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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 103-108

Preoperative exercise therapy preventing postoperative complications following complex abdominal wall reconstruction: A feasibility study


1 Department of Physical Therapy, Elkerliek Hospital, Helmond, The Netherlands
2 Department of Surgery, Elkerliek Hospital, Helmond, The Netherlands
3 Department of Sport Medicine, Elkerliek Hospital, Helmond, The Netherlands
4 Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
5 Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands

Date of Submission31-May-2021
Date of Decision07-Jul-2021
Date of Acceptance13-Jul-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Elske H M Berkvens
Department of Physical Therapy, Elkerliek Hospital, Wesselmanlaan 25, 5707 HA Helmond.
The Netherlands
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_33_21

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  Abstract 

PURPOSE: The population undergoing complex abdominal wall reconstructions (CAWR) tends to have significant associated, multiple comorbidities, complicating the recovery of a reconstruction. Undergoing CAWR exposes these patients to a risk for respiratory complications, which is common after CAWR. These complications are associated with an increased surgical morbidity and mortality, prolonged length of hospital stay (LOHS), an additional cost burden, and decrease in health-related quality of life (HRQoL). Improving the physical capacity before CAWR, by preoperative exercise therapy (PexT), is likely to give a better recovery and lower complication rate. In this study, we will survey the feasibility of PexT in patients undergoing a CAWR. Outcome measures will be added to demonstrate a possible effect of PexT. MATERIALS AND METHODS: A feasibility study was performed. The intervention consisted of a 3-month lasting exercise program consisting of cardiovascular, strength, and respiratory muscle training under direct supervision of a physiotherapist. The primary outcome was feasibility, defined as the occurrence of adverse events and the possibility to perform more than 80% of the intervention. The secondary outcomes were the physical capacity, HRQoL, the amount of pulmonary complications, and the LOHS. Physical capacity was measured with a cardiopulmonary exercise test (CPET) before and after the intervention and after surgery. RESULTS: Nine males and two females were included with a median age of 59 years [95% confidence interval (CI) 51–71] and a median body mass index of 31.6 kg/m2 (95% CI 28.1–36.7). The median width of the ventral hernia was 16.0 cm (95% CI 15.0–23.0). No adverse events occurred and all patients could complete the intervention. Both physical capacity and HRQoL improved after the intervention. All patients had a successful reconstruction with fascial closure. CONCLUSION: Intensive PExT is feasible in patients waiting for a CAWR. A randomized controlled trial needs to be conducted to objectivate the effect of PExT to prevent pulmonary complications and to reduce LOHS in this population.

Keywords: Complex ventral hernia, feasibility, physical therapy, prehabilitation


How to cite this article:
Berkvens EH, Wegdam JA, Visser RJ, Bouvy ND, Nienhuijs SW, Reilingh Td. Preoperative exercise therapy preventing postoperative complications following complex abdominal wall reconstruction: A feasibility study. Int J Abdom Wall Hernia Surg 2021;4:103-8

How to cite this URL:
Berkvens EH, Wegdam JA, Visser RJ, Bouvy ND, Nienhuijs SW, Reilingh Td. Preoperative exercise therapy preventing postoperative complications following complex abdominal wall reconstruction: A feasibility study. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:103-8. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/67/327065




  Introduction Top


With increasing life expectancies, more comorbidities, and progress in operative solutions, abdominal wall reconstruction (AWR) is available for more complex hernias in more complex patients. The technical advancement in AWR is mainly by myofascial releases on several levels and addition of aids like pneumoperitoneum or Botox.[1],[2] This enhances the movement of muscles relative to other muscles in order to overcome the defect. Examples of techniques such as Ramirez/CST, eCST, or TAR have been introduced.[3],[4],[5] However, the population undergoing an AWR tends to have significant associated, multiple comorbidities, complicating the recovery of a repair.[6],[7]

Through AWR, diaphragmatic function, use of respiratory accessory muscles, and coughing strength are negatively affected,[8] which expose these patients to a higher risk for respiratory complications. Especially when a myofascial release is used, the external oblique muscle or transversus abdominus muscle is released. Patients may have difficulty with coughing and forced expiration as the external oblique muscles and transversus abdominal muscle are accessory respiratory muscles.

Respiratory complications (pneumonia or respiratory insufficiency), following AWR are common, up to 20%.[8],[9] These complications are associated with a significant increased surgical morbidity and mortality, prolonged hospital and ICU stay, a significant additional cost burden,[9],[10] and indirectly a decrease in quality of life.[11]

