Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis

Adherence to fast track measures in colorectal surgery-a survey among German and Austrian surgeons

PURPOSE

The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement.

METHODS

Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel.

RESULTS

While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains).

CONCLUSION

The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.

Surgical Prehabilitation in Patients with Gastrointestinal Cancers: Impact of Unimodal and Multimodal Programs on Postoperative Outcomes and Prospects for New Therapeutic Strategies-A Systematic Review

The advantages of prehabilitation in surgical oncology are unclear. This systematic review aims to (1) evaluate the latest evidence of preoperative prehabilitation interventions on postoperative outcomes after gastrointestinal (GI) cancer surgery and (2) discuss new potential therapeutic targets as part of prehabilitation. Randomized controlled trials published between January 2017 and August 2022 were identified through Medline. The population of interest was oncological patients undergoing GI surgery. Trials were considered if they evaluated prehabilitation interventions (nutrition, physical activity, probiotics and symbiotics, fecal microbiota transplantation, and ghrelin receptor agonists), alone or combined, on postoperative outcomes. Out of 1180 records initially identified, 15 studies were retained. Evidence for the benefits of unimodal interventions was limited. Preoperative multimodal programs, including nutrition and physical activity with or without psychological support, showed improvement in postoperative physical performance, muscle strength, and quality of life in patients with esophagogastric and colorectal cancers. However, there was no benefit for postoperative complications, hospital length of stay, hospital readmissions, and mortality. No trial evaluated the impact of fecal microbiota transplantation or oral ghrelin receptor agonists. Further studies are needed to confirm our findings, identify patients who are more likely to benefit from surgical prehabilitation, and harmonize interventions.

Multimodal Prehabilitation in Patients Undergoing Complex Colorectal Surgery, Liver Resection, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Pilot Study on Feasibility and Potential Efficacy

BACKGROUND

Surgery for complex primary and metastatic colorectal cancer (CRC), such as liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), in academic settings has led to improved survival but is associated with complications up to 75%. Prehabilitation has been shown to prevent complications in non-academic hospitals. This pilot study aimed to determine the feasibility and potential efficacy of a multimodal prehabilitation program in patients undergoing surgery in an academic hospital for complex primary and metastatic CRC.

METHODS

All patients awaiting complex colorectal surgery, liver resection, or HIPEC from July 2019 until January 2020 were considered potentially eligible. Feasibility was measured by accrual rate, completion rate, adherence to the program, satisfaction, and safety. To determine potential efficacy, postoperative outcomes were compared with a historical control group.

RESULTS

Sixteen out of twenty-five eligible patients (64%) commenced prehabilitation, and fourteen patients fully completed the intervention (88%). The adherence rate was 69%, as 11 patients completed >80% of prescribed supervised trainings. No adverse events occurred, and all patients expressed satisfaction with the program. The complication rate was significantly lower in the prehabilitation group (37.5%) than the control group (70.2%, p = 0.020). There was no difference in the type of complications.

CONCLUSION

This pilot study illustrates that multimodal prehabilitation is feasible in the majority of patients undergoing complex colorectal cancer, liver resection, and HIPEC in an academic setting.

Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs

INTRODUCTION

Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio.

METHODS

Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics.

RESULTS

The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633).

CONCLUSIONS

A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run.

Pulmonary prehabilitation and smoking cessation

PURPOSE OF REVIEW

This review aims to summarize the current literature on pulmonary prehabilitation programs, their effects on postoperative pulmonary complications, and the financial implications of implementing these programs. Additionally, this review has discussed the current trends in pulmonary prehabilitation programs, techniques for improving rates of perioperative smoking cessation, and the optimal timing of these interventions.

RECENT FINDINGS

Prehabilitation is a series of personalized multimodal interventions tailored to individual needs, including lifestyle and behavioral measures. Pulmonary prehabilitation has shown to reduce postoperative pulmonary complications (PPCs).

