Prehabilitation and education in major abdominal and thoracic surgery reduces length of stay and ventilation days

Abstract

INTRODUCTION:

Poor cardiopulmonary fitness is associated with an increased risk of morbidity and mortality following major surgery. Targeted prehabilitation interventions with adequate intensity improve cardiopulmonary function. Several systematic reviews have noted the variation in outcomes for prehabilitation, providing poor evidence due to inadequate patient numbers and poor compliance. Our aim was to assess the outcomes of the Preoperative Education and Prehabilitation Program (PrEPP) for patients undergoing major abdominal or thoracic surgery.

METHODS:

PrEPP is a supervised education and exercise training program twice a week and an at-home exercise program three times a week for up to four weeks. A comparison of outcomes was made using the data collected on each patient in PrEPP with a historical control group.

RESULTS:

There were 370 patients, 185 in each group. They were matched for age (+/- 10 years), gender, and surgery type. There were significant reductions in prolonged ventilation (>48 hours) from 5.4% to 1.1% (p = 0.03) and mean length of stay (LOS) from 10.2 days to 8.5 days (p = 0.04) in the PrEPP group. The incidence of superficial surgical site infection was also found to be less in the PrEPP group (p = 0.02). There were no significant differences in the incidence of pneumonia (3.8% to 2.7%), unplanned re-intubation (3.8% to 1.6%), readmission rate (12.4% to 9.7%), cardiac events or other post-surgical infections.

CONCLUSION:

The PrEPP was associated with reduced ventilation days and LOS. Further studies are required to confirm these results.

Keywords

Exercise prehabilitation physical conditioning patient education physiotherapy postoperative pulmonary complication

1 Introduction

Poor cardiopulmonary fitness (functional capacity) is associated with increased morbidity and mortality following major abdominal surgery [1, 2]. Poor cardiopulmonary fitness with an aerobic threshold of less than 10ml/kg/min predicts increased morbidity, longer Intensive Care Unit (ICU) stay, and total length of stay (LOS) in patients with abdominal surgery [3]. Cardiopulmonary fitness is significantly improved with a 4-week supervised exercise training program [4, 5]. In the last decade, the benefits of prehabilitation are not only been increasingly recognised but also frequently offered to patients awaiting major surgery [6]. Prehabilitation is delivered in various forms, such as a) supervised exercise training with or without education component, b) home-based exercise training with or without education, and c) education only. Also, the duration of the prehabilitation program can range from a single session to up to eight weeks, however, a 2–4 week-long program appears to be common [6]. Several systematic reviews report that there is insufficient evidence to support the routine use of prehabilitation programs for major abdominal surgery [7 –9]. Some studies demonstrated a significant outcomes improvement [10 –12], while others have not [13, 14]. The variation in outcomes is in part due to low patient numbers, heterogeneity in the exercise program, and the wide variation in patient compliance rates (16–100%), with the need for further studies noted [7, 15]. However, a recent meta-analysis demonstrated a significant reduction in pulmonary morbidity following major abdominal surgery [16]. Another recent randomised control trial (RCT) showed a significant cost benefit for preoperative physiotherapy prior to major abdominal surgery [17]. Interestingly, prehabilitation in most studies has employed a unimodal approach offering a single intervention only using either exercise training or education or inspiratory muscle training or nutritional support. A unimodal approach employed by a recent multicentre trial including 441 abdominal surgery patients reported that 30 minutes of patient education reduced the incidence of postoperative pneumonia by 50% [18]. However, there is a paucity of studies evaluating the effectiveness of prehabilitation using multimodal interventions [19]. As a result, the effectiveness of multimodal prehabilitation programs remains unclear. The aim of this study was to examine the effect of a Preoperative Education and Prehabilitation Program (PrEPP) in reducing hospital length of stay, reducing postoperative complications, minimising the need for mechanical ventilation, and reducing the readmission rates following major abdominal and thoracic procedures.

2 Methods

The PrEPP was introduced in January 2018. Eligible patients having elective major abdominal or thoracic surgery were enrolled in the PrEPP. The Nepean Ethics Committee approved the assessment of the PrEPP outcomes (Approval: 18/51A). PrEPP has two components: Patient education and exercise training. Data from the PrEPP group were compared with the historical control group data. Patients in the historical control group were matched by a blinded team member (KS) for age (+/- 10 years), gender, and surgery type with the patients in the PrEPP group. The control group data were obtained from the medical records and National Surgical Quality Improvement Program (NSQIP) data, which is available for all the abdominal and thoracic surgery patients in Nepean Hospital.

