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Background Criteria-led discharge (CLD) has promising potential to reduce unnecessary hospital stay after abdominal surgery; however, the validity and utility of CLD is uncertain as studies are limited to small single-centre studies involving predominantly elective colorectal surgery. Methods This prospective international multicentre cohort study explored the relationship between a CLD checklist, post-operative recovery, and hospital length of stay using patient-level data from four clinical trials involving 1071 adults undergoing all types of emergency and elective abdominal surgery at five hospitals across Australia and New Zealand. Patients were assessed daily for 21 post-operative days using a standardised CLD checklist. Surgeons and hospital clinicians were masked to findings. Criterion, construct, and content validity of the checklist to accurately reflect discharge decisions by surgical teams, assess physiological recovery, and encompass parameters signalling physiological readiness to discharge were tested. Potential utility of CLD to minimise unnecessary hospital stay was assessed by comparing day of readiness to discharge to actual day of discharge. Results The CLD checklist had concordance with existing discharge planning practices and accurately measured a longer post-operative recovery in more complex clinical situations. The CLD checklist in its current format did not detect all legitimate medical and surgical reasons necessitating a continued stay in hospital. Day of readiness to discharge was 0.8 days (95% CI 0.7 to 0.9, p < 0.001) less than actual day of discharge. Conclusion A CLD checklist has excellent criterion and construct validity in measuring physiological recovery following all types of major elective and emergency abdominal surgery. Content validity could be improved. The use of CLD has the potential to reduce unnecessary hospital stay although the safety of discharging patients according to the criteria requires investigation prior to implementation. Trial registration Trials were prospectively registered at the Australian New Zealand Clinical Trials Registry (LIPPSMAck POP 12613000664741, ICEAGE 12615000318583, PLASTIC 12619001344189, NIPPER PLUS 12617000269336).

Prehabilitation transforms the preoperative waiting period into an opportunity for patients to actively improve their health before surgery. With surgical populations ageing and presenting with increasing frailty, patient prioritised outcomes, such as postoperative complications and disability, affect >20% of patients undergoing major surgery, resulting in substantial healthcare costs. This review combines the current evidence for prehabilitation components, including exercise, and respiratory, nutritional, cognitive, and psychosocial interventions. Although respiratory prehabilitation showed high certainty evidence for reducing postoperative pulmonary complications after major surgery, other components showed promising but lower certainty benefits. Multimodal prehabilitation, especially when exercise and nutrition are combined, seems to be most effective for improving clinical and patient centred outcomes. Significant knowledge gaps remain, however, about optimal programme design, delivery models, target populations, and strategies to maximise adherence. Patient perspectives emphasise the importance of individualised coaching or support from healthcare professionals, or both, home based accessibility, and collaborative care. Future research should include a focus on pragmatic multicentre trials with robust cost effectiveness analyses to support implementation in the health system of effective, scalable prehabilitation programmes that can meaningfully improve outcomes for surgical patients. Opportunities to enhance the effectiveness and reach of prehabilitation include exploiting existing and emerging technologies, as well as optimising participant support to maximise adherence.

IntroductionFew clinical trials have investigated physiotherapy interventions to treat hypoxaemia following abdominal surgery. The objective of this study is to determine the feasibility and safety of conducting a clinical trial of physiotherapist-led non-invasive ventilation (NIV).Methods and analysisThis single-centre, 50-patient, parallel-group, assessor blinded, pilot feasibility randomised controlled trial with concealed allocation will enrol spontaneously ventilating adults with hypoxaemia within 72 hours of major abdominal surgery. Participants will receive either (1) usual care physiotherapy of a single education session (talk), daily walking of 10–15 min (walk) and four sessions of coached deep breathing and coughing (breathe) or (2) usual care physiotherapy plus four 30 min sessions of physiotherapist-led NIV delivered over 2 postoperative days. Primary feasibility and safety outcome measures are; number of eligible patients recruited per week, total time of NIV treatment delivered, acceptability of treatments to patients and clinicians and incidence of adverse events. Secondary feasibility outcomes include measures of recruitment and treatment adherence. Exploratory outcome measures include change in respiratory parameters, postoperative pulmonary complications, length of hospital stay, health-related quality of life, postoperative activity levels and mortality.Ethics and disseminationEthics approval has been obtained from the relevant institution. Results will be published to inform future research.Trial registration numberACTRN12622000839707.

