The physiotherapist and the esophageal cancer patient: from prehabilitation to rehabilitation
By academic.oup.com
Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches, the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoperative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobilization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies, however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored. While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.
Esophageal cancer is a debilitating disease, frequently diagnosed at an advanced stage and traditionally associated with poor outcomes. Despite considerable advances, surgical resection remains the mainstay of treatment with curative intent. Surgery carries significant risks of major morbidity, and in-hospital mortality up to 5%, consequently strategies to reduce postoperative complication are of considerable importance.1
Physiotherapists play a key role in enhancing cardiopulmonary function and managing pulmonary complications following esophagectomy.2 Traditionally, physiotherapy focused on postoperative care, but the role is evolving to include surgical prehabilitation and Enhanced Recovery After Surgery (ERAS). ERAS provides a multidisciplinary, standardized postoperative pathway for the management of patients on a common clinical course.3 A meta-analysis of ERAS pathways in colorectal surgery reported reduced hospital stay (−2.55 [95% CI −3.24, −1.85] days) and overall complication rates (relative risk 0.53 [95% CI 0.44, 0.64]) with standardized protocols. In esophagectomy, length of stay (LOS) studies report a difference of up to 3 days in hospital in patients on ERAS versus non-ERAS pathways,4–6 largely driven by a reduction in minor and serious complication rates. Prehabilitation and early mobilization are two key components of ERAS in which physiotherapy plays a key role. The aim of this paper is to review the literature describing the rationale for physiotherapy interventions in the management of patients undergoing esophagectomy.
METHODS
This paper provides a narrative review of the literature examining the role of the physiotherapist through the management of patients with esophageal cancer. The review discusses the complete patient journey, from diagnosis, through neoadjuvant treatment and post-esophagectomy. The role of exercise management and physiotherapy interventions in this complex cancer are considered from a multiple literature sources and in addition to esophageal cancer specific work. Studies specific to esophageal cancer were identified through a search of the key databases EMBASE, PubMed, CINAHL, and Scopus using a combination of key terms including ‘o/esophageal cancer’, ‘o/esophagectomy’,’ ‘o/esophageal surgery’, ‘neoadjuvant treatment’, ‘chemotherapy’, ‘radiotherapy’, ‘radiation therapy’, ‘chemoradiotherapy’, ‘multimodal treatment’, ‘physical therapy modalities’, ‘chest physiotherapy’, ‘chest physical therapy’, ‘physical function/ing’, ‘postoperative pulmonary complications’, ‘physical activity’, ‘fitness’, ‘physical performance’, ‘physical capacity’, ‘exercise’, ‘strength’, ‘cachexia’, and ‘functional status’. A manual search of relevant reference lists was also completed. All papers in the English language published up until August 2015 were considered for inclusion.
EMERGING ROLE FOR PHYSIOTHERAPY PRE-ESOPHAGECTOMY
Esophagectomy remains one of the most complex cancer surgical procedures. Postoperative pulmonary complications (PPC) are the most serious morbidity following esophagectomy with rates as high as 45%7 and are the leading cause of postoperative mortality, accounting for over 50% of in-hospital deaths.8 Curative treatment can involve either surgical resection only or multimodality involving esophagectomy and either neoadjuvant chemoradiotherapy or perioperative chemotherapy protocols, with the CROSS9 and MAGIC10 protocols the most common approaches for each, respectively.
Preoperative assessment aims to determine surgical candidacy, anticipate postoperative care requirements, and reduce postoperative complications. Physiotherapists have a role in evaluating preoperative cardiopulmonary fitness and physical functioning, established predictors of major surgical outcome,11 that are amenable to prehabilitative interventions.
Source: https://academic.oup.com/dote/article/doi/10.1111/dote.12514/2725522/The-physiotherapist-and-the-esophageal-cancer