2.1 Inclusion and exclusion criteria

Consecutive patients who met the following criteria for PrEPP were included. Adults≥18 years awaiting thoracic, major upper gastrointestinal, or open colorectal surgery, in addition, those≥70 years having laparoscopic colorectal resection, laparoscopic cholecystectomy, or large incisional hernia repairs were also included. Exclusion criteria were; cognitive impairment, conditions preventing exercise training, and severe mental illness.

2.2 Outcome measures

The primary outcome of interest was hospital length of stay (LOS). Secondary outcomes assessed were; incidence of postoperative pneumonia, unplanned ICU intubation, prolonged mechanical ventilation (>48 hours), hospital readmission and mortality. Patient experience for the PrEPP cohort was prospectively evaluated using a short ten-question patient satisfaction survey focusing on their experiences with the program, usefulness of the program, their preference (education vs. exercise vs. both), and the usefulness of the home exercise program. However, no prospectively collected satisfaction data was available for the control group.

2.3 Initial assessment

The initial face-to-face assessment was conducted by an experienced physiotherapist within a week of receiving referral. For those unable to attend, the assessment was completed by videoconferencing (Telehealth). A medical, surgical, psychological, social, and smoking history was obtained. Baseline measures of anthropometric, exercise tolerance, and quality of life (QoL) were recorded. Exercise tolerance was measured using a six-minute walk test (6MWT) [20]. For endurance training prescription, we converted 80% of the 6MWT distance to a one-minute walk distance by dividing by six. The resultant one-minute walk distance was used to determine the total walking distance in 20 minutes. For training on the walk track, the total walking distance was divided by the length of the walking track to obtain the number of laps to be completed in the given time [21]. For strength training intensity prescription, a one-repetition maximum (1RM) test was used. Patients with musculoskeletal problem(s) were tested by a 5RM test [22]. QoL was assessed using a self-assessed health questionnaire (5-level EQ-5D) to identify preoperative psychosocial and pain related issues. Based on assessment findings, patients were referred to appropriate services as required [23]. The most frequently referred services were dietetics, pain management service, stoma care, and pharmacy. Patients willing to quit smoking were referred to their general practitioner for nicotine replacement therapy.

2.4 Patient education program

Face-to-face education was delivered by a multidisciplinary team (nurse consultant, dietician, and pharmacist) on topics including weight management, nutrition, post-op pain management, medication review, and smoking cessation. In addition, physiotherapist provided respiratory care education which included breathing exercises, airway clearance techniques and postoperative mobilisation. Psychosocial support was provided to those experiencing anxiety or depression. For those unable to attend, telehealth education was provided. All patients received a comprehensive handbook consisting of all the educational resources, home exercise program and an exercise diary. Patients were encouraged to read the booklet and follow the home exercise program.

2.5 Exercise program

The PrEPP was designed to provide an exercise dosage that was well tolerated, improved compliance and achieve improvements in exercise capacity. The exercise prescription was individualised, considering premorbid fitness measured by 6MWT, musculoskeletal limitations, and medical comorbidities. Patients attended two supervised gym-based exercise sessions per week. Components of the exercise program included cardiovascular endurance and strength training to increase cardiopulmonary capacity and limb strength. A threshold inspiratory muscle training (IMT) device (Philips Respironics^®, USA) was provided to patients undergoing cardiothoracic surgery and upper GI surgeries. IMT was performed at 60% of maximal inspiratory pressure twice a day till surgery [24, 25]. Patients completed inspiratory muscle training and breathing exercises at the start of the session. Patients performed slow deep breathing to their total lung capacity and attempted an extra “sniff” with an inspiratory hold for 2–3 seconds for ten repetitions, followed by practising huffing and coughing techniques. The wound splinting technique was also demonstrated. The exercise classes began with a warm-up for 5 minutes using a stationary bike or walking on a flat surface. An exercise circuit was set up at the gymnasium, which included free weight stations, upright and recumbent bikes, arm ergometer, walk-track, treadmill, pulley machine, chest, and leg press machines. Functional exercises such as step-up and down, sit-to-stand and staircase climbing were also included in the exercise circuit. During the workout period, patients rotated around the physiotherapy gymnasium circuit and completed various exercises at their prescribed intensity. Strength training incorporated a training dosage of 8 to 12 repetitions for 2–3 sets with a rest of 1–2 minutes between sets. For aerobic exercise, a moderate training intensity target was assessed using the rating of perceived exertion (RPE) scale, which correlates to a 40–60% heart rate reserve [26, 27]. Patients completed 20 minutes of walking on a flat walking track or treadmill and used a stationary bike for 10 minutes. An RPE scale (0–10) was used to guide the exercise intensity. During the cardiovascular endurance training, patients were advised to exercise at moderate intensity (3–4 on the RPE scale). Exercise intensity was monitored and progressed individually. The exercise session concluded with a 5-minute cooldown using a light walk and stretches.

2.6 Home exercise program

In addition to two days of gym-based supervised training, patients were encouraged to exercise at home at least three days per week. Patients were provided with a home exercise program diary, which included simple functional exercises with illustrations and instructions. Walking for 20–30 minutes was also recommended. Patients were advised to follow the “talk-test” (able to talk with mild shortness of breathing) to regulate their exercise intensity. Patients were encouraged to do breathing exercises and inspiratory muscle training twice a day. An incentive spirometer was also provided and instructed to practice daily once or twice at home. Patients were encouraged to maintain their home exercise program diary.

2.7 Data collection and statistical analysis

Clinical outcomes were assessed using the relevant data collected from patients who completed PrEPP [28, 29]. Data collected for patients with major abdominal or thoracic surgery in the 30 months prior to introducing the PrEPP (June 2015 to December 2017) were used as the control group. A normality test was performed using the Shapiro-Wilk test for continuous data to assess normal distribution. Statistical analysis also included patient demographic and clinical characteristics, which have been reported as either an incidence or mean and standard deviation (SD). A comparison of the incidence data between groups produced an odds ratio (OR), including 95% confidence intervals (CI) based on a univariate logistical regression model. Data reported as a mean and SD were assessed with a paired t-test. Chi-squared and Fisher exact tests were also used for categorical data. All p-values calculated were two-tailed; the alpha level of significance was 0.05.

3 Results

Data for a total of 370 patients were analysed and compared. There were 185 patients in the PrEPP group and 185 in the control group.

3.1 Baseline comparison

The types of surgeries performed were similar (Table 1). The patient demographics such as age, gender, and BMI were also similar for the two groups (Table 2). The incidence of smoking was significantly higher in the control group (29%) compared to the PrEPP group (17.3%) (OR = 0.5, CI = 0.32 –0.90, p = 0.02) (Table 2). The ASA score was available for 134 (72.4%) of controls and 142 (76.7%) of PrEPP patients. There was a significant difference in the ASA scores (p = 0.03) which could be due to a higher proportion of ASA 3 patients in the PrEPP group and fewer with an ASA score of 1 or 2 (Table 2).

Table 1
Operative procedures performed

Type of surgeries PrEPP group (N = 185) Control group (N = 185)

n (%) n (%)

Abdominal surgeries (Total) 127 68% 132 71%

Upper gastrointestinal/ Hepatobiliary

Oesophagectomy 17 9.2% 18 9.7%

Gastrectomy 8 4.3% 13 7.0%

Hepatic resection 28 15.1% 20 10.8%

Pancreatico-duodenectomy 7 3.8% 10 5.9%

Distal pancreatectomy 4 2.12% 2 1.08%

Laparoscopic cholecystectomy (complex) 6 3.2% 6 3.2%

Other –hepaticojejunostomy procedure 3 1.6% 0 0%

Colorectal

Open/laparoscopic rectal surgery 2 1.1% 4 2.2%

Open/laparoscopic anterior resection 18 9.7% 15 8.1%

Colectomy 17 9.2% 29 15.7%

Hartmann’s / reversal procedure 3 1.6% 4 2.2%

Open/laparoscopic small bowel resection 3 1.6% 0 0%

Other

Large ventral/ incisional hernia repair 11 6.0% 11 6.0%

Thoracic surgery

Lobectomy/pneumonectomy 58 32% 53 29%

Type of surgeries	PrEPP group (N = 185)	Control group (N = 185)
Abdominal surgeries (Total)	127	68%	132	71%
Upper gastrointestinal/ Hepatobiliary
Oesophagectomy	17	9.2%	18	9.7%
Gastrectomy	8	4.3%	13	7.0%
Hepatic resection	28	15.1%	20	10.8%
Pancreatico-duodenectomy	7	3.8%	10	5.9%
Distal pancreatectomy	4	2.12%	2	1.08%
Laparoscopic cholecystectomy (complex)	6	3.2%	6	3.2%
Other –hepaticojejunostomy procedure	3	1.6%	0	0%
Colorectal
Open/laparoscopic rectal surgery	2	1.1%	4	2.2%
Open/laparoscopic anterior resection	18	9.7%	15	8.1%
Colectomy	17	9.2%	29	15.7%
Hartmann’s / reversal procedure	3	1.6%	4	2.2%
Open/laparoscopic small bowel resection	3	1.6%	0	0%
Other
Large ventral/ incisional hernia repair	11	6.0%	11	6.0%
Thoracic surgery
Lobectomy/pneumonectomy	58	32%	53	29%

PrEPP = pre-operative education and prehabilitation program.

Table 2

Patient demographics

Criteria	PrEPP (n = 185)	Control (n = 185)	OR	Cl	p value
Male	102 (55.13%)	100 (54.05%)	–	–	0.91
Age	65.9 + /–12.5	65.8 + /–11.7	–	–2.4–2.5	0.97
BMI	29.2 + /–6.6	28.4 + /–6.2		–0.5–2.1	0.23
Smoking	32 (17.29%)	53 (28.64%)	0.5	0.3–0.9	0.02
ASA score					0.03
ASA 1	4 (2.16%)	12 (6.49%)	0.32	0.01–1.02	–
ASA 2	46 (24.86%)	62 (33.51%)	0.66	0.42–1.03	–
ASA 3	85 (45.95%)	54 (29.19%)	2.06	1.34–3.17	–
ASA 4	7 (3.78%)	6 (3.24%)	1.17	0.39–3.56	–
Unassigned	43 (23.24%)	51 (27.57%)	0.80	0.5–1.27	–

PrEPP = pre-operative education and prehabilitation program, OR = odds ratio, Cl = confidence interval, ASA = American Society of Anaesthesiologists.

3.2 Compliance

Compliance was measured by session attendance and completion of the home exercise program recorded in the patient exercise diary. All 185 PrEPP patients completed the education and breathing exercise components and 174 (94%) completed the strength and endurance training.

3.3 Primary outcome

There was a significant reduction in the mean hospital LOS from 10.2 days in the control group to 8.5 days in the PrEPP group (Table 3).

