ASO Author Reflections: What is the Role of Cardiopulmonary Exercise Testing Prior to Oesophagectomy?
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: What is the Role of Cardiopulmonary Exercise Testing Prior to Oesophagectomy? Jonathan Sivakumar, MBBS, PGDipSurgAnat, MSurg1,2 , Harry Sivakumar, MBBS, BMedSci (Hons), FANZCA3, and Michael W. Hii, MBBS, BMedSci, PGDipSurgAnat, FRACS1,2 1
3Department of Upper Gastrointestinal Surgery, St Vincent’s Hospital Melbourne, Melbourne, Australia; 2Department of Surgery, St Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, Australia; 3Department of Anaesthesia, The Alfred Hospital, Melbourne, Australia
PAST
FUTURE
Cardiopulmonary exercise testing (CPET) provides an integrated assessment of a patient’s tolerance to metabolic stress. As an extrapolation, this may correlate with a patient’s capacity to cope with the metabolic derangements associated with surgery.1 Theoretically, CPET may improve risk stratification and assist patient management by identifying those who may benefit from further workup and optimisation, and also those who may benefit from advanced care postoperatively. Evolving evidence supports the utility of CPET across a range of surgical disciplines; however, CPET has not been assessed by randomized trials in patients undergoing oesophagectomy.
CPET has not been compared with other established patient assessment methods, and there is no randomised evidence showing improved outcomes following the use of CPET. A pragmatic first step, which would greatly increase the utility of preoperative CPET before oesophagectomy, would be the determination of critical threshold values for _ 2 peak) and anaerobic threshold peak oxygen uptake (VO (AT) in terms of risk categorisation.3 Other undefined factors requiring investigation include the timing at which CPET should be administered as well as the validity of CPET reassessment in high-risk patients who have completed prehabilitation. Understanding this would facilitate the development of standardised guidelines for the use of CPET in oesophageal surgery. Additional challenges to widespread implementation of CPET include time for testing and financial cost, and the need for trained-clinicians who are familiar with deriving _ 2 peak and AT values.4 If the use of and interpreting VO CPET can be shown to improve patient selection or reduce postoperative morbidity, through prehabilitation, and potentially reduce the need for a complex postoperative recovery, then this may support these initial upfront costs.
PRESENT Our meta-analysis has demonstrated a moderate correlation between CPET-derived variables and cardiopulmonary complications, unplanned ICU admission and 1-year survival.2 This supports the current practice of using CPET as part of the decision-making algorithm in patients being considered for an oesophageal resection. As an isolated test, however, CPET is unable to definitively determine which patients are safe for surgery and so its precise role amongst the suite of possible investigations requires refinement.
Ó Society of Surgical Oncology 2020 First Received: 8 May 2020 J. Sivakumar, MBBS
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