonia ( 0 vs. 7 cases , [ P = 0.004 ] ) , and atrial fibrillation or flutter ( RR = 0.2 ; 95 % CI : 0.05–0.8 ) . Length of in-hospital stay after surgery was also reduced in the Rehab group ( 5.9 ± 1.1 vs. 10.3 ± 4.6 days [ P < 0.001 ] ) . Conclusion : Pre- and postoperative cardiopulmonary rehabilitation in patients who await CABG in the hospital is superior to st and ard care and leads to a reduced rate of postoperative complications and shorter hospital stay Complete surgical resection is the most effective curative treatment for lung cancer . However , many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered " inoperable . " Preoperative pulmonary rehabilitation ( PR ) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no r and omized study has been published to date . We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a r and omized single blinded design . Outcomes were length of hospital stay and postoperative complications . The first study tested 4 weeks of guideline -based PR vs. usual care : that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery . Nine patients were r and omized and no differences were found between arms . The second study tested ten preoperative PR sessions using a customized protocol with nonst and ard components ( exercise prescription based on self efficacy , inspiratory muscle training , and the practice of slow breathing ) ( n=10 ) vs. usual care ( n=9 ) . The PR arm had shorter length of hospital stay by 3 days ( p=0.058 ) , fewer prolonged chest tubes ( 11 % vs. 63 % , p=0.03 ) and fewer days needing a chest tube ( 8.8 vs. 4.3 days p=0.04 ) compared to the controlled arm . A ten-session preoperative PR intervention may improve post operative lung reexpansion evidence d by shorter chest tube times and decrease the length of hospital stay , a crude estimator of post operative morbidity and costs . Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection . 4 weeks of conventional preoperative PR seems non feasible Abstract Objective To assess the efficacy of a single preoperative physiotherapy session to reduce  postoperative pulmonary complications ( PPCs )  after upper abdominal surgery . Design Prospect i ve , pragmatic , multicentre , patient and assessor blinded , parallel group , r and omised placebo controlled superiority trial . Setting Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zeal and . Participants 441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were r and omly assigned through concealed allocation to receive either an information booklet ( n=219 ; control ) or preoperative physiotherapy ( n=222 ; intervention ) and followed for 12 months . 432 completed the trial . Interventions Preoperatively , participants received an information booklet ( control ) or an additional 30 minute physiotherapy education and breathing exercise training session ( intervention ) . Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery . Postoperatively , all participants received st and ardised early ambulation , and no additional respiratory physiotherapy was provided . Main outcome measures The primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score . Secondary outcomes were hospital acquired pneumonia , length of hospital stay , utilisation of intensive care unit services , and hospital costs . Patient reported health related quality of life , physical function , and post-discharge complications were measured at six weeks , and all cause mortality was measured to 12 months . Results The incidence of PPCs within 14 postoperative hospital days , including hospital acquired pneumonia , was halved ( adjusted hazard ratio 0.48 , 95 % confidence interval 0.30 to 0.75 , P=0.001 ) in the intervention group compared with the control group , with an absolute risk reduction of 15 % ( 95 % confidence interval 7 % to 22 % ) and a number needed to treat of 7 ( 95 % confidence interval 5 to 14 ) . No significant differences in other secondary outcomes were detected . Conclusion In a general population of patients listed for elective upper abdominal surgery , a 30 minute preoperative physiotherapy session provided within existing hospital multidisciplinary preadmission clinics halves the incidence of PPCs and specifically hospital acquired pneumonia . Further research is required to investigate benefits to mortality and length of stay . Trial registration Australian New Zeal and Clinical Trials Registry ANZCTR 12613000664741 BACKGROUND Today , most of the pre-emptive hemodynamic optimization algorithms are based on variables associated with invasive techniques like arterial cannulation . The non-invasive Nexfin ™ technology is able to estimate continuous Cardiac Index ( CI ) and pulse pressure variation ( PPV ) . However , the efficiency of an early goal directed therapy ( EGDT ) algorithm based on non-invasive variables has to be proven . The aim of our study was to investigate the feasibility of a non-invasive driven EGDT protocol and its impact on patient 's outcome . METHODS Seventy-nine patients ( ASA II-III ) undergoing elective major abdominal surgery were r and omized to either study group ( SG , N.=39 ) or control group ( CG , N.