Table 3
Outcome measures

Outcomes PrEPP (n = 185) Control (n = 185) OR Cl p value

Pneumonia 5 (2.70%) 7 (3.78%) 0.75 0.17–2.6 0.70

Unplanned re-intubation 3 (1.62%) 7 (3.78%) 0.49 0.07–2.34 0.51

MV>48 hours 2 (1.08%) 10 (5.41%) 0.19 0.02–0.9 0.03

DVT 5 (2.70%) 6 (3.24%) 1.2 0.26–6.4 0.95

PE 6 (3.24%) 0 (0%) – – –

MI 1 (0.54%) 1 (0.54%) 1 0.01–78.8 1

Superficial SSI 4 (2.16%) 14 (7.56%) 0.27 0.06–0.88 0.02

UTI 7 (3.78%) 10 (5.4%) 0.68 0.21–2.05 0.62

Sepsis 4 (2.16%) 11 (5.94%) 0.3 0.08–1.3 0.17

Organ/Space SSI (anastomotic leak) 10 (5.4%) 11 (5.94%) 0.91 0.35–2.32 1

LOS (days) 8.5 + /–8.3 10.2 + /–8.3 – – 0.04

Readmission 18 (9.73%) 23 (12.43%) 0. 7 0.37–1.53 0.5

Mortality 1 (0.54%) 3 (1.62%) 0.3 0.0–4.1 0.6

Outcomes	PrEPP (n = 185)	Control (n = 185)	OR	Cl	p value
Pneumonia	5 (2.70%)	7 (3.78%)	0.75	0.17–2.6	0.70
Unplanned re-intubation	3 (1.62%)	7 (3.78%)	0.49	0.07–2.34	0.51
MV>48 hours	2 (1.08%)	10 (5.41%)	0.19	0.02–0.9	0.03
DVT	5 (2.70%)	6 (3.24%)	1.2	0.26–6.4	0.95
PE	6 (3.24%)	0 (0%)	–	–	–
MI	1 (0.54%)	1 (0.54%)	1	0.01–78.8	1
Superficial SSI	4 (2.16%)	14 (7.56%)	0.27	0.06–0.88	0.02
UTI	7 (3.78%)	10 (5.4%)	0.68	0.21–2.05	0.62
Sepsis	4 (2.16%)	11 (5.94%)	0.3	0.08–1.3	0.17
Organ/Space SSI (anastomotic leak)	10 (5.4%)	11 (5.94%)	0.91	0.35–2.32	1
LOS (days)	8.5 + /–8.3	10.2 + /–8.3	–	–	0.04
Readmission	18 (9.73%)	23 (12.43%)	0. 7	0.37–1.53	0.5
Mortality	1 (0.54%)	3 (1.62%)	0.3	0.0–4.1	0.6

MV = mechanical ventilation, DVT = deep venous thrombosis, PE = pulmonary embolism, MI = myocardial infarction, SSI = surgical site infection, UTI = urinary tract infection, LOS = length of stay.

3.4 Secondary outcomes

The hospital readmission rate was lower in the PrEPP group (9.3%) compared to the control (12.4%) but was not significant (Table 3). There was no significant difference in the incidence of postoperative pneumonia (3.8% control and 2.7% PrEPP) (Table 3) or in the incidence of unplanned re-intubation and mechanical ventilation (Table 3). There was a significant reduction in the number of patients requiring mechanical ventilation beyond 48 hours, from 10 in the control group to 2 in the PrEPP group (p = 0.03) (Table 3). Study findings also noted a significant reduction in superficial surgical site infections (SSI) in the PrEPP group (Table 3). Although the control group had no episodes of pulmonary embolism (PE), the PrEPP group had six episodes (Table 3). There was no significant difference in the incidence of DVT, sepsis, or mortality (Table 3).

Program feedback was obtained from 67 (36% response rate) patients in the PrEPP group, of which 63 patients (94%) rated their program experience between 8–10 out of a total score of 10, and four patients rated between 5–7. Sixty-six patients (98%) preferred the combination of education and exercise, whereas one patient preferred education only. Sixty-five patients (97%) found the patient handbook and home exercise program helpful; two patients did not respond.

4 Discussion

Our results found improved outcomes in abdominal or thoracic surgery patients who received prehabilitation. There was a significant reduction in the incidence of patients requiring ventilation beyond 48 hrs and a 2-day reduction in hospital LOS. However, there was no significant reduction in other forms of respiratory morbidity, including pneumonia. Our results may provide support for the positive effect of a PrEPP prior to major abdominal or thoracic surgery.

A confounding factor in our study could be the higher incidence of smokers in the control group, increasing the risk of pulmonary complications and may contribute to the higher incidence of prolonged ventilation in this group. In contrast, a confounding factor potentially increasing the incidence of pulmonary complications in the PrEPP group could be the higher proportion of ASA 3 patients, which were significantly higher in the PrEPP group compared to the control group. However, although the differences in ASA scores were significant, this may have occurred by chance due to a number of unassigned ASA scores in each group (control = 27%, PrEPP = 23%). This problem has been noted in other studies too [30, 31].

The PrEPP group had a higher incidence of PE, which is an unexpected finding not previously reported [7–11 , 15]. Our preoperative assessment did not include PE screening to identify at-risk patients pre-operatively. Future studies are needed to evaluate the benefits of screening in mitigating the incidence of PE. Furthermore, there was no change in VTE prophylaxis or in mobilisation practice over the study period. The higher proportion of ASA 3 patients in the PrEPP group may have been a contributing factor. Further studies are required to assess if this is a real but unexpected phenomenon associated with PrEPP.

Hospital readmissions can have a significant impact on health care costs. A recent study by Lee and colleagues (2019) reported a significant increase in the readmission rate after complex surgery [32]. Our study found a small reduction in hospital readmission rate in the PrEPP group (PrEPP = 9.3%, control = 12.4%); however, this difference was not statistically significant. This finding could have occurred by chance, as it did not reach a statistical significance, or maybe due to improved postoperative care, as highlighted by Lee et al. (2019) [32]

Previous studies have demonstrated significant improvement in cardiopulmonary exercise testing results following four weeks of supervised intensive exercise programs [33, 34]. Our program used similar supervised exercise programs with the assumption that cardiopulmonary function improved. A 6MWT was done at the time of assessment in the PrEPP group but this was used for individualised exercise prescription.