SUMMARY

The implications of clinical practice and research findings regarding PPCs are an increased burden of postoperative complications and financial cost to both patients and hospital systems. There is convincing evidence that pulmonary prehabilitation based on endurance training should be started 8-12 weeks prior to major surgery; however, similar rates of improved postoperative outcomes are observed with high-intensity interval training (HIIT) for 1-2 weeks. This shorter interval of prehabilitation may be more appropriate for patients awaiting thoracic surgery, especially for cancer resection. Additionally, costs associated with creating and maintaining a prehabilitation program are mitigated by shortened lengths of stay and reduced PPCs. Please see Video Abstract, http://links.lww.com/COAN/A90.

Multimodal prehabilitation program valuation for thoracic surgical patients

PURPOSE OF REVIEW

Modifiable patient-related risk factors, such as physical, emotional, and cognitive frailty, poor nutritional status, sleep hygiene, anemia, alcohol abuse, and smoking reduce a patient's ability to effectively recover from the insult of surgery. Herein, we review the value of implementing a comprehensive prehabilitation program for patients undergoing thoracic surgery.

RECENT FINDINGS

Although prehabilitation is not a novel concept, recent evidence suggest that 4-6 weeks of prehabilitation prior to surgery is likely to increase a patient's preoperative functional status allowing patients to return to independence earlier after surgery. The value of a prehabilitation program can be determined using cost effectiveness analysis, cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-consequence analysis (CCA).

SUMMARY

It stands to reason that well designed prehabilitation programs can add value by improving quality metrics at a lower cost to our healthcare system. Definitive randomized trials are needed to confirm this notion.

Outcomes of a Multi-Modal Hospital-Associated Home-Based Cancer Prehabilitation Program

OBJECTIVE

To assess the impact of a "one-stop", multi-modal, hospital-associated-home-based prehabilitation model, helmed by a small core team, on newly diagnosed gastrointestinal and urological cancer patients planned for surgery.

METHODS

This is a retrospective study in a tertiary public hospital, involving all newly diagnosed gastrointestinal and urological cancer patients planned for surgery. The primary outcome measure was the 6-minute walk test (6MWT). Other outcomes included physical, psychological and quality-of-life measures, and patient satisfaction surveys, taken at baseline, pre-operatively (post-prehabilitation), and at 3 months post-operatively.

RESULTS

When comparing the baseline to pre-operatively (post-prehabilitation), there was a statistically significant improvement in the 6MWT (21.52 m, p<0.001), 30-Second Sit to Stand test (STS) (1.08 repetitions, p<0.001), Timed Up and Go test (TUG) (0.83 seconds, p=0.014) and Hospital Anxiety and Depression Scale (HADS) (total score 1.77, p<0.001). These were sustained (6MWT: 0.22, p=0.964; STS: 0.08 repetitions, p=0.863; TUG: 0.04 seconds, p=0.939) or further improved (HADS total score 2.06, p=0.003) at 3 months post-operatively. There was also a statistically significant improvement in the EuroQol-5 dimension health score (health-related quality-of-life measure) from baseline to 3 months post-operatively (7.04 points, p=0.001), with more than 90% overall patient satisfaction reported.

CONCLUSION

Prehabilitation applied via our model resulted in significant improvements in functional capacity, psychological and quality-of-life outcomes, sustained at 3 months post-operatively, and is a feasible and effective approach that is well-received by our patients.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy

BACKGROUND

Coordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center.

METHODS

We performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13.

RESULTS

A total of 82 patients were enrolled between February - December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation.

CONCLUSIONS

Implementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis

BACKGROUND

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery.

METHODS

Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively.

CONCLUSIONS

As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

The impact of prehabilitation interventions on affective and functional outcomes for young to midlife adult cancer patients: A systematic review

OBJECTIVE

Cancer remains one of the most enduring health crises of the modern world. Prehabilitation is a relatively new intervention aimed at preparing individuals for the stresses associated with treatment from diagnosis. Prehabilitation can include exercise, psychological and nutrition-based interventions. The present systematic review aimed to assess the efficacy of prehabilitation on affective and functional outcomes for young to midlife adult cancer patients (18-55 years). Outcomes of interest included prehabilitation programme composition, duration, mode of delivery and measures used to determine impact on affective and functional outcomes.