=40 ) . The SG was treated according to an algorithm based on non-invasive CI and PPV , whereas the CG received st and ard of care . Postoperative complications up to 28 days and length of hospital stay ( LOS ) in both groups were recorded . RESULTS There was no significant difference between the groups regarding demographics , hemodynamic variables , preoperative risk scores and duration of surgery . The total amount of complications was higher in the CG ( SG 94 vs. CG 132 complications , P=0.22 ) without reaching statistical significance . LOS revealed no difference between both groups ( SG , 9 [ 7 - 15 ] vs. CG , 9 [ 7 - 15.25 ] days , P=0.82 ) . We have seen no impact of the non-invasive optimization protocol with respect to postoperative mortality . CONCLUSIONS In this patient collective , we could demonstrate the feasibility of a non-invasive approach for hemodynamic optimization . However , EGDT based on non-invasive variables was not able to significantly improve outcome Minimally invasive transforaminal lumbar interbody fusion ( MIS TLIF ) has become an increasingly popular method of lumbar arthrodesis . However , there are few published studies comparing the clinical outcomes between unilateral and bilateral instrumented MIS TLIF .  Sixty-five patients with degenerative lumbar spine disease were enrolled in this study . Thirty-one patients were r and omized to the unilateral group and 34 to the bilateral group . Recorded demographic data included sex , age , preoperative diagnosis , and degenerated segment .  Operative time , blood loss , hospital stay length , complication rates , and fusion rates were also evaluated . The Oswestry Disability Index ( ODI ) score and Visual Analog Scale ( VAS ) pain score data were obtained . All patients were asked to follow-up at 3 and 6 months after surgery , and once every 6 months thereafter . The mean follow-up was 26.6 months ( range 18 - 36 months ) . The two groups were similar in sex , age , preoperative diagnosis , and operated level . The unilateral group had significantly shorter operative time , lower blood loss , and shorter hospital time than the bilateral group . The average postoperative ODI and VAS scores improved significantly in each group . No significant differences were found between the two groups in relation to ODI and VAS . All patients showed evidence of fusion at 12 months postoperatively . The total fusion rate , screw failure , and general complication rate were not significantly different . Results showed that single-level MIS TLIF with unilateral pedicle screw fixation would be sufficient in the management of preoperatively stable patients with lumbar degenerative disease . It seems that MIS TLIF with unilateral pedicle screw instrumentation is a better choice for single-level degenerative lumbar spine disease Background Postoperative pulmonary complications ( PPC ) are the most frequently observed complications following lung resection , of which pneumonia and atelectasis are the most common . PPCs have a significant clinical and economic impact associated with increased observed number of deaths , morbidity , length of stay and associated cost . The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors . Methods A prospect i ve observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months .  PPC was assessed using a scoring system based on chest x-ray , raised white cell count , fever , microbiology , purulent sputum and oxygen saturations . Results Thirty-four of 234 subjects ( 14.5 % ) had clinical evidence of PPC . The PPC patient group had a significantly longer length of stay ( LOS ) in hospital , high dependency unit ( HDU ) LOS , higher frequency of intensive care unit ( ITU ) admission and a higher number of hospital deaths . Older patients , body mass index ( BMI ) ≥30 kg/m2 , preoperative activity < 400 m , American Society of Anesthesiologists ( ASA ) score ≥3 , smoking history , chronic obstructive pulmonary disease ( COPD ) , lower preoperative forced expiratory volume in 1 s ( FEV1 ) and predicted postoperative ( PPO ) FEV1 were all significantly ( p<0.05 ) associated with PPC on univariate analysis . Multivariate analysis confirmed that age > 75 years , BMI ≥30 kg/m2 , ASA ≥3 , smoking history and COPD were significant independent risk factors in the development of PPC ( p<0.05 ) . Conclusion The clinical impact of PPCs is marked . Significant independent preoperative risk factors have been identified in current clinical practice . Potentially modifiable risk factors include BMI , smoking status and COPD . The impact of targeted therapy requires further evaluation Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive Background Evidence suggests that elective cardiac patients are at risk of functional and psychological deterioration in the time preceding surgery . This poses a risk to successful post-operative rehabilitation . This prospect i ve one-group pre-test , post-test evaluation was design ed to assess a clinical Pre-operative Rehabilitation ( PREHAB ) home-based exercise programme , to optimise pre-operative physical function and frailty in patients