Background Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone. Methods The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery. Discussion The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial. Trial registration ACTRN 12615000318583 . Registered 8 April 2015

AbstractObjectiveTo assess the efficacy of a single preoperative physiotherapy session to reduce postoperative pulmonary complications (PPCs) after upper abdominal surgery.DesignProspective, pragmatic, multicentre, patient and assessor blinded, parallel group, randomised placebo controlled superiority trial.SettingMultidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zealand.Participants441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were randomly assigned through concealed allocation to receive either an information booklet (n=219; control) or preoperative physiotherapy (n=222; intervention) and followed for 12 months. 432 completed the trial.InterventionsPreoperatively, participants received an information booklet (control) or an additional 30 minute physiotherapy education and breathing exercise training session (intervention). Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery. Postoperatively, all participants received standardised early ambulation, and no additional respiratory physiotherapy was provided.Main outcome measuresThe primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score. Secondary outcomes were hospital acquired pneumonia, length of hospital stay, utilisation of intensive care unit services, and hospital costs. Patient reported health related quality of life, physical function, and post-discharge complications were measured at six weeks, and all cause mortality was measured to 12 months.ResultsThe incidence of PPCs within 14 postoperative hospital days, including hospital acquired pneumonia, was halved (adjusted hazard ratio 0.48, 95% confidence interval 0.30 to 0.75, P=0.001) in the intervention group compared with the control group, with an absolute risk reduction of 15% (95% confidence interval 7% to 22%) and a number needed to treat of 7 (95% confidence interval 5 to 14). No significant differences in other secondary outcomes were detected.ConclusionIn a general population of patients listed for elective upper abdominal surgery, a 30 minute preoperative physiotherapy session provided within existing hospital multidisciplinary preadmission clinics halves the incidence of PPCs and specifically hospital acquired pneumonia. Further research is required to investigate benefits to mortality and length of stay.Trial registrationAustralian New Zealand Clinical Trials Registry ANZCTR 12613000664741.

Extended scope of practice (ESoP) and advanced scope of practice (ASoP) physiotherapy roles have been in place in the UK for over 20 years. However, interest in these types of services appears to be only just evolving within Australia. Although ESoP and/or ASoP cardiorespiratory roles in intensive care units (ICU) may be perceived to be more achievable in large metropolitan teaching hospitals, at least 67% of Australian ICUs provide physiotherapy services. Very little has been published on the practicalities (e.g. training pathways, evidence for use and guidelines) of developing advanced or extended scope cardiorespiratory physiotherapy services within Australian ICUs. This report describes the development and implementation of a physiotherapy-led bronchoscopy service from a regional hospital perspective.

Background/Objectives: Major surgery for gastrointestinal cancer carries a 50% risk of postoperative complications. Physiotherapists commonly provide interventions to patients undergoing gastrointestinal surgery for cancer with the intent of preventing complications and improving recovery. However, the evidence is unclear if physiotherapy is effective compared to providing no physiotherapy, nor if timing of service delivery during the perioperative pathway influences outcomes. The objective of this review is to evaluate and synthesise the evidence examining the effects of perioperative physiotherapy interventions delivered with prophylactic intent on postoperative outcomes compared to no treatment or early mobilisation alone. Methods: A protocol was prospectively registered with PROSPERO and a systematic review performed of four databases. Randomised controlled trials examining prophylactic physiotherapy interventions in adults undergoing gastrointestinal surgery for cancer were eligible for inclusion. Results: Nine publications from eight randomised controlled trials were included with a total sample of 1418 participants. Due to inconsistent reporting of other perioperative complications, meta-analysis of the effect of physiotherapy was only possible specific to postoperative pulmonary complications (PPCs). This found an estimated 59% reduction in risk with exposure to physiotherapy interventions (RR 0.41, 95%CI 0.23 to 0.73, p < 0.001). Sub-group analysis demonstrated that timing of delivery may be important, with physiotherapy delivered only in the preoperative phase or combined with a postoperative service significantly reducing PPC risk (RR 0.32, 95%CI 0.17 to 0.60, p < 0.001) and hospital length of stay (MD–1.4 days, 95%CI −2.24 to −0.58, p = 0.01), whilst the effect of postoperative physiotherapy alone was less certain. Conclusions: Preoperative-alone and perioperative physiotherapy is likely to minimise the risk of PPCs in patients undergoing gastrointestinal surgery for cancer. This challenges current traditional paradigms of providing physiotherapy only in the postoperative phase of surgery. A review with broader scope and component network analysis is required to confirm this.

