Short-term recovery following colorectal surgery

© 2012 Dr. Julio Flavio Fiore JuniorPostoperative recovery is a nebulous concept. There is no universally accepted definition of recovery and there are few tests or indices to measure this construct. The effectiveness of interventions aimed to enhance short-term recovery following colorectal surgery (i.e. the period of recovery between surgery and hospital discharge) is frequently investigated through the assessment of length of stay (LOS). The validity of this measure as an indicator of recovery, however, is controversial as LOS is recognized to be influenced by several personal and organisational factors that are not related to the construct. These include health care systems, hospital culture, surgeon’s preferences, patient’s expectations and availability of postoperative support. Considering the limitations involved in the assessment of LOS, studies comparing perioperative care regimens have commenced assessing the time to achieve specific discharge criteria as an index of short-term recovery. For the purpose of this research, this outcome measure will be referred to as ‘time to readiness for discharge’ (TRD). Rather than indicating the exact number of days patients stay in hospital after surgery, TRD indicates the number of days patients take to achieve the stage of recovery when they no longer require inpatient treatment and are considered ready to leave the hospital. As only factors related to physiological recovery are taken into account in this assessment, TRD may be a more appropriate index of postoperative recovery than LOS. Nevertheless, comparison of results between studies reporting TRD have been limited by the use of different discharge criteria and the lack of research investigating the psychometric properties of this measure. The overall purpose of the research contained within this doctoral thesis was to gain consensus on hospital discharge criteria for patients undergoing colorectal surgery and to provide further development, standardize and assess the psychometric properties of TRD as an outcome measure of short-term recovery. To achieve this purpose, three inter-related studies were undertaken. Study 1 consisted of a systematic review conducted to identify and synthesize the hospital discharge criteria which have been used in the colorectal surgery literature. The review highlights the discharge criteria most frequently used and discusses the limitations observed in the description of criteria and endpoints to determine their achievement. The results of this review suggested the need for clinicians involved in postoperative care to agree on standardised discharge criteria to be used in patient care and research. In Study 2, a Delphi approach was used to gain an international expert consensus on discharge criteria for this surgical population. Fifteen highly-published experts from 15 different countries participated in a three-round Delphi process. These experts agreed that patients should be considered medically ready for discharge when they achieve five short-term recovery criteria: tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control on oral analgesia, ability to mobilise and self care and no evidence of complications or untreated medical problems. Specific endpoints for each of these criteria were defined. Study 3 aimed to investigate the psychometric properties (construct validity and reliability) of TRD by assessing this outcome measure in a prospective cohort of patients undergoing colorectal surgery. TRD was defined as the number of days patients take to achieve discharge criteria defined by consensus (Study 2). Construct validity of was investigated by testing the hypotheses that TRD is: (1) longer in patients undergoing open colorectal surgery; (2) longer in patients with lower physical status prior to surgery (American Society of Anaesthesiology Score > 3); (3) longer in elderly patients (>80 years old); (4) longer in patients developing postoperative complications; (5) longer in patients undergoing emergency surgery and (6) shorter than LOS. Interobserver reliability was calculated by comparing measures of TRD by two independent assessors. In a secondary analysis, data from this cohort was used to estimate and compare sample size requirements for randomised controlled trials (RCTs) using TRD or LOS as outcome measures. Seventy patients participated in the construct validity study and 21 patients participated in the interobserver reliability study. Five of the six hypotheses were supported by the data (p<0.05) and interobserver reliability was excellent (ICC2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23% less participants compared to studies using LOS. The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using this outcome measure as an alternative to LOS may reduce sample size requirements, which has the potential to decrease research costs, reduce study duration and increase feasibility of full implementation of RCTs

Pressões respiratórias máximas e capacidade vital: comparação entre avaliações através de bocal e de máscara facial

INTRODUÇÃO: A medida das pressões respiratórias máximas e a capacidade vital são importantes na avaliação da função pulmonar, no entanto, variações metodológicas podem interferir na interpretação dos resultados obtidos. OBJETIVO: Comparar os valores das pressões respiratórias máximas e da capacidade vital, obtidos através de bocal e de máscara facial. MÉTODO: Foram estudados 30 pacientes (16 homens), com idade de 55,9 ± 15,7 anos, em período pré-operatório de cirurgia abdominal. As variáveis pressão inspiratória máxima, pressão expiratória máxima e capacidade vital foram avaliadas através de um bocal rígido achatado e de uma máscara facial, em ordem randomizada. RESULTADOS: A avaliação com máscara facial não alterou de forma significativa os valores de capacidade vital e pressão inspiratória máxima, porém a pressão expiratória máxima foi significantemente menor do que quando avaliado com bocal rigido. A presença de escape aéreo ao redor da máscara durante a medida da pressão expiratória máxima foi observada em 60% das avaliações. Quando consideradas apenas as medidas de pressão expiratória máxima avaliadas sem a presença de escape de ar, os valores com o uso da máscara foram maiores do que os com o bocal. CONCLUSÃO: A avaliação da pressão inspiratória máxima e capacidade vital pode ser realizada com uso de máscara facial, sem interferência nos resultados obtidos. A avaliação da pressão expiratória máxima através de máscara facial mostrou-se adequado quando foi possível evitar o escape de ar ao redor da máscara, porém a grande prevalência de vazamentos e a conseqüente redução dos valores obtidos na avaliação tornam seu uso limitado

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial

Abstract Introduction: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. Objective: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. Methods: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. Results: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. Conclusions: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial

<div><p>Abstract Introduction: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. Objective: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. Methods: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. Results: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. Conclusions: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain.</p></div

Influência do dreno pleural sobre a dor, capacidade vital e teste de caminhada de seis minutos em pacientes submetidos à ressecção pulmonar Influence of pleural drainage on postoperative pain, vital capacity and six-minute walk test after pulmonary resection

OBJETIVO: Avaliar a influência do dreno pleural sobre a distância percorrida no teste de caminhada de seis minutos, da intensidade da dor e da capacidade vital de pacientes submetidos à ressecção pulmonar. MÉTODOS: Foram avaliados treze pacientes consecutivos, internados na Enfermaria da Cirurgia de Tórax do Hospital São Paulo, submetidos à drenagem pleural fechada (dreno tubular multiperfurado de 0,5 polegada), no período pós-operatório de ressecção pulmonar (lobectomia, segmentectomia e nodulectomia). A opção pela retirada do dreno seguiu critérios clínicos definidos por médicos da equipe cirúrgica alheios ao estudo. A determinação da capacidade vital, da intensidade da dor através da escala visual analógica de dor e da distância percorrida no teste de caminhada de seis minutos foram realizadas 30 min antes da retirada do dreno e 30 min após. A análise estatística dos dados foi realizada através do teste t pareado, com nível de significância estabelecido em 0,05. RESULTADOS: Após a retirada do dreno, os valores obtidos na avaliação da escala visual analógica de dor foram significativamente menores (3,46 cm vs. 1,77 cm; p = 0,001), e a distância percorrida no teste de caminhada de seis minutos foi significativamente maior (374,34 m vs. 444,62 m; p = 0,03). A capacidade vital antes e após a retirada do dreno não foi alterada de forma significativa (2,15 L vs. 2,25 L, respectivamente; p = 0,540). CONCLUSÕES: Os resultados deste estudo sugerem que a presença do dreno pleural é um importante fator associado à dor pós-operatória e à limitação funcional em pacientes submetidos à ressecção pulmonar.<br>OBJECTIVE: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. METHODS: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. RESULTS: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p = 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). CONCLUSIONS: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection