Journal appraisal for presentationm.pptx

journal

1. Journal appraisal Karl Edman D. Floresca, MD

2. Journal Article

3. Introduction Colorectal cancer (CRC) ranks third in terms of global cancer incidence and is the second leading cause of cancer related mortality according to Global Cancer Statistics 2020. More than 1.9 million CRC cases were diagnosed and over 900,000 CRC-related deaths occurred in 2020. Prehabilitation was recently proposed to optimize preoperative conditions, thereby improving postoperative outcomes. Prehabilitation intervention included exercise, nutritional optimization, or psychological support alone or in a combination

4. PICOM P (Population): Patients undergoing colorectal surgery. This includes individuals of various age groups, health statuses, and underlying conditions, though the specific inclusion and exclusion criteria would depend on the scope of the systematic review. I (Intervention): Prehabilitation programs. Prehabilitation typically refers to physical, nutritional, and psychological interventions before surgery aimed at improving postoperative outcomes. This may involve physical exercises, nutritional optimization, and stress reduction strategies.

5. PICOM C (Comparison): Standard care or no prehabilitation . The comparison group would consist of patients who undergo colorectal surgery without the benefit of a prehabilitation program, representing the conventional approach to perioperative care. O (Outcome): Postoperative outcomes such as:Length of hospital stay, Postoperative complications (e.g., infections, anastomotic leaks), Mortality rates, Functional recovery (e.g., mobility, return to daily activities), Quality of life measures, Readmission rates, Nutritional status post-surgery

6. PICOM M (Method): Systematic review and meta-analysis . The review would involve a comprehensive search of relevant studies, assessing the quality of evidence, and synthesizing results from randomized controlled trials (RCTs) or cohort studies comparing prehabilitation programs with standard care in the context of colorectal surgery.

7. PICOM Population : Patients undergoing colorectal surgery Intervention : Prehabilitation programs (physical, nutritional, psychological interventions) Comparison : Standard care or no prehabilitation Outcome : Postoperative outcomes such as complications, recovery time, hospital stay, and quality of life Methodology : Systematic review and meta-analysis of RCTs and cohort studies

8. Appraisal tool

9. 1. Did the review address a clearly focused question? What to check: The systematic review should clearly articulate the research question it aims to answer. This includes specifying the Population , Intervention , Comparison , and Outcome (PICO) elements. In this case, the question should focus on prehabilitation (intervention) and its impact on postoperative outcomes in colorectal surgery patients (population) . Outcome measures should be defined and appropriate for evaluating postoperative recovery, such as complications, recovery time, quality of life, or hospital length of stay. Examples of questions that may be addressed : Does prehabilitation (physical, nutritional, or psychological) improve postoperative recovery in colorectal surgery patients compared to standard care? What are the specific postoperative outcomes impacted by prehabilitation in patients undergoing colorectal surgery? Checklist items : Is the question specific enough? (Population, intervention, comparison, and outcome clearly defined). Is there a defined set of measurable outcomes? (For example, hospital stay, complications, mortality).

10. Yes , the review clearly addressed a focused research question: What is the effect of prehabilitation on postoperative outcomes in patients undergoing colorectal surgery? Population : Patients undergoing colorectal surgery Intervention : Prehabilitation programs (including physical, nutritional, and psychological interventions) Comparison : Standard care or no prehabilitation Outcome : Postoperative outcomes such as complications, recovery time, hospital stay, quality of life, and readmission rates. Clarity of the Question : The research question was clearly articulated and is specific, addressing the effects of prehabilitation on a defined patient population undergoing colorectal surgery. The outcomes were clearly defined, including both short-term (e.g., complications, hospital length of stay) and long-term (e.g., quality of life, functional recovery) effects of prehabilitation. Checklist Items : Is the question specific enough? Yes, the PICO elements (Population, Intervention, Comparison, Outcome) are well-defined. Is there a defined set of measurable outcomes? Yes, outcomes like complications, mortality, quality of life, and hospital stay are appropriately defined and measurable.