METHODS

The following databases were searched with controlled and free text vocabulary; Psychological Information database (PsychINFO), Culmunated Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE) and Public MEDLINE (PubMed). Abstract and full-text screening was conducted with a secondary reviewer and final texts were subject to risk of bias analysis.

RESULTS

Thirteen texts were included at full-text. These included data of 797 prehabilitation participants (mean age 53 years) and a large representation of female participants (71% average). Evidence was found for the efficacy of psychological prehabilitation for anxiety reduction. Prehabilitation did not significantly affect health related quality of life. Findings moderately supported the therapeutic validity of exercise prehabilitation for functional outcomes, both in terms of clinical and experimental improvement with respect to the quality of evidence. Variation between all prehabilitation types was observed. There was insufficient evidence to support the efficacy of psychological prehabilitation on stress, distress or depression.

CONCLUSION

Implications for future research are highlighted and then discussed with respect to this young to midlife age group.

Cancer Prehabilitation in Practice: the Current Evidence

PURPOSE OF REVIEW

This article serves to describe recent controversies in cancer prehabilitation including efficacy, dose, cost effectiveness, stakeholder input, and international implementation.

RECENT FINDINGS

Appropriate frequency, type, and timing have yet to be determined, but high intensity exercise is recommended. Costs are favorable when modeled and information on costs of real-world application are forthcoming. Patients are interested in and willing to attend cancer prehabilitation. Cancer prehabilitation research is spreading throughout the world. Cancer prehabilitation includes assessment of a newly diagnosed cancer patient's baseline fitness and targeted interventions to improve their health before surgery, chemotherapy, or radiation. Cancer prehabilitation improves fitness as measured preoperatively and improves outcomes postoperatively.

The Impact of CT-Assessed Liver Steatosis on Postoperative Complications After Pancreaticoduodenectomy for Cancer

INTRODUCTION

Liver steatosis (LS) has been increasingly described in preoperative imaging of patients undergoing pancreaticoduodenectomy (PD). The aim of this study was to assess the impact of preoperative LS on complications after PD and identify possible contributors to LS development in this specific cohort.

METHODS

Pancreatic head adenocarcinoma (PDAC) patients scheduled for PD, with preoperative CT-imaging available were included in the study. LS was defined as mean liver density lower than 45 Hounsfield units. Patients showing preoperative LS were matched for patient age, gender, BMI, ASA score, neoadjuvant treatment, and vascular and multivisceral resections, based on propensity scores in a 1:2 ratio to patients with no LS. The primary outcome was postoperative complication severity at 90 days as measured by the comprehensive complication index (CCI) RESULTS: Overall, 247 patients were included in the study. Forty-three (17%) patients presented with LS at preoperative CT-scan. After matching, the LS group included 37 patients, whereas the non-LS group had 74 patients. LS patients had a higher mean (SD) CCI, 29.7 (24.5) versus 19.5 (22.5), p = 0.035, and a longer length of hospital stay, median [IQR] 12 [8-26] versus 8 [7-13] days, p = 0.006 compared with non-LS patients. On multivariate analysis, variables independently associated with CCI were: LS (16% increase, p = 0.048), male sex (19% increase, p = 0.030), ASA score ≥ 3 (26% increase, p = 0.002), fistula risk score (FRS) (28% increase for each point of FRS, p = 0.001) and vascular resection (20% increase, p = 0.019).

CONCLUSION

Preliminary evidence suggests that preoperative LS assessed by CT-scan influences complication severity in patients undergoing PD for PDAC.

Postoperative Nutrition Management: Who Needs What?

Background

Early oral feeding after major abdominal surgery has been clearly shown to be safe and not a risk factor for anastomotic dehiscence. Within the Enhanced Recovery after Surgery protocol, it is the nutritional plan A. Nonetheless, one must consider that postoperative protein and energy requirements will often be not covered by oral food intake alone. Because nutritional status has been shown to be a prognostic factor in patients undergoing major abdominal surgery, the preoperative identification of patients at risk may be mandatory. Malnutrition may be underestimated in an overweight society. With special regard to patients with cancer and those with preexisting malnutrition, an accumulating caloric gap may be harmful in the early and late postoperative periods. Furthermore, complications requiring reoperation and intensive care treatment may occur.