Prehabilitation programs are ineffective when there is poor compliance [8, 15]. Previous studies demonstrated that structured, supervised programs increase compliance [35]. In our study, the education program was specifically designed to improve compliance, which was achieved at 100%. Similarly, the exercise program was designed to ensure high compliance with both supervised and unsupervised exercise training, achieving a high compliance rate (94%).

Frailty has been reported to be associated with significantly poor post-surgical outcomes and increased mortality [36, 37]. Studies have recommended use of including frailty assessment to identify at-risk patients pre-operatively [37]. However, our study lacked frailty assessment. NSQIP and other predictive scores such as the National Emergency Laparotomy Audit (NELA) have yet to include frailty scores as part of their assessment. However, both programs shall be including frailty scores as part of the preoperative assessment.

In multimodality prehabilitation programs, it is difficult to assess the effectiveness of the individual components [8]. Although there is evidence that the exercise program improves cardiopulmonary function, reduces morbidity and LOS [10 , 16], however, the effect of the education program is difficult to measure. The components of the education program were included based on evidence that they improved postoperative outcomes. Education about pain management and early postoperative mobilisation has been demonstrated to reduce pulmonary complications following cardiothoracic surgery [38].

In addition to a reduced LOS and respiratory morbidity, the other potential benefits of a prehabilitation program are a more rapid return to normal activities and an improved QoL during the postoperative recovery period. Prehabilitation programs have been demonstrated to improve QoL in the postoperative period. Although the PrEPP group has had QoL data collected, no QoL data were available for the control group. Previous studies have demonstrated a significant reduction in the time to return to normal activities [39]. While we could have collected this data in the PrEPP group, it was not possible to assess for the control group.

Changes in clinical practices between the control period and PrEPP groups may be a confounding factor, resulting in changes in outcomes. Data not presented demonstrated there was no difference in the duration of surgeries, types of postoperative analgesia used, blood transfusion requirements, VTE and wound infection prophylaxis. There was, however, a significant change in the management of postoperative hyperglycaemia in colorectal resections with a significant reduction in SSI which has been recently reported [31]. This is likely to have contributed to the reduction in SSI in the present study.

Furthermore, NSQIP has very specific definitions for various complications [28, 29], however, they are not defined according to the Clavien-Dindo system [40] for severity, which could be another limitation of our study.

Another limitation of our study was the use of historical case controls to compare the outcome of the PrEPP. The control group was matched and comparable to the PrEPP group with respect to age, gender, and surgery type. However, as noted that despite matching the control group had a greater number of smokers, but the PrEPP group had a significantly greater proportion of ASA 3 patients. Currently, there are two RCTs underway examining prehabilitation prior to oesophagectomy [41] and major gastrointestinal surgery [42] to address these limitations.

Furthermore, we did not perform sample size calculations, which is another limitation of this study.

Our results have demonstrated that PrEPP can be administered with a high compliance rate and may result in improved outcomes such as reduction in ventilation days and hospital LOS. Further comparative studies shall need to be done to assess the effects of prehabilitation on pulmonary morbidity. These studies may also demonstrate a more rapid return to normal activities and improved quality of life.

5 Conclusion

The findings of this study demonstrate that a prehabilitation program that includes exercise and patient education is associated with a shorter duration of mechanical ventilation and hospital LOS in patients undergoing major abdominal or thoracic surgery. However, a significant reduction in other forms of respiratory morbidity and hospital readmission was not found. An increased incidence of PE was seen in the PrEPP group. Further well-designed comparative studies with adequate sample size are required to investigate the effects of a multimodal prehabilitation program in improving postoperative pulmonary outcomes.

Implications for future practice

Inclusion of exercise and education before major abdominal or thoracic surgery may improve patient outcomes. Preoperative exercise training and multidisciplinary patient education can be offered to patients awaiting abdominal and thoracic surgery. Inclusion of screening protocols to identify patients at risk of PE postoperatively should be considered.

Conflict of interest

The authors have no conflict of interest to declare

Ethical considerations

This study is approved by the Nepean Blue Mountains Local Health District Ethics committee (Approval number: 18/51A).

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