Olivia Sand: Recovery after surgery for peritoneal metastases: Pulmonary complications, prehabilitation and physical recovery

Abstract

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgical treatment aimed at improving survival in patients with peritoneal metastases. However, it is associated with high morbidity rates and delayed postoperative recovery. The overall aim of this thesis was to explore postoperative recovery after CRS and HIPEC, focusing on pulmonary complications, prehabilitation and physical recovery. 

Methods: In Study I, the incidence and risk factors for severe postoperative pulmonary complications (PPCs) and the association with overall survival was assessed in 417 patients who underwent CRS and HIPEC between 2007 and 2017. Study II was a scoping review on prehabilitation, including at least one component of physical exercise, prior to surgery for peritoneal metastases. In Study III, the feasibility of preoperative inspiratory muscle training (IMT) was evaluated using a randomized controlled design. Finally, Study IV explored physical activity, physical recovery and support needs after CRS and HIPEC using a longitudinal mixed methods approach. 

Results: Severe PPCs were common with full thickness diaphragmatic injury and/or diaphragmatic resection identified as the most influential risk factors. Furthermore, severe PPCs, together with severe non-pulmonary complications, were associated with worse overall survival. Prehabilitation including physical exercise before surgery for peritoneal metastases, is an emerging research field with most articles published 2024 onwards and evidence primarily derived from small and heterogeneous studies. In Study III, IMT was found to be safe and acceptable. However, recruitment and attrition were aspects that need to be addressed prior to a full-scale randomized controlled trial. Study IV demonstrated that individuals with higher physical activity levels three months after surgery expressed a higher need for support for physical recovery compared with less active individuals. 

Conclusions: This thesis demonstrates the high incidence of severe postoperative pulmonary complications following CRS and HIPEC and their negative impact on overall survival. It further highlights that research on prehabilitation in patients with peritoneal metastases remains at an early stage of development and synthesises methodological considerations for future research. In addition, the thesis informs the design of a future large-scale randomized controlled trial evaluating the effect of preoperative IMT and provides an in-depth understanding of pre- and postoperative physical activity levels, physical recovery and support needs after CRS and HIPEC.