Surgery places significant stress on the body, especially major surgery that involves being fully “knocked out” with general anesthesia. Patients recovering from surgery often need to build strength back up and may also be affected by complications. In particular, post-surgery pulmonary (lung) complications, ranging from mild atelectasis to severe hospital-acquired pneumonia and respiratory failure, negatively affect health and recovery. Lung complications are one of the most common types of complications following major abdominal surgery, which is the most common major surgery performed in developed countries.1 Improving strength and health before surgery, such as with pre-surgery physical therapy, is a potential strategy to prevent or reduce complications.
A recent large and rigorous study, the Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial,2 replicated previous findings3 by demonstrating that a single pre-surgery physicial therapy education and training session decreased the postoperative pulmonary complication incidence rate by half.
In general, pre-surgery physical therapy has been associated with reducing pulmonary collapse and airway infection, resulting in reduced oxygen therapy needs and antibiotic prescriptions.4 In addition, it has been demonstrated to improve pulmonary functions and decrease the incidence of postoperative lung complications in obese patients undergoing upper abdominal surgery as well.5
Pre-surgery physical therapy has also been shown to be highly effective in this aspect, and international consensus has been reached on the importance of preventing postoperative pulmonary complications in perioperative care. Nonetheless, preoperative physiotherapy is still uncommon.6
In order to understand and address this gap, a study from 2020 sought to carry out a cost-effectiveness analysis from the hospitals’ perspective.7 Overall, results revealed that preoperative physiotherapy had a 95% probability of being cost-effective – with a net benefit to hospitals of nearly $5,000 Australian dollars for each postoperative pulmonary complication prevented. For each pulmonary complication prevented, preoperative physiotherapy was likely to cost the hospitals less than the cost of treating a pulmonary complication. Potential quality of life improvement gains remain to be confirmed, however.
Additional research has identified that different physical therapy techniques, as a part of the comprehensive management of patients undergoing cardiac, upper abdominal, and thoracic surgery, may prevent and treat a variety of postoperative pulmonary complications, including but not limited to pneumonia.8
Despite the clear benefits of preoperative physical therapy in certain clinical contexts, for patients with chronic obstructive pulmonary disorder undergoing lung cancer resection, the role of exercise, which strengthens muscles but does not improve impaired lung function, remains uncertain due to limited data. Additional research trials are needed on this topic.9
Preoperative physical therapy may reduce the incidence of lung complications associated with surgery. Unfortunately, uncertainty surrounding the economic costs and benefits of preoperative physiotherapy may be preventing the implementation of this intervention. Greater awareness through surgeon education may be useful. Additional research is required, meanwhile, to see what specific physical therapy regimens are best.10
References
1. Shander, A. et al. Clinical and economic burden of postoperative pulmonary complications: Patient safety summit on definition, risk-reducing interventions, and preventive strategies. Critical Care Medicine (2011). doi:10.1097/CCM.0b013e31821f0522
2. Boden, I. et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: Pragmatic, double blinded, multicentre randomised controlled trial. BMJ (2018). doi:10.1136/bmj.j5916
3. Fagevik Olsén, M., Hahn, I., Nordgren, S., Lönroth, H. & Lundholm, K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br. J. Surg. (1997). doi:10.1002/bjs.1800841111
4. Boden, I. et al. Effects of preoperative physiotherapy on signs and symptoms of pulmonary collapse and infection after major abdominal surgery: secondary analysis of the LIPPSMAck-POP multicentre randomised controlled trial. Perioper. Med. 10, 36 (2021). doi: 10.1186/s13741-021-00206-3.
5. Abdelaal, G. A., Eldahdouh, S. S., Abdelsamie, M. & Labeeb, A. Effect of preoperative physical and respiratory therapy on postoperative pulmonary functions and complications after laparoscopic upper abdominal surgery in obese patients. Egypt. J. Chest Dis. Tuberc. 66, 735–738 (2017). doi:10.1016/j.ejcdt.2017.10.012
6. Reeve, J. et al. The physiotherapy management of patients undergoing abdominal surgery: A survey of current practice. New Zeal. J. Physiother. (2019). doi:10.15619/NZJP/47.2.02
7. Boden, I. et al. Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial. J. Physiother. 66, 180–187 (2020). doi: 10.1016/j.jphys.2020.06.005.
8. Makhabah, D. N., Martino, F. & Ambrosino, N. Peri-operative physiotherapy. Multidisciplinary Respiratory Medicine (2013). doi:10.1186/2049-6958-8-4
9. Li, X. et al. Impact of preoperative exercise therapy on surgical outcomes in lung cancer patients with or without COPD: A systematic review and meta-analysis. Cancer Manag. Res. (2019). doi:10.2147/CMAR.S186432
10. Pouwels, S. et al. Preoperative exercise therapy in lung surgery patients: A systematic review. Respiratory Medicine (2015). doi:10.1016/j.rmed.2015.08.009