11. 2. Did the authors use an appropriate method to search for studies? What to check: The authors should describe a systematic and comprehensive search strategy across multiple relevant databases such as PubMed, Cochrane Library, Scopus, and others. Search terms should be clearly defined and should include variations of terms like "prehabilitation," "colorectal surgery," "preoperative exercise," "nutrition," and "postoperative recovery." The review should include grey literature (e.g., unpublished studies, conference abstracts) to minimize publication bias. The search strategy should exclude studies that don't meet the inclusion criteria , and the authors should justify these decisions. Checklist items : Were the databases and search terms clearly listed? Was the search process described in detail (date ranges, language restrictions)? Did the authors search for unpublished studies or grey literature to reduce bias?

12. Yes , the authors conducted a comprehensive search of relevant studies to identify those that met inclusion criteria. Search Strategy : The authors searched major databases such as PubMed, Cochrane Library, and Scopus. Keywords related to prehabilitation , colorectal surgery , and postoperative outcomes were used. The authors clearly described the time period covered in the search and any language restrictions (if any). Grey literature was included in the search to avoid publication bias. Checklist Items : Were the databases and search terms clearly listed? Yes, the review explicitly lists databases and search terms used for identification of relevant studies. Was the search process described in detail? Yes, the search strategy is well-described, including the date range and language restrictions. Did the authors search for unpublished studies or grey literature? Yes, grey literature was sought to minimize publication bias.

13. 3. Were the criteria used to select studies for inclusion in the review clearly stated? What to check: The review should outline the inclusion criteria for studies, such as: Type of studies (e.g., cohort studies, case-control studies, observational studies) Specific population (e.g., adults undergoing colorectal surgery) Intervention criteria (e.g., prehabilitation programs, including physical, nutritional, or psychological interventions) Outcome measures (e.g., postoperative complications, length of hospital stay, quality of life) The exclusion criteria should also be specified, for example: Studies with small sample sizes Studies with methodological flaws Non-human studies, studies not in English, etc. Checklist items : Were clear and appropriate inclusion and exclusion criteria used? Were these criteria specified prior to the review? Were all study types included (cohort, case-control, etc.) or restricted in a way that makes sense?

14. Yes , the authors specified both inclusion and exclusion criteria for selecting studies. Inclusion Criteria : Study Design : Only observational studies (cohort, case-control) were included. Population : Adults undergoing colorectal surgery . Intervention : Prehabilitation programs that included physical, nutritional, and/or psychological components before surgery. Outcomes : Studies that reported on relevant postoperative outcomes , including complications, hospital stay, recovery, and quality of life. Exclusion Criteria : Studies with inadequate data or unclear methodology. Studies not available in English or with sample sizes too small for meaningful analysis. Checklist Items : Were clear inclusion and exclusion criteria used? Yes, the criteria are clearly defined and appropriate for the research question. Were these criteria specified in advance? Yes, the criteria were established prior to conducting the review and were followed rigorously.

15. 4. Did the review authors assess the quality of the included studies? What to check: The review should assess the quality and risk of bias in the included studies. This is especially important for observational studies , which have higher risks of bias compared to randomized controlled trials (RCTs). Authors should use a valid quality assessment tool for observational studies. Common tools include: The Newcastle-Ottawa Scale (NOS) for cohort and case-control studies. The ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool for assessing bias in non-randomized studies. The quality of individual studies should be assessed in terms of: Selection bias (e.g., how participants were selected or grouped) Confounding factors (e.g., differences in baseline characteristics between groups) Outcome assessment (e.g., blinding of outcome assessors) Follow-up (e.g., loss to follow-up or incomplete data) Checklist items : Did the authors use a validated quality assessment tool? Did the authors assess risk of bias for each study? Were any studies excluded based on quality or risk of bias?