The occurrence of respiratory complications and the progress of postoperative recovery are influenced by the preoperative physical capacity.[12],[13] Impaired physical capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Physical capacity can be tested with a cardiopulmonary exercise test (CPET). One of the outcome measurements is the anaerobic threshold (AT). The AT is the transition of the aerobic exertion (with oxygen) to the anaerobic exertion (with deficiency of oxygen). An AT lower than 11 ml/kg/min is associated with a higher mortality in great abdominal wall surgery.[14] Improving the physical capacity before surgery, by preoperative exercise therapy (PexT), is likely to give a better recovery and lower complication rate after surgery. In the last few years, several systematic reviews had been published about prehabilitation in different populations, recently also for major abdominal surgeries.[15],[16] These reviews show a positive effect of prehabilitation on postoperative pulmonary complications but not on length of hospital stay (LOHS). All reviews recommended to implement prehabilitation routinely before major abdominal surgery. In these reviews, diverse surgical procedures are included but there is no single trial in patients waiting for a complex abdominal wall hernia. Most recent studies about prehabilitation in patients with complex ventral hernia focus on weight loss and not on physical capacity.[17],[18] Due to the excessive loss of domain and/or enormous size of the belly, patients often are afraid to do exercises.

In this study, we will survey the feasibility of an intensive PexT in patients undergoing a complex AWR. Outcome measures will be added to demonstrate a possible effect of PexT on the physical capacity, health-related quality of life (HRQoL), pulmonary complications, and LOHS.


  Materials and Methods Top


A prospective cohort study was conducted between January and April 2018. Adult patients (aged 18–80 years) with a midline ventral hernia of >10 cm width were included. Patients were excluded with a body mass index (BMI) 20 ≤ or ≥ 40 kg/m2, American Society of Anesthesiologists (ASA) physical status classification system ≥ 4, or any comorbidity interfering with the ability to perform exercise (e.d. neuromuscular or orthopedic disabilities). The sample size was set on 11 patients, since this number is within the capability of a single-center study and should provide sufficient evidence to evaluate the feasibility of the intervention.

Intervention

The intervention was a 3-months program consisting of three components. At first, patients were given information about the benefits of preoperative exercise therapy (PexT) and encouragement to adhere to the intervention. Secondly, patients were instructed to use an inspiratory threshold-loading device (IMT) for 15 min daily. The initial load was set at 20% of the maximal inspiratory pressure, increasing weekly by 10% if the exhaustion score (Borg-score) was <13.[19],[20] Thirdly, three times a week patients had to do cardiovascular and strength training: two supervised and one unsupervised session at home. The supervised session lasted for 60–90 min and consisted of 30–40 min aerobic training on 60%-80% of the VO2max or just below the anaerobe threshold. Resistance training of six to eight great muscle groups was executed on 80% of 1-repeated maximum (1RM), for eight repetitions in four series.[21] Patients were instructed to wear their abdominal binder and to breath out during the exercise. In the unsupervised session, the patient had to do a functional activity, according to his/her capabilities and interest. The activity had to last for at least 45 min and the exhaustion score (Borg-score) must be between 11 and 13. The patient receives guides on active cycle of breathing exercise, including coughing and huffing, prior to the operation.[22] If necessary, patients were instructed to quit smoking or to lose weight, as this is usual care in the Elkerliek Hospital.

Outcome measurements

The primary outcome was feasibility, defined as the occurrence of adverse events and the possibility to perform more than 80% of the training on the before set intensity. The secondary outcomes were the physical capacity, HRQoL, the amount of pulmonary complications, and the LOHS. Physical capacity, measured with the CPET, was conducted at baseline, after the intervention, and 3 months after the operation. The CPET was performed on a cycle ergometer (Lode Corrival, Groningen, The Netherlands). The test was conducted by a sports physician and consisted of an anaerobic threshold and maximal oxygen consumption measurement (VO2max). The test was symptom-limited, and respiratory gas analysis was conducted.

HRQoL was measured with the RAND-36[23] at baseline and after intervention. Pulmonary complications were defined as >48 h on the mechanical ventilator after surgery, re-intubation, acute respiratory distress syndrome, atelectasis, or pneumonia (either pulmonary infiltration on X-ray in combination with clinical symptoms or positive sputum culture). LOHS was noted from day of surgery until day of discharge.

Statistics

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics will be noted in median and 95% confidence interval (CI). Due to small number of patients, no normality of data will be reached. Domains of the RAND-36 and physical capacity were analyzed with the non-parametric Wilcoxon signed-rank test. The amount of pulmonary complications and LOHS were noted and compared with all comparable patients in 2018 using Fisher’s exact test and Mann–Whitney U-test, respectively. For all analyses, a significance of P < 0.05 was used.


  Results Top


From all the approached patients, one did not want to participate in this study (due to the distance to the training center). Eleven patients were included between January and April 2018. Nine males and two females were included with a median age of 59 years (51–71) and a BMI of 31.6 kg/m2 (28.1–36.7). The median diameter of the width of the ventral hernia was 16.0 cm (15.0–23.0). Demographics can be found in [Table 1]. During the PexT, no adverse events occurred and all patients could perform the intervention for >80% on the before set intensity. All patients completed the full program.
Table 1: Patient demographics

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A difference in VO2 max was found between the baseline measurement and after the intervention [Table 2]. Also a clinically relevant difference was found in the overall HRQoL between baseline and after the intervention (P = 0.028). Evaluating the different domains of the RAND-36, there was an improvement in most domains [Figure 1] and [Table 3].
Table 2: Outcome CPET in median (95% CI)

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Figure 1: Domains of HRQoL according to the RAND-36.