awaiting elective Coronary Artery By-Pass Graft ( CABG ) or Valve Surgery . Method Consenting patients awaiting cardiac surgery , with wait time ≥ 6 weeks were referred to a Senior Physiotherapist for baseline assessment . Patients were offered PREHAB in the form of functional home-based exercise that was prescribed from baseline physical outcomes . All patients were followed up via telephone to ensure progression of exercise and any problems associated with it . This continued weekly until the patient attended Surgical Pre- assessment clinic , where all outcome measures were re-assessed . Results Twenty two patients , out of a total number of 36 patients seen in the surgical clinic between March 2016 and August 2016 , participated in the prehab clinical evaluation . Twenty patients completed their prescribed exercises on a weekly basis prior to surgery . No adverse events or cardiac symptoms were reported as a result of the home exercise intervention . Paired t-Test analyses revealed a significant mean difference in clinical frailty score ( CFS ) of −0.53 ± 0.51 ( 95 % CI [ −0.774 , −0.279 ] , P = 0.0003 ) . Significant mean difference in six-minute walk test ( 6MWT ) distance of 42.5 ± 27.8 m ( 95 % CI [ 23.840 , 61.251 ] , P = 0.0005 ) , 6MWT walking speed of 0.5 ± 0.4 kmh ( 95 % CI , [ 0.2433 , 0.7567 ] , P = 0.001 ) , and short physical performance battery ( SPPB ) total score of 2.2 ± 1.7 , ( 95 % CI [ 3.066 , 1.200 ] , P = 0.0002 ) were also observed . The change in 6MWT distance was shown to be significantly associated with hospital length of stay ( LOS ) ( r = 0.7 ; P = 0.03 ) . Conclusion This small exploratory evaluation suggests that providing a home-based PREHAB programme for frail patients undergoing CABG or Valve surgery may be able to improve functional ability and reduce hospital length of stay for those patients undergoing cardiac surgery . A frailty score with greater sensitivity may be required to eluci date the influence frailty could have in reducing length of stay . A large r and omised controlled study is required to reveal the potential beneficial effects of PREHAB in this patient population This systematic review and meta- analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults . We included r and omized controlled trials of adult patients ( aged 16 years or older ) undergoing surgery . We included 31 studies of 5292 participants . There was no difference in mortality at the longest follow-up : 282/2615 ( 10.8 % ) died in the control group and 238/2677 ( 8.9 % ) in the treatment group , RR of 0.89 ( 95 % CI : 0.76 - 1.05 ; P=0.18 ) . However , the results were sensitive to analytical methods and withdrawal of studies with method ological limitations . The intervention reduced the rate of three morbidities ( renal failure , respiratory failure , and wound infections ) but not the rates of arrhythmia , myocardial infa rct ion , congestive cardiac failure , venous thrombosis , and other types of infections . The number of patients with complications was also reduced by the intervention . Hospital length of stay was reduced in the treatment group by 1.16 days . There was no difference in critical care length of stay . The primary analysis of this review showed no difference between groups but this result was sensitive to the method of analysis , withdrawal of studies with method ological limitations , and was dominated by a single large study . Patients receiving this intervention stayed in hospital 1 day less with fewer complications . It is unlikely that the intervention causes harm . The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced OBJECTIVES Older patients undergoing knee replacement surgery can recover more slowly than younger patients and require extended rehabilitation . Because administration of supraphysiological testosterone ( T ) dramatically increases strength , we hypothesized that preoperative T therapy would improve functional recovery and reduce hospital stay in older men undergoing knee replacement surgery . DESIGN Double-blinded , placebo-controlled pilot trial . SETTING A Veterans Affairs orthopedics clinic and inpatient postoperative unit . PARTICIPANTS Twenty-five men , mean age 70 , undergoing elective knee replacement . INTERVENTION Preoperative , supraphysiological T administration ( 600 mg T enanthate intramuscularly weekly for 4 weeks ) or sesame oil placebo . MEASUREMENTS Length of hospital stay and functional ability by Functional Independence Measure ( FIM ) score . RESULTS Mean length of hospital stay + /- st and ard deviation was nonsignificantly reduced in the T group ( 5.9 + /- 2.4 days vs 6.8 + /- 2.5 days ; P = .15 ) . At postoperative Day 3 , there was a significant improvement in ability to st and ( mean FIM score 5.2 + /- 1.0 vs 4.0 + /- 1.1 ; P = .04 ) and trends towards improvements in walking and stair climbing in the T group . There were no complications attributable to T therapy . CONCLUSIONS In older men undergoing knee replacement surgery , preoperative supraphysiological T administration may confer some clinical benefit . Future studies using longer courses of preoperative T administration in