IntroductionGastrointestinal cancer surgery commonly leads to postoperative complications and other adverse outcomes. While prehabilitation shows promise in reducing adverse postoperative outcomes, most hospitals have resource limitations that preclude its use as standard of care. Additionally, the need to expedite surgery from diagnosis often creates a narrow window for prehabilitation initiatives. Online, self-reported screening tools may address these challenges by facilitating early identification of high-risk patients and enabling targeted preoperative interventions, thereby allowing equitable allocation of limited resources. Therefore, the primary aim of this study is to evaluate the predictive utility of a tri-modal (physical, nutritional, psychological) screening tool for patients undergoing gastrointestinal cancer surgery.MethodsThis prospective international cohort study will recruit 1214 adults undergoing elective gastrointestinal cancer surgery across 35 sites from 19 countries. Participants will complete an online screening tool developed through a comprehensive, multistep, predefined process. The screening tool comprises the Duke Activity Status Index, Patient-Generated Subjective Global Assessment Short Form and the Patient Health Questionnaire-4, in English, Spanish, French or Portuguese. These tools were selected based on a scoping review, followed by an international Delphi consensus process. The primary outcomes include rate of postoperative complications, major complications (Clavien-Dindo Classification grade III–V) and overall complication severity assessed by the Comprehensive Complications Index; all assessed 30 days postoperatively. Secondary outcomes include hospital length of stay, readmission rate within 30 days, discharge destination (home vs other), days at home and alive in 30 days postsurgery, 30-day all-cause mortality and 12-month survival. Primary analyses will establish optimal screening tool cut-points to stratify patients into clinically actionable risk categories for postoperative complications and examine the independent predictive value of these screening scores after adjusting for established clinical risk factors.Ethics and disseminationThis study has received ethical approval from the Sydney Local Health District Human Research and Ethics Committee (X25-0333 and 2025/ETH02465) and has been registered on the Open Science Framework (10.17605/OSF.IO/HVCGD). The results of Preoperative Risk Evaluation for Cancer Treatment will be submitted to reputable journals and presented at national and international conferences.

IntroductionPostoperative pulmonary complications (PPCs) are a common serious complication following upper abdominal surgery leading to significant consequences including increased mortality, hospital costs and prolonged hospitalisation. The primary objective of this study is to detect whether there is a possible signal towards PPC reduction with the use of additional intermittent non-invasive ventilation (NIV) compared with continuous high-flow nasal oxygen therapy alone following high-risk elective upper abdominal surgery. Secondary objectives are to measure feasibility of: (1) trial conduct and design and (2) physiotherapy-led NIV and a high-flow nasal oxygen therapy protocol, safety of NIV and to provide preliminary costs of care information of NIV and high-flow nasal oxygen therapy.Methods and analysisThis is a single-centre, parallel group, assessor blinded, pilot, randomised trial, with 130 high-risk upper abdominal surgery patients randomly assigned via concealed allocation to either (1) usual care of continuous high-flow nasal oxygen therapy for 48 hours following extubation or (2) usual care plus five additional 30 min physiotherapy-led NIV sessions within the first two postoperative days. Both groups receive standardised preoperative physiotherapy and postoperative early ambulation. No additional respiratory physiotherapy is provided to either group. Outcome measures will assess incidence of PPC within the first 14 postoperative days, recruitment ability, physiotherapy-led NIV and high-flow nasal oxygen therapy protocol adherence, adverse events relating to NIV delivery and costs of providing a physiotherapy-led NIV and a high-flow nasal oxygen therapy service following upper abdominal surgery.Ethics and disseminationEthics approval has been obtained from the relevant institution and results will be published to inform future multicentre trials.Trial registration numberACTRN12617000269336; Pre-results.