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Table 3: Quality of life (RAND-36) in median (95% CI)

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All patients had a successful reconstruction with fascial closure. Reconstruction was performed with transversus abdominal release (n = 6), endoscopic component separation technique (n = 2) or Rives–Stoppa repair (n = 3). Three patients had a pulmonary complication, which is 27% of the total population in the study. This complication rate did not differ from the other likewise patients in our institute (n = 50, P = 0.676). The median of hospital stay was 6.8 days (range 3–15) and did also not differ from the patients outside this study [n = 50, 6.9 days (range 2–19), P = 0.455].


  Discussion Top


This study shows that intensive PExT is feasible in patients with a complex abdominal ventral hernia. Next to that, we found a relevant difference on the physical capacity and HRQoL after the intervention. No difference was found on pulmonary complication rate or LOHS after surgery.

In the most recent reviews on prehabilitation in major abdominal surgery, contradictory evidence was found on the effect of prehabilitation on physical capacity, mainly through the heterogeneous use of outcome measurements.[15],[16] Physical condition is mostly measured with the 6-min walking test. The 6-min walking test is an acceptable and cheap alternative to test the physical function in daily practice, but it is not as specific as the CPET, which is the golden standard for measuring physical capacity.[14] A CPET is more sensitive to identify significant differences in physical capacity. The CPET also provides outcome measures as the VO2max and AT. These outcomes are desired to identify the precise intensity of the cardiovascular training.

To achieve the best result of preoperative training, not only the intensity is important but also the duration of the training. The interventions in the studies included in the most recent reviews are short (max. 6 weeks) and low intensive with a duration of maximal 60 min. To create a significant and clinical relevant difference on physical capacity, it is desired to prolong the time of the intervention program and to intensify the therapy program [Figure 2].[21] This might clarify why the effects of preoperative training that are published are minimal. In case of a complex abdominal ventral hernia, it is in most cases possible to postpone surgery. This time should be taken to achieve a greater result of PExT.
Figure 2: A patient performing the strength training on the leg press

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The results of 3 months training in this study show a positive change on physical capacity and also in overall score and most domains of the HRQoL. This can be attributed to the general effects of physical activity on HRQoL.[24] Thereby, patients with a great abdominal hernia are often afraid to exercise as they have developed a ventral hernia before. The fear for exercise can contribute to the decrease of HRQoL in patients with a complex abdominal hernia. The positive findings on feasibility might motivate patients with a complex abdominal wall hernia to exercise before surgery. Next to that, patients often feel like they are handed down to the medical system when they are waiting for surgery. To improve physical performance, they can positively contribute to their own care path. This will increase the autonomy of the patient and, when good instructions are given, it will increase the compliance to the exercise which is proposed to be essential for a potential prehabilitation program’s success.[16]

Another essential aspect for succeeding of the PExT is the supervised session, as it tends to have a greater effect than unsupervised sessions in other diseases.[25],[26] The interventions as described in this study include intensive strength training at 80% of the 1RM. When this amount of strength is conducted, the intra-abdominal pressure (IAP) raises which increases the bulging through the ventral hernia. This is associated with discomfort and pain. It is essential to give instructions during the intervention to prevent increased IAP, through raising the diaphragm by breathing out during the contraction of the strength exercise. This is in addition to the counter-pressure of the abdominal binder. Therefore, PExT in patients with a complex abdominal wall hernia needs to be guided by an experienced physical therapist.

In contradiction with the other studies, we found no effect on the prevention of pulmonary complications or LOHS. As the population of this study is small, it was not expected to find a significant difference between groups. In the Elkerliek Hospital, prehabilitation (quit smoking and to lose weight) and enhanced recovery after surgery are applied for years for all patients after an AWR. As this contributes to improved clinical outcomes and decreased LOHS,[27] it is harder to find a significant difference on these outcomes, especially in this small number of patients.

Limitations

The greatest limitation of this study was the small sample size and the lack of a control group. As this is the first initiative for an intensive preoperative training program in patients with great abdominal wall hernias, a greater population should be tested in the future.

Selection bias occurred in this study because the patients who agreed to participate in the study are mainly patients who are motivated to fill the intervention.

Lastly, all patients had a successful AWR but different operation techniques are used. It is not described that whether or not a myofascial release provides more (pulmonary) complications.


  Conclusion Top


Intensive PExT is feasible in patients waiting for a complex AWR. A randomized controlled trial need to be conducted to objectivate the effect of PExT to prevent pulmonary complications and to reduce LOHS in this population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/ have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical approval

This study was approved by Medical research Ethics Committees United (MEC-U) (No.: NL59207.100.16) in May 2017.

Financial support and sponsorship

The study protocol received the research grant of the European Hernia Society.

Conflicts of interest

There are no conflicts of interest.



 
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