Authors' objectives: HTW undertook an evidence review to address the following questions: (1) in people undergoing major intra-abdominal surgery, how accurately do factors measured by preoperative cardiopulmonary exercise testing (CPET) predict postoperative outcomes? (2) in people undergoing major intra-abdominal surgery, what is the effect of adding CPET to standard preoperative assessment on postoperative outcomes?

Authors' results and conclusions: The review identified a large body of evidence on the use of factors measured by CPET to predict postoperative outcomes after major intra-abdominal surgery. The evidence suggests CPET variables can be used to predict postoperative outcomes, with the evidence varying widely according to the type of surgery, CPET factors considered, and outcomes of interest. The factors most consistently shown to be predictive of outcomes were anaerobic threshold (AT) and ventilatory equivalent for CO2 (VE/VCO2). Evidence on how adding preoperative CPET to standard preoperative care influences postoperative outcomes was very limited. Evidence was found only for patients undergoing abdominal aortic aneurysm (AAA) repair or colorectal surgery (one non-randomised study for each) and the strength of the evidence was considered low. One study reported that adding CPET to preoperative assessment could improve 30-day survival after surgery and shorten length of hospital stay in people undergoing AAA repair. One study reported an increase in planned critical care unit admission for people who had CPET compared to those who did not, but reported no difference in any other outcomes. We did not identify any evidence on how CPET influences patients’ satisfaction with their treatment, or their quality of life. We did not identify any evidence on how the use of CPET influences other aspects of preoperative assessment, such as whether it can reduce the need for other types of cardiovascular testing to be carried out, or whether the addition of consultant led high-risk surgical anaesthetic review in general is beneficial. One published cost consequences analysis was included in the health economic review. The study was a non-randomised retrospective cohort study with a historic control group. In people undergoing open AAA repair, CPET saved £4,408 compared with no CPET. In addition, the study found a reduced length of inpatient stay and a reduced length of intensive therapy unit stay in the CPET era compared with the pre-CPET era for those undergoing open AAA repair. There was an improvement in 30-day mortality in the CPET era compared with the CPET era for those undergoing open AAA repair but no difference for those undergoing endovascular AAA repair (EVAR). The cost effectiveness of CPET remains uncertain due to the limitations of the included study.

Authors' recommendations: CPET shows promise when used to inform decision-making prior to major intra-abdominal surgery. The evidence shows that the use of CPET in addition to standard risk assessment improves the identification of patients at increased risk of surgery-related morbidity and mortality and facilitates the planning of peri-operative care. The evidence therefore partially supports the adoption of CPET for people undergoing major intra-abdominal surgery.

Authors' methods: The Evidence Appraisal Report is based on a literature search (strategy available on request) for published clinical and economic evidence on the health technology of interest. It is not a full systematic review but aims to identify the best available evidence on the health technology of interest. Researchers critically evaluate and synthesise this evidence. We include the following clinical evidence in order of priority: systematic reviews; randomised trials; non-randomised trials. We only include evidence for “lower priority” evidence where outcomes are not reported by a “higher priority” source. We also search for economic evaluations or original research that can form the basis of an assessment of costs/cost comparison. We carry out various levels of economic evaluation, according to the evidence that is available to inform this.

Authors' identified further research: Further research is recommended to define the impact of CPET on clinical outcomes, patient experience and cost effectiveness as compared with standard risk assessment alone in people undergoing major intra-abdominal surgery.

Project Status: Completed

Year Published: 2020

URL for published report: https://www.healthtechnology.wales/reports-guidance/cardiopulmonary-exercise-testing/

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Wales, United Kingdom

Organisation Name: Health Technology Wales

Contact Address: Floor 3, 2 Capital Quarter, Tyndall Street, Cardiff, CF10 4BZ

Contact Name: Susan Myles, PhD

Contact Email: healthtechnology@wales.nhs.uk

Copyright: Health Technology Wales