The Impact of Physical Activity on the Outcome of Surgery
Physical activity (PA) has been in focus over the last two decades as a life style factor of
importance. A review summarizing nearly 170 studies states that the scientific evidence for
the association between lack of physical activity and cancer is convincing regarding breast
and colon cancer and probable for prostate cancer and possible for lung and endometrial
cancer (8). Regarding postoperative rehabilitation the benefits from preoperative physical
exercise together with a postoperative early rehabilitation schedule has been reported for
spinal surgery (9). In colorectal surgery the benefits of enhanced recovery programs have
been clearly demonstrated (10). The impact of preoperative prehabilitation has been
evaluated and seems beneficial (11, 12), however most studies have not used clinically
important outcome measures such as complications or postoperative morbidity. The evidence
for prehabilitation as a measure to reduce postoperative morbidity is scarce (12). To
evaluate the recovery after a surgical procedure in a broader sense is difficult. Several
scales have been tried to assess recovery (13-16).
The simple instrument for self-reported PA introduced by Saltin and Grimby has been shown to
discriminate between sedentary and active counterparts regarding maximum oxygen uptake (17)
and has been validated against biological measures (18). Indeed, studies have indicated that
such single self-reported approximation of the level of PA, may predict risk for morbidity
and cardiovascular as well as total mortality (19-21). The self-assessed PA-level concurs
well with the actual physical fitness of the individual (22-24). This is also important,
since cardiorespiratory fitness may also predict cardiovascular risk and mortality (25).
There are also studies indicating that other life-style factors such as alcohol consumption
has a negative impact on outcome after surgery as well as outcome after health-care
associated infections (26, 27). To screen for excessive alcohol consumption the Alcohol Use
Disorders Identification Test-Consumption (AUDIT) test has been used. Several recent studies
have indicated that a shorter survey with the top three questions in the AUDIT questionnaire
(AUDIT-C) is sufficient to provide information on alcohol use (28, 29).
Smoking is also a life-style factor that affects surgical outcome (30). It has been shown to
increase the risk for complications and studies indicate that smoking cessation prior to the
surgical procedure to reduce the risk for complications (31). Self-reported assessment of
smoking seems to be accurate and reflect the actual nicotine use of the individual (32).
Length of hospital stay is of importance both to patients and the society. A surgical
procedure that shortens hospital stay may be cost-effective even in cases with higher
operation room costs (33). It is also of importance to consider time to work/sick leave; a
cost for patients and society that can affect the cost analysis of a surgical procedure
The aim of this study is to investigate whether a higher physical activity prior to a
surgical procedure reduces hospital stay, sick leave and the complication rate.
A secondary aim is to investigate the effect of preoperative physical activity on the rate
of resumption of QoL and normal physical function.
In order to explore the importance of PA for the outcome after a surgical procedure due to
gallbladder disease, breast cancer and colorectal cancer we will ask all patients operated
for any of the three above mentioned conditions to answer a short questionnaire (Appendix I)
including the Saltin and Grimby (7) questions to study of the effects of the level of PA
immediately before surgical operations. The patients will be asked to estimate their
physical activity four weeks prior to the surgical procedure.
1. Mostly sedentary
2. Light PA (such as gardening or walking or bicycling to work) at least two hours a week
3. Moderate PA such as aerobics, dancing, swimming, playing football or heavy gardening)
at least two hours a week
4. Vigorous PA (high intensity) at least five hours daily several times a week.
They will also be asked to report weight, length, smoking habits, alcohol consumption,
socioeconomic situation, diabetes, hypertension, hyperlipidaemia and BMI as well as certain
questions with relation to Quality of Life and their postoperative recovery (Appendix I).
The questions are to some extent validated through previous research (28, 29, 32, 47, 48)
but some questions are newly constructed. The new questions have been constructed by an
expert panel consisting of colorectal and general surgeons, cardiologist and specialized
nurses. The domains chosen have been related to previous research regarding recovery (42).
The questionnaire has been face-to face validated by patients with gall bladder surgery
planned or a previous cholecystectomy performed, patients with breast cancer both prior and
after surgery and colorectal cancer patients prior and after surgery using the same
validation methods previously described for prostate cancer (48).
All patients will be contacted by telephone and a subsequently receive a mailed
questionnaire (similar to the pre-operative questionnaire) (Appendix II) regarding their
self-assessed QoL post-operatively and postoperative recovery, the timing of this will be
related to the estimated time for recovery as follows:
- 3 weeks after gallbladder surgery
- 3 and 6 weeks after surgery for breast cancer
- 3 and 6 weeks after surgery for colorectal cancer
Observational Model: Cohort, Time Perspective: Prospective
Length of sick-leave/time to work
for breast cancer and gallbladder surgery
Eva Angenete, M.D., Ph.D.
SSORG, Scandinavian Surgical Outcomes Research Group
Sweden: Institutional Review Board