larger numbers of older men undergoing knee replacement surgery are warranted INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended Background The extent to which lifestyle factors such as tobacco consumption and obesity affect the outcome after inguinal hernia surgery has been poorly studied . This study was undertaken to assess the effect of smoking , smokeless tobacco consumption and obesity on postoperative complications after inguinal hernia surgery . The second aim was to evaluate the effect of tobacco consumption and obesity on the length of hospital stay . Methods A cohort of 12,697 Swedish construction workers with prospect ively collected exposure data on tobacco consumption and body mass index ( BMI ) from 1968 onward were linked to the Swedish inpatient register . Information on inguinal hernia procedures was collected from the inpatient register . Any postoperative complication occurring within 30 days was registered . In addition to this , the length of hospitalization was calculated . The risk of postoperative complications due to tobacco exposure and BMI was estimated using a multiple logistic regression model and the length of hospital stay was estimated in a multiple linear regression model . Results After adjusting for the other covariates in the multivariate analysis , current smokers had a 34 % ( OR 1.34 , 95 % CI 1.04 , 1.72 ) increased risk of postoperative complications compared to never smokers . Use of “ Swedish oral moist snuff ” ( snus ) and pack-years of tobacco smoking were not found to be significantly associated with an increased risk of postoperative complications . BMI was found to be significantly associated with an increased risk of postoperative complications ( P = 0.04 ) . This effect was mediated by the underweighted group ( OR 2.94 ; 95 % CI 1.15 , 7.51 ) . In a multivariable model , increased BMI was also found to be significantly associated with an increased mean length of hospital stay ( P < 0.001 ) . There was no statistically significant association between smoking or using snus , and the mean length of hospitalization after adjusting for the other covariates in the model . ConclusionS moking increases the risk of postoperative complications even in minor surgery such as inguinal hernia procedures . Obesity increases hospitalization after inguinal hernia surgery . The Swedish version of oral moist tobacco , snus , does not seem to affect the complication rate after hernia surgery at all Background Esophageal resection is associated with a high incidence of postoperative pneumonia . Respiratory complications account for almost half of the readmissions to the critical care unit . Postoperative complications can result in prolonged hospital stay and consequently increase healthcare costs . In cardiac surgery a preoperative inspiratory muscle training program has shown to prevent postoperative pneumonia and reduce length of hospital stay . While in some surgical centers inspiratory muscle training is already used in the preoperative phase in patients undergoing esophageal resection , the added value of this intervention on the reduction of pulmonary complications has not yet been investigated in large surgical population s other than cardiac surgery in a r and omized and controlled study design . Methods / Design The effect of a preoperative inspiratory muscle training program on the incidence of postoperative pneumonia in patients undergoing esophageal resection will be studied in a single blind multicenter r and omized controlled trial ( the PREPARE study ) . In total 248 patients ( age > 18 years ) undergoing esophageal resection for esophageal cancer will be included in this study . They are r and omized to either usual care or usual care with an additional inspiratory muscle training intervention according to a high-intensity protocol which is performed with a tapered flow resistive inspiratory loading device . Patients have to complete 30 dynamic inspiratory efforts twice daily for 7 days a week until surgery with a minimum of 2 weeks . The starting training load will be aim ed to be 60 % of maximal inspiratory pressure and will be increased based on the rate of perceived exertion . The main study endpoint is the incidence of postoperative pneumonia . Secondary objectives are to evaluate the effect of preoperative inspiratory muscle training on length of hospital stay , duration of mechanical ventilation , incidence of other postoperative ( pulmonary ) complications , quality of life , and on postoperative respiratory muscle function and lung function . Discussion The PREPARE study is the first multicenter r and omized controlled trial to evaluate the hypothesis that preoperative inspiratory muscle training leads to decreased pulmonary complications in patients undergoing esophageal resection . Trial registration NCT01893008
Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates .
By contrast , length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and /or mobility training .
Conclusion : Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery .
Objective : To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay .