Enhanced Perioperative Pulmonary Physiotherapy for Prevention of Pulmonary Complications After Laparoscopic Liver Surgery

Background: Postoperative pulmonary complications (PPC) are the most common serious complications after major abdominal surgery. PPC rate varies between 10-50% after open abdominal surgery, depending on the definitions used (Miskovic & Lumb, 2017; PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology et al., 2014). According to the European Perioperative Clinical Outcome (EPCO) definition, PPCs enclose clinically relevant pulmonary complications including respiratory infection, atelectasis, pleural effusion, respiratory failure, bronchospasm/ exacerbation of chronic pulmonary condition, pulmonary embolism, aspiration pneumonitis and pneumothorax (Table 1) (Jammer et al., 2015). PPCs cause extensive health care costs due to increased length of stay, ICU days, medication costs, and mortality (Miskovic & Lumb, 2017).

Table 1. Definitions of PPCs (Jammer et al., 2015)

PPCs after abdominal surgery result from shallow breathing due to pain, and abdominal distension, bed rest, long duration of surgery, mucociliary clearance disorder, and dysfunction of diaphragm after mechanical ventilation (Miskovic & Lumb, 2017). Laparoscopic surgery and use of modern Enhanced Recovery After Surgery (ERAS) protocols are associated with reduced PPC rates compared to open surgery, and to poor ERAS compliance (Jurt et al., 2018; Milone et al., 2017). However, PPCs still are the most frequent postoperative complications also after laparoscopic liver surgery, occurring in approximately 12-13% of cases (Fuks et al., 2016; Qin et al., 2021). The relatively high incidence is likely due to laparoscopy and pneumoperitoneum as such, since elevated intra-abdominal pressure accelerates atelectasis formation, decreases respiratory compliance, and causes ventilation/perfusion mismatch, leading to PPCs (Lunardi et al., 2013; Park et al., 2016). PPCs are however more common after laparoscopic liver surgery than after e.g. laparoscopic gastrectomy, where PPC rate is commonly only around 7%(Ntutumu et al., 2016). This implies that specific characteristic of liver surgery, such as manipulation of diaphragm, tendency for postoperative fluid collections under the diaphragm and the disease specific susceptibility of cirrhotic patients for developing PPCs, all most likely affect the higher rate of PPCs after liver surgery.

Different types of interventions have been suggested for preventing PPCs. Preoperative pulmonary physiotherapy education has been shown to reduce PPCs after open major upper abdominal surgery by Boden at al. (Boden et al., 2018). In their RCT of 441 patients, intervention was a single preoperative physiotherapy session, during which the investigators informed the patient about PPCs in general, directed the postoperative physiotherapy exercises, and assessed each patients' individual risk for PPC. The high-quality study showed that this type of small-scale intervention halved the rate of PPCs after open upper abdominal surgery. Cochrane analysis by do Nascimento et al. assessed the effect of incentive spirometry on PPCs compared to no therapy or pulmonary physiotherapy, and found no significant benefit (do Nascimento et al., 2014). Usefulness of perioperative physiotherapy in reducing PPCs after laparoscopic surgery has been studied in two Chinese randomized trials, which both found almost 75% decrease in PPCs in the intervention group (Chen et al., 2022; Qin et al., 2021). The trials were conducted with nearly identical protocols, and by the same research group with patients undergoing laparoscopic colorectal surgery (Qin et al., Chen et al. Clin Rehab 2022). The intervention involved a strenuous, and expensive in-hospital physiotherapy for five days prior to surgery and home-bound pulmonary training for 90 postoperative days.

Prehabilitation programs are recognized as potentially beneficial in avoiding postoperative complications and reducing health care costs (Sliwinski et al., 2023). Protocols in prevention of PPCs are however highly heterogeneous and complex programs and generate a need for extra staff for execution in clinical practice. Research concerning prehabilitation has been criticized for discrepant outcome and methodology measures (Sliwinski et al., 2023), and this also concerns PPC prevention studies. At the moment, no evidence exists on prevention measures to reduce PPCs after any type of laparoscopic upper abdominal surgery. Previous studies on the prevention of PPCs after laparoscopic colorectal surgery present programs that cannot be reasonably integrated to current practices.