Summary

Therefore, a plan B for postoperative nutrition therapy is needed, using preferentially the enteral route. The European Society for Clinical Nutrition and Metabolism recently addressed perioperative nutritional management and the indications for enteral and even parenteral supplementation to achieve caloric requirements in the postoperative course. In the first months after surgery, persisting weight loss is common in patients with upper gastrointestinal resections, even in those with an uncomplicated course. This may delay the initiation of adjuvant chemotherapy, increase toxicity, and worsen long-term outcomes.

Preoperative exercise and prehabilitation

PURPOSE OF REVIEW

The purpose of this narrative review is to give an overview about the effects of multimodal prehabilitation and current existing and prospectively planned studies. The potential efficacy of exercise in the context of prehabilitation ranges from preoperatively improving patients' functional capacity to inducing cellular mechanisms that affect organ perfusion via endothelial regeneration, anti-inflammatory processes and tumour defense.

RECENT FINDINGS

Current studies show that prehabilitation is capable of reducing certain postoperative complications and length of hospital stay in certain patient populations. These findings are based on small to mid-size trials with large heterogeneity, lacking generalizability and evidence that prehabilitation has positive effects on long term survival.

SUMMARY

The concept of prehabilitation contains the features, namely preoperative exercise, nutritional intervention and psychological support. Preoperative exercise holds potential molecular effects that can be utilized in the perioperative period in order to improve patients' postoperative outcome. Future multimodal prehabilitation trials must specifically clarify the clinical impact of this concept on patients' quality of life after major cancer surgery and cancer-specific survival.

Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis

PURPOSE

Functional capacity is an independent indicator of morbidity in colon and rectal cancer surgery. This systematic review describes the evaluated and synthesized effects of exercise prehabilitation depending on the duration of interventions on functional and postoperative outcomes in colon and rectal cancer surgery.

METHODS

Three electronic databases (MEDLINE Pubmed, Web of Sciences, and Cochrane Registry) were systematically searched (January 2022) for controlled trials that investigated the effects of prehabilitation prior to colo-rectal cancer resection.

RESULTS

Twenty-three studies were included in this systematic review and 14 in our meta-analyses assessing these outcomes: the 6 min walk distance (6MWD), postoperative overall complications, and length of stay (LOS). We observed a significant improvement in preoperative functional capacity as measured with 6MWD (mean difference: 30.8 m; 95% CI 13.3, 48.3; p = 0.0005) due to prehabilitation. No reductions in LOS (mean difference: - 0.27 days; 95% CI - 0.93, 0.40; p = 0.5) or postoperative overall complications (Odds ratio: 0.84; 95% CI 0.53, 1.31; p = 0.44) were observed. Prehabilitation lasting more than 3 weeks tended to lower overall complications (Odds ratio: 0.66; 95% CI 0.4, 1.1; p = 0.11). However, the prehabilitation time periods differed between colon and rectal carcinoma resections.

CONCLUSION

Prehabilitation while the patient is preparing to undergo surgery for colorectal carcinoma improves functional capacity; and might reduce postoperative overall complications, but does not shorten the LOS. The studies we reviewed differ in target variables, design, and the intervention's time period. Multicenter studies with sufficient statistical power and differentiating between colon and rectal carcinoma are needed to develop implementation strategies in the health care system.

REGISTRATION

PROSPERO CRD42022310532.

The Role of Exercise Before Cancer Treatment

OBJECTIVES

We aim to describe on the role of exercise in preparation for cancer treatments (prehabilitation) that include surgery and neoadjuvant or nonsurgical approaches. We discuss the evidence for the role of exercise and provide guidelines to exercise prescription and examples of the structure of prehabilitation exercise programs.

DATA SOURCE

We use peer-reviewed articles obtained through PubMed searches with search terms: exercise, oncology, cancer surgery, exercise physiology, respiratory exercises, prehabilitation, and behavior change.

