Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study

Malcolm A West^{1

2}, Saqib Rahman¹, Sandy Jack^{2

3}, Michael P W Grocott^{2

3}, Denny Z H Levett^{2

3}; Perioperative Exercise Testing and Training Society (POETTS); Yasir Rashid^{4

5}, John Griffiths^{4

5}, Martin Ezra^{4

5}, Lyndsay Ayres⁶, Helen Neville-Webbe^{6

7}, Muhammad Shafiq Javed⁷, Milind Shrotri⁷, Iftikhar Khan⁷, David Whitmore^{6

8}, Pradeep Prabhu⁹, David Timbrell^{9

10}, Sophie Allen¹¹, Andrew O Packham¹², David Sharpe¹³, Helen Anderson¹⁴, Gary Minto¹⁴, Samuel McAleer^{14

15}, Stuart McPhail^{14

16}, Mohamed Alasmar^{17

18}, Robert A Hartley^{17

18}, Javed Sultan^{11

17

18}, Ben Grace¹, Timothy J Underwood^{1

2

19}, James Byrne¹⁹, Fergus Noble¹⁹, Jamie Kelly¹⁹, Gillian Ansell^{2

3

19}, Mark Edwards^{2

3

19}

Affiliations

¹ School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
² Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK.
³ Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
⁴ Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵ Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
⁶ Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
⁷ Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
⁸ Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
⁹ Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK.
¹⁰ Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK.
¹¹ Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK.
¹² Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK.
¹³ Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK.
¹⁴ Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK.
¹⁵ Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK.
¹⁶ Institute of Naval Medicine, Alverstoke, UK.
¹⁷ Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK.
¹⁸ Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK.
¹⁹ University Hospitals Southampton, Department of Surgery, Southampton, UK.

PMID: 38947220
PMCID: PMC11214286
DOI: 10.1016/j.bjao.2024.100289

Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study

Malcolm A West et al. BJA Open. 2024.

. 2024 Jun 7:10:100289.

doi: 10.1016/j.bjao.2024.100289. eCollection 2024 Jun.

Authors

Affiliations

¹ School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
² Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK.
³ Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
⁴ Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵ Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
⁶ Departments of Anaesthesia and Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
⁷ Department of General Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
⁸ Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
⁹ Department of Anaesthetics, The Royal Surrey Foundation NHS Trust, Guildford, UK.
¹⁰ Anaesthetic Department, Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK.
¹¹ Department of General Surgery, The Royal Surrey NHS Foundation Trust Hospital, Minimal Access Therapy Training Unit (MATTU), Guildford, UK.
¹² Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK.
¹³ Department of Gastro-Intestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK.
¹⁴ Directorate of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK.
¹⁵ Emergency Medical Retrieval and Transfer Service, Cymru, Joint Hospital Group (Southwest), UK.
¹⁶ Institute of Naval Medicine, Alverstoke, UK.
¹⁷ Salford Royal NHS Foundation Trust, Salford Royal, Salford, UK.
¹⁸ Division of Cancer Sciences, School of Medical Sciences, University of Manchester, UK.
¹⁹ University Hospitals Southampton, Department of Surgery, Southampton, UK.

PMID: 38947220
PMCID: PMC11214286
DOI: 10.1016/j.bjao.2024.100289

Abstract

Background: Outcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.

Methods: Patients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO₂ peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.

Results: Seven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO₂ peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien-Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and V_E/VCO₂ at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.

Conclusions: VO₂ peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.

Clinical trial registration: NCT03637647.

Keywords: cardiopulmonary exercise testing; fitness; morbidity; mortality; neoadjuvant cancer treatments; oesophagogastric cancer; tumour outcomes.

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Figures

**Fig 1**
Study flow diagram detailing inclusions and exclusions to reach final sample size. CPET, cardiopulmonary exercise test; GOJ, gastro-oesophageal junction.

**Fig 2**
Kaplan–Meier curve showing the overall survival after surgery stratified at median (a) oxygen uptake at peak (VO₂ peak [ml kg⁻¹ min⁻¹]) and (b) oxygen uptake at anaerobic threshold (AT [ml kg⁻¹ min⁻¹]) for the whole cohort. No survival difference was found when patients were dichotomised around median VO₂ peak (P=0.771) or AT (P=0.794).

See this image and copyright information in PMC

References

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Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study

Affiliations

Cardiopulmonary exercise variables and their association with postoperative morbidity and mortality after major oesophagogastric cancer surgery-a multicentre observational study

Authors

Affiliations

Abstract

Figures

References

Associated data

LinkOut - more resources

Full Text Sources

Medical