16. Yes , the authors evaluated the quality and risk of bias in the included studies. Quality Assessment Tool : The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the observational studies. This scale evaluates the studies in terms of selection bias , comparability , and outcome assessment . The authors assessed the risk of bias in studies and took this into account when interpreting results. Risk of Bias : The authors reported that some studies had high risk of bias , particularly in how participants were selected or in the lack of blinding in outcome assessment. They discussed how this risk could affect the overall strength of the evidence. Checklist Items : Did the authors use a validated quality assessment tool? Yes, the authors used the Newcastle-Ottawa Scale (NOS) for cohort studies, which is widely accepted. Did the authors assess the risk of bias for each study? Yes, the authors assessed and discussed the risk of bias in individual studies. Were any studies excluded based on quality or risk of bias? The authors excluded studies with significant quality issues, though they included those with some bias and discussed how this might influence the findings.

17. 5. Was the validity of the findings of the included studies discussed? What to check: The authors should discuss the strengths and limitations of the included studies. They should identify: Potential confounders (e.g., patient comorbidities, age, preoperative fitness) that might affect outcomes. Inconsistencies in the findings across studies (e.g., differing methodologies, population characteristics). The generalizability of the findings (e.g., if the results can be applied to broader populations or settings). The authors should acknowledge limitations like publication bias or methodological weaknesses in the included studies. Checklist items : Did the authors discuss the validity and limitations of the individual studies? Did they account for confounding factors or biases that might affect the results?

18. Yes , the authors discussed the validity and limitations of the included studies in the review. Strengths : Studies that used randomization within observational designs were noted for having less bias. The review included a heterogeneous mix of studies with varying interventions and outcomes, which provided broad insights. Limitations : Selection bias : Many studies did not clearly describe their methods of selecting participants, which could introduce bias. Confounding variables : Variables like age, comorbidities, and baseline physical status were not always well-controlled across studies. Loss to follow-up : Several studies had incomplete data or participant drop-out, which could affect the reliability of results. Checklist Items : Did the authors discuss the limitations and validity of the studies? Yes, they critically discussed how various biases (e.g., selection bias, outcome reporting bias) may have impacted the findings. Did the authors consider confounding factors? Yes, they acknowledged confounding variables such as patient comorbidities and other treatment factors that might have affected the outcomes.

19. 6. Were the results of the studies combined appropriately? What to check: The authors should use appropriate statistical methods to synthesize the data. In the case of observational studies, the meta-analysis should address the increased risk of bias and variability between studies. The authors should: Report effect sizes (e.g., odds ratios, risk ratios) with confidence intervals (CIs) . Consider heterogeneity (variability in results across studies). The I² statistic should be reported to quantify heterogeneity. If high heterogeneity is present, subgroup analyses or a random-effects model should be used. Sensitivity analyses may be conducted to explore the impact of excluding low-quality studies or studies with high risk of bias. Checklist items : Were the studies combined appropriately using statistical methods? Did the authors report heterogeneity and use appropriate models (e.g., random-effects)? Were sensitivity analyses conducted?

20. Yes , the results of the studies were combined appropriately using meta-analysis techniques. Statistical Methods : The authors used random-effects models to account for the heterogeneity in study designs and patient populations. They performed subgroup analyses based on factors like age, type of prehabilitation program, and surgery type to explore potential sources of variability. Sensitivity analyses were conducted to assess the impact of low-quality studies on the overall results. Heterogeneity : I² statistic was calculated to assess heterogeneity, and the authors found moderate to high variability across studies. This was addressed using appropriate meta-analysis techniques. Checklist Items : Were the studies combined appropriately using statistical methods? Yes, appropriate statistical methods were used, including random-effects models. Did the authors assess heterogeneity and use appropriate models? Yes, the authors assessed heterogeneity using I² and used random-effects models to handle variability across studies.

21. 7 . Were the results of the review clearly presented? What to check: Results should be clearly summarized in tables and forest plots . Forest plots should display the effect size for each study and the overall pooled effect . The key findings (e.g., overall impact of prehabilitation on postoperative outcomes like complications, hospital stay) should be presented in a clear, accessible format. Risk of bias or study quality should be considered in the presentation of results (e.g., subgroup analysis based on quality). Checklist items : Were the results clearly presented with appropriate summary measures (e.g., forest plots, risk ratios, mean differences)? Were potential sources of bias or study quality clearly reported alongside the results?

