Bhalla, Ashish
(2016)
Skeletal muscle modulation and functional recovery after colonic resection.
PhD thesis, University of Nottingham.
Abstract
Introduction: Colorectal cancer surgery involves a period of recovery in hospital followed by convalescence at home. Enhanced recovery programs, in particular the use of laparoscopic surgery have reduced length of inpatient stay. Knowledge regarding the impact of surgery upon functional recovery is lacking. Loss of lean muscle mass and strength may compromise function. We conducted two studies (1) To assess skeletal muscle modulation and functional recovery after potentially curative colon cancer surgery, comparing traditional open surgery (OS) with laparoscopic (LS) techniques and (2) To review return to work (RTW) 1 year post colorectal cancer surgery.
Methods: (1) A prospective longitudinal observational study was conducted at a single UK institution (April 2013 and December 2014). Participants undergoing OS and LS for colon cancer were recruited preoperatively and assessed over 6 months. The study was powered to changes in hand grip strength (minimum sample size of 24 patients in each group), and included analysis of serological inflammatory markers (granulocyte lymphocyte ratio (GLR)); muscle architecture (pennation angle (PA), muscle thickness (MT) and fascicle length (FL)), muscle protein synthesis rate and assessment of function (numerical pain score, dukes activity status index (DASI)) and health status (EQ5d5L).
(2) A retrospective cohort questionnaire study was conducted. A specific questionnaire was created and dispatched to 204 patients who had undergone surgery with curative intent for colorectal cancer within a single teaching hospital in 2011-2012.
Results: (1) Fifty-three patients (OS n=27; LS n=26) were recruited with no statistical differences between groups (age, sex, body mass index, tumour stage, blood loss). LS associated with longer mean operating time (182.5mins v 142.1mins, p<0.05), fewer complications (p<0.05) and shorter length of stay (3 days v 5 days, p<0.05).
Hand grip decreased post surgery (maximum decrease day 3 (OS 24% v LS 15%, p<0.05), with OS data significantly lower at 2, 4 and 6 weeks (p<0.05)). GLR peaked on day 1 post surgery with no difference between groups at any time point. Muscle architecture assessment noted OS associated with decreased MT (8% v 1%, p<0.05) and PA (6% v 1%, p<0.05) at 4 and 6 weeks post surgery. Muscle protein synthesis rate for OS was 1.02±0.02%/day. OS pain scores were significantly higher at 2, 4 and 6 weeks (p<0.05). EQ5d5L and DASI scores were significantly lower for OS at 2, 4, 6 weeks and 6 months (p<0.05).
(2) Response rate was 75% (OS=82%, LS=51%). LS reported earlier 'return to full fitness' (1-3 months) than OS (>6 months; p<0.05). Recovery from LS was 'better than expected' compared to OS 'worse than expected' (p<0.05). Forty-nine patients were employed preoperatively and 61% (n=30) returned to work. RTW was more frequent after LS (p<0.05). Length of time to RTW was significantly less after LS [44 (6-84) days] than OS [71 (14-252) days] (p<0.05).
Conclusions: OS was associated with increased loss of strength, muscle mass and reduced MPS in the first six weeks after surgery, together with poorer functional recovery including RTW. One-third of patients failed to RTW 1 year post colorectal cancer surgery. We must invest more in managing expectations and provide better post discharge support to improve long term functionality.
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