Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials.

BACKGROUND: There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes. METHODS: MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival. RESULTS: We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay. DISCUSSION: Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings. TRIAL REGISTRATION NUMBER: CRD42021232067.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery.

OBJECTIVES: Malnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a reduction in malnutrition, complications or quality of life. DESIGN: A randomised, open label, controlled feasibility study was conducted to assess the feasibility of carrying out a large multicentre randomised trial of nutritional intervention. The intervention involved preoperative carbohydrate-loading drinks (4×200 mL evening before surgery and 2×200 mL the morning of surgery) and early postoperative nutritional protein supplement drinks two times per day for 14 days compared with the control group receiving an equivalent volume of water. SETTING: Single adult thoracic centre in the UK. PARTICIPANTS: All adult patients admitted for major lung surgery. Patients were included if were able to take nutritional drinks prior to surgery and give written informed consent. Patients were excluded if they were likely unable to complete the study questionnaires, they had a body mass index <18.5 kg/m2, were receiving parenteral nutrition or known pregnancy. RESULTS: All patients presenting for major lung surgery were screened over a 6-month period, with 163 patients screened, 99 excluded and 64 (41%) patients randomised. Feasibility criteria were met and the study completed recruitment 5 months ahead of target. The two groups were well balanced and tools used to measure outcomes were robust. Compliance with nutritional drinks was 97% preoperatively and 89% postoperatively; 89% of the questionnaires at 3 months were returned fully completed. The qualitative interviews demonstrated that the trial and the intervention were acceptable to patients. Patients felt the questionnaires captured their experience of recovery from surgery well. CONCLUSION: A large multicentre randomised controlled trial of nutritional intervention in major lung surgery is feasible and required to test clinical efficacy in improving outcomes after surgery. TRIAL REGISTRATION NUMBER: ISRCTN16535341.

Fit 4 surgery, a bespoke app with biofeedback delivers rehabilitation at home before and after elective lung resection.

BACKGROUND: Pulmonary rehabilitation programme for lung surgery patients can reduce the risk of post-operative complications but compliance to programmes can be limited by access to health care. We developed a home-based rehabilitation app and tested its feasibility in patients undergoing lung resection surgery. METHODS: A cohort study was conducted over 18 months at a regional thoracic unit. The Fit 4 Surgery app included ten exercises. Patients were instructed to exercise for at least three minutes for each exercise. Data was transmitted back to the researchers remotely. Data was also collected from a contemporaneous group of surgery patients who attended local outpatient-based Chronic Obstructive Pulmonary Disease rehabilitation classes. Quality of Life and outcomes data in the app group were collected. Patients were also interviewed about their experience of the app. RESULTS: App patients had a shorter wait before surgery compared to patients attending rehabilitation classes (24 vs 45 days) but managed four times as many sessions (2 vs 9), improving incremental shuttle walk test distance by 99 ± 83 (p < 0.05) metres before surgery. Five themes were gathered from the interviews. CONCLUSION: An app based programme of rehabilitation can be delivered in a timely fashion to lung surgery patients with demonstrable physiological benefits; this will need to be confirmed in further clinical trials. CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN00061628. Registered 27 May 2011.

Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications.

BACKGROUND: Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. METHODS: 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. RESULTS: No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI -5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI -7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (-7.4% to 2.6%). CONCLUSIONS: Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

Developments in the management of patients with lung cancer in the United kingdom have improved quality of care.

The management of patients with lung cancer has undergone significant improvement in the last decade in the United Kingdom. The 5-year survival for all patients diagnosed with lung cancer had remained unchanged at 5% over the previous decade, well behind Europe and the United States. Together, government and medical bodies produced guidelines based on best available evidence. The dissemination of these guidelines into clinical practice became the remit of Cancer Networks. The establishment of Multidisciplinary teams (MDTs) has streamlined care and allowed individual teams to discuss patients' management within a wider body of expertise. The Cancer Network quality assurance team assesses the MDTs to ensure that standards are maintained. Though the efficacy of the MDTs in improving quality and consistency of care for patients with lung cancer is irrefutable, the effects on overall survival rates are less certain. The majority of patients have advanced incurable disease at presentation. Changes in awareness of the general public and in the primary care setting are required to address this issue. Severe co-morbidities in patients with potentially curable disease can also preclude operative treatment. The delivery of specialized care for patients with lung cancer has improved dramatically in the United Kingdom with the advent of national guidelines and the local MDT. These measures may not be enough in remedying the poor long-term survival of patients with lung cancer in the United Kingdom without attention to underlying cause. A holistic attitude to the "Big Three" smoking-induced diseases offers hope of novel approach to this problem.