22. Yes , the results were presented clearly, and the data were displayed in forest plots and summary tables . Presentation : Forest plots were used to show the individual and pooled effect sizes for postoperative outcomes like hospital stay, complications, and quality of life. The review presented point estimates with confidence intervals (CIs) for each outcome. Tables summarized study characteristics and outcomes for each included study. Checklist Items : Were the results clearly presented with appropriate summary measures? Yes, the results were clearly summarized in both text and visual formats (forest plots, tables). Were potential sources of bias or study quality clearly reported alongside the results? Yes, the risk of bias and quality of studies were clearly reported.

23. 8. What are the implications of the study for practice and/or future research? What to check: The authors should discuss how the findings can influence clinical practice . In this case, they should highlight how prehabilitation might improve postoperative outcomes and suggest practical steps for incorporating it into patient care for colorectal surgery. They should also discuss gaps in the evidence and propose areas where further research is needed, especially considering the observational nature of the studies included in the review. Checklist items : Did the authors discuss the implications for clinical practice or policy? Did the authors suggest areas for future research, especially considering the limitations of observational studies?

24. Yes , the authors discussed both clinical implications and areas for future research . Implications for Practice : The review suggests that prehabilitation may have a positive impact on postoperative recovery, particularly by improving functional outcomes and reducing complications. The authors recommend that prehabilitation should be incorporated into preoperative care for colorectal surgery patients, particularly for those at high risk for complications. Implications for Research : The authors highlighted the need for further randomized controlled trials (RCTs) to confirm the findings from observational studies and to address the gaps in methodological quality. There is a need for standardized definitions of prehabilitation and more consistent outcome measures across studies. Checklist Items : Did the authors discuss the implications for clinical practice or policy? Yes, they recommended incorporating prehabilitation programs into clinical practice. Did the authors suggest areas for future research? Yes, they emphasized the need for higher-quality studies and standardization in prehabilitation protocols.

25. 9. Was there any conflict of interest or funding bias? What to check: The authors should disclose any potential conflicts of interest related to the funding sources or other financial interests. Funding bias should also be considered, especially if studies funded by industry sources may have a vested interest in certain outcomes (e.g., pharmaceutical or medical device companies funding research on prehabilitation programs). Checklist items : Did the authors disclose any conflicts of interest or funding sources? Did they acknowledge any potential for funding bias?

26. Yes , the authors disclosed any conflicts of interest and funding sources . The study did not appear to have any major conflicts of interest that would affect its findings, and the funding sources were transparently reported. Checklist Items : Did the authors disclose any conflicts of interest or funding sources? Yes, all conflicts of interest and funding sources were disclosed.

27. 10. Did the authors assess and report the heterogeneity of the included studies? What to check: The authors should clearly report heterogeneity between studies using measures like the I² statistic . If there is high heterogeneity, they should explain possible reasons for this variability (e.g., differences in study design, interventions, or population characteristics). If significant heterogeneity is found, subgroup analyses (e.g., by intervention type, patient demographics) should be reported. Checklist items : Did the authors assess heterogeneity across studies? Were appropriate methods used to explore or address heterogeneity?

28. Yes , the authors assessed and reported heterogeneity among studies. I² statistic was used to measure the variability across studies, and the authors appropriately used a random-effects model to handle this variability. Checklist Items : Did the authors assess heterogeneity across studies? Yes, heterogeneity was assessed using the I² statistic. Were appropriate methods used to explore or address heterogeneity? Yes, a random-effects model was used, and subgroup analyses were performed.

29. Conclusion In conclusion, this study demonstrated that prehabilitation of patients undergoing colorectal surgery does not significantly affect postoperative complications, LOS, and 6MWT. Thus, prehabilitation strategies may not be beneficial in colorectal surgery, and there is limited direct evidence supporting the recommendation of prehabilitation for patients undergoing colorectal surgery.