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Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program.

Author(s): Francesco Carli, MD, MPhil, Rashami Awasthi, BSc, Chelsia Gillis, MSc, Wassim Kassouf, MD, FRCSC

Introduction

In 2012, the Canadian Cancer Society estimated that 7800 people in Canada were diagnosed with bladder cancer, and surgical resection is part of the standard treatment.[sup.1] Radical cystectomy, like all major abdominal surgery, is associated with a 40% to 60% reduction in physiological and functional capacity, which is often expressed as fatigue for 8 to 12 weeks after hospital discharge.[sup.2] The following report outlines the perioperative care of a frail man diagnosed with bladder cancer who had significantly impaired functional capacity at baseline and underwent a 4-week multimodal prehabilitation program to increase his physiological and metabolic reserve.

Case report

An 85-year-old man, diagnosed with bladder cancer, was scheduled for an elective radical cystectomy and ileal conduit. His medical history was significant for poorly controlled type 2 diabetes, anemia, acute on chronic renal failure requiring bilateral nephrostomy tubes, glaucoma, and severe weight loss (over 15% of usual body weight) during the previous 6 months (Table 1). Previous uneventful surgeries included left inguinal hernia repair, cataract, transurethral bladder resection, and right total knee arthroplasty. He was a regular smoker until he stopped 30 years ago, and now occasionally smoked a cigar. His present medications included gliclazide 80 mg, dorzolamide + timolol drops, pantoprazole 40 mg, ASA 81 mg, and acetaminophen 325 mg. The patient was residing at home and independent, but recently was moved to an assisted-living facility in view of the progressive physical deterioration prior to surgery.

The patient undertook a standard medical risk assessment in the preoperative clinic. His exercise tolerance was poor (3 metabolic equivalent [MET]). His American Society of Anesthesiologists (ASA) health status was 3. Chest x-ray was unremarkable and his electrocardiography showed some ischemic changes and sinus rhythm. The patient was referred by the surgeon for a 4-week preoperative prehabilitation program.

The assessment of functional capacity, physical strength, nutritional and psychological status was conducted by a kinesiologist, a registered dietitian, and a psychologist, respectively. Baseline walking capacity (6-minute walk test [6MWT]) was poor at 210 metres, and well below the predicted value for elderly population of his age and gender.[sup.3] Nutritional risk was assessed using the cancer-validated patient-generated subjective global assessment (PG-SGA) tool, which revealed a global score of B moderate under-nutrition requiring dietary intervention.[sup.4] The self-reported health-related quality of life (SF-36) score was very low compared with other men of his age on the physical and mental functions (Table 1). On a self-rating scale of 0 to 100 for physical fitness, he scored 30. The patient's psychological state (Hospital Anxiety and Depression Scale [HADS] score) was very high on depression and moderate on anxiety (Table 2).[sup.6] These results were consistent with the psychological report indicating depressive symptoms, lack of energy, and poor motivation. Self-reported physical activity (Community Healthy Activities Model Program for Seniors [CHAMPS])[sup.7] at baseline was low (<1 kcal/kg/week).

Prehabilitation program

The multimodal program described was carried out for 27 days preoperatively and included aerobic and resistance exercise 3 times per week with 20 g of whey protein to be taken orally within 1 hour of exercise, and relaxation exercises. The home-based exercise program was initiated after the baseline assessment. The patient was asked to perform the given exercise program for an hour, for a minimum of 3 times per week. The program consisted of cardiovascular and resistance exercises. Thirty minutes were allocated to the cardiovascular component (5 minutes for warm up, 25 minutes of walking at a moderate intensity and 5 minutes for a cool down). Moderate intensity was assessed with the use of the BORG scale (rate of perceived exertion). The resistance exercises were prescribed starting at 1 set of 10 repetitions, which increased gradually per week (Table 2). Follow-up was done with phone calls every week. During this period the patient improved significantly in all the categories.

Perioperative course

The patient underwent radical cystoprostatectomy and ileal conduit diversion which lasted 5 hours and 25 minutes. The patient was diagnosed with invasive urothelial carcinoma, clinical T3b disease. Radical cystectomy was performed and pathological staging was pT4N.

The patient received general anesthesia and epidural analgesia. Intravenous fluids included 2 L of Ringer's Lactate, 500 mL of plasma expander, and 2 units of blood. Perioperative blood glucose was kept between 6 and 8 mmol/L with continuous intravenous infusion of actarapid insulin. Estimated total blood loss was 750 mL. His recovery was uneventful, except for hyperglycemia and hypomagnesemia which was treated for a period of 48 hours with insulin sliding scale and intravenous magnesium sulfate, respectively. On postoperative day 4, the patient progressed to a regular diet. The drains were removed on day 5 and the patient was discharged on postoperative day 7. At home the patient resumed the multimodal program for 8 weeks. He returned at 4 and 8 weeks after surgery to see the surgeon and for a physical, nutritional and cognitive assessment. Consistent improvements were reported on 6MWT, both physical and mental components of the SF-36, self-rated physical fitness, together with a significant increase in functional walking capacity (Table 3, Table 4).

Discussion

Poor preoperative physical performance has been shown to increase the risk of mortality,[sup.8] postoperative complications,9 and prolong functional recovery.[sup.10] Our case illustrates how a frail patient, with considerable risk factors for postoperative complications, underwent a short but intense, period of physical, nutritional and cognitive preparation. Because of this preparation, he was able to overcome the stress of surgery, and returned home after 1 week where he continued to improve his functional capacity and remained independent.

Endeavours to accelerate convalescence have focused on "post-surgery rehabilitation;" however patients during this period are tired and concerned about their health and prognosis. The preoperative period (prehabilitation) may in fact be a better time to optimize their physiological and mental function so they can withstand the stress of surgery and enhance postoperative recovery.[sup.11] This program could be applied to patients who receive neoadjuvant chemotherapy to attenuate the associated side effects, such as fatigue and weight loss. Previous studies on the impact of a multimodal prehabilitation program in patients undergoing colorectal resection for cancer have shown significant improvement in postoperative functional capacity and quality of life.[sup.12]

Conclusion

In this case report the prehabilitation program contributed to an increase, not only of the patient's functional walking capacity, but in emotional and cognitive function as previously reported.[sup.13] Such improvement in cardiorespiratory function is evident in the increased capacity to perform more activities of independent daily living. Significant gains in functional capacity were well above the minimum (15 to 20 metres).[sup.14] Although the possible mechanism underlying the improvement in functional capacity is unclear, physical exercise may have played a major role, together with the ingestion of whey protein within "the anabolic window of opportunity" following exercise. This improved physiologic reserve and gains in muscular strength as evidenced by the increase in grip-strength, 6MWT, and lean body mass measurements.[sup.15] A registered randomized controlled trial (NCT01836978) in this population is ongoing.

Competing interests: Dr. Carli, R. Awasthi, C. Gillis and Dr. Kassouf declare no competing financial or personal interests.

This paper has been peer-reviewed.

References

1.. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69-90http://dx.doi.org/10.3322/caac.20107.

2.. Christensen T, Bendix T, Kehlet H. Fatigue and cardiorespiratory function following abdominal surgery. Br J Surg 1982;69:417-24http://dx.doi.org/10.1002/bjs.1800690721.

3.. Guyatt GH, Sullivan MJ, Thompson PJ, et al. The 6-minute walk: A new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985;132:919-23.

4.. Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr 2002;56:779-85http://dx.doi.org/10.1038/sj.ejcn.1601412.

5.. Hopman WM, Towheed T, Anastassiades T, et al. Canadian normative data for the SF-36 health survey. Can Med Assoc J 2000;163:265-71.

6.. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70http://dx.doi.org/10.1111/j.1600-0447.1983.tb09716.x.

7.. Ainsworth BE, Haskell WL, Herrmann SD, et al. Compendium of physical activities: A second update of codes and MET values. Med Sci Sports Exer 2011;43:1575-81http://dx.doi.org/10.1249/MSS.0b013e31821ece12.

8.. Wilson RJT, Davies S, Yates D, et al. Impaired functional capacity is associated with all-cause mortality after major elective intraabdominal surgery. Br J Anaesth 2010;105:297-303http://dx.doi.org/10.1093/bja/aeq128.

9.. Robinson N, Daniel W, Pointer L, et al. Simple frailty score predicts post-operative complications across surgical specialties. Am J Surg 2013;206:544-50http://dx.doi.org/10.1016/j.amjsurg.2013.03.012.

10.. Lawrence V, Hazuda H, Cornell J, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 2004;199:762-72http://dx.doi.org/10.1016/j.jamcollsurg.2004.05.280.

11.. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metabol Care 2005;8:23-32http://dx.doi.org/10.1097/00075197-200501000-00005.

12.. Carli F, Brown S, Kennepohl S. Prehabilitation to enhance postoperative recovery of an octogenarian following robotic-assisted hysterectomy with endometrial cancer. Can J Anesthes 2012;59:779-813http://dx.doi.org/10.1007/s12630-012-9734-4.

13.. Li C, Carli F, Lee L, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: A pilot study. Surg Endosc 2013;27:1072-82http://dx.doi.org/10.1007/s00464-012-2560-5.

14.. Antonescu I, Scott S, Tran TT, et al. Measuring postoperative recovery: What are clinically meaningful differences? Surgery 2014;156:319-27http://dx.doi.org/10.1016/j.surg.2014.03.005.

15.. Burd NA, Tang JE, Moore DF, et al. Exercise training and protein metabolism: Influence of contraction, protein intake, anfd sex-based differences. J Appl Physiol 2008;298:E8-16.

Tables

Table 1.: Patient demographic and clinical data [Table omitted]

Table 2.: Prehabilitation program including physical activity, nutrition and relaxation exercises [Table omitted]

Table 3.: Health-related quality of life SF-36 subscales [Table omitted]

Table 4.: Body impedance, grip strength, self-reported physical activity (energy expenditure), hospital anxiety and depression scale [Table omitted]

Author Affiliation(s):

[1] Department of Anesthesia, McGill University Health Centre, Montreal, QC;

[2] Department of Surgery, McGill University Health Centre, Montreal, QC

Correspondence: Mr. Francesco Carli, Department of Anesthesia, McGill University Health Centre, 1650 Cedar Ave., Room D10.144, Montreal, QC H3G 1A4; franco.carli@mcgill.ca
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Article Details
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Title Annotation:Case Report
Author:Carli, Francesco; Awasthi, Rashami; Gillis, Chelsia; Kassouf, Wassim
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Clinical report
Geographic Code:1CANA
Date:Nov 1, 2014
Words:1969
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