CONCLUSION

The emergence of prehabilitation in preparing patients for cancer care has followed a rapidly upward trajectory over the past 20 years. Exercise prehabilitation remains the cornerstone of management, particularly in patients attending for major surgery. Multimodal approaches to supporting patients before cancer treatment are now well accepted and include screening and individualized treatments of functional, nutritional, and psychological impairments. Respiratory training before surgery and the addition of behavior change strategies to improve adherence to interventions and promote improved longer-term outcomes are now included in many prehabilitation programs. For exercise to be an effective treatment in improving fitness and strength, supervised aerobic and resistance exercises at moderate intensity are recommended. There remains debate regarding the use of higher-intensity exercise, the appropriate outcome to measure efficacy, and the mechanisms driving the efficacy of exercise.

IMPLICATIONS FOR NURSING PRACTICE

We provide background evidence and knowledge pertaining to the role and provision of exercise prehabilitation. Understanding screening, risk factors, and potential efficacy assists in knowing who to refer for prehabilitation and what the programs include. This enables more effective com munication with patients attending for cancer treatments.

Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline

PURPOSE

To provide guidance on exercise, diet, and weight management during active cancer treatment in adults.

METHODS

A systematic review of the literature identified systematic reviews and randomized controlled trials evaluating the impact of aerobic and resistance exercise, specific diets and foods, and intentional weight loss and avoidance of weight gain in adults during cancer treatment, on quality of life, treatment toxicity, and cancer control. PubMed and the Cochrane Library were searched from January 2000 to May 2021. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 52 systematic reviews (42 for exercise, nine for diet, and one for weight management), and an additional 23 randomized controlled trials. The most commonly studied types of cancer were breast, prostate, lung, and colorectal. Exercise during cancer treatment led to improvements in cardiorespiratory fitness, strength, fatigue, and other patient-reported outcomes. Preoperative exercise in patients with lung cancer led to a reduction in postoperative length of hospital stay and complications. Neutropenic diets did not decrease risk of infection during cancer treatment.

RECOMMENDATIONS

Oncology providers should recommend regular aerobic and resistance exercise during active treatment with curative intent and may recommend preoperative exercise for patients undergoing surgery for lung cancer. Neutropenic diets are not recommended to prevent infection in patients with cancer during active treatment. Evidence for other dietary and weight loss interventions during cancer treatment was very limited. The guideline discusses special considerations, such as exercise in individuals with advanced cancer, and highlights the critical need for more research in this area, particularly regarding diet and weight loss interventions during cancer treatment.Additional information is available at www.asco.org/supportive-care-guidelines.

Prehabilitation before gastrointestinal cancer surgery (Prehab-GI): Protocol for an implementation study. (Preprint)

BACKGROUND

Surgery remains the standard curative treatment for early-stage colorectal and upper gastrointestinal cancer. Reduced preoperative functional capacity, nutritional status, and psychological well-being are associated with poor postoperative outcomes. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and psychological interventions. Yet, how it transitions from a trial setting to being integrated into a real-world health setting is unknown.

OBJECTIVE

The primary aim is to evaluate the implementation of a multimodal (supervised exercise, nutrition, and nursing support) prehabilitation program into standard care for patients with gastrointestinal cancer (colorectal and upper gastrointestinal cancer) scheduled for curative intent surgery. The secondary aim is to determine the impact of a multimodal prehabilitation program on functional capacity, nutritional and psychological status, and surgical outcomes.

METHODS

This is an implementation study that will investigate a multimodal prehabilitation intervention, in a nonblinded, nonrandomized, single-group, pre-post design. Patients diagnosed with colorectal and upper gastrointestinal cancer scheduled for potentially curative intent surgery at Concord Repatriation General Hospital, with ≥14 intervention days prior to surgery and are medically cleared to exercise will be eligible. The study will be evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Evaluation Framework.

RESULTS

The protocol was approved in December 2019 by the Concord Repatriation General Hospital Human Research Ethics Committee (reference number 2019/PID13679). Recruitment commenced in January 2020. In response to the COVID-19 pandemic, recruitment was paused in March 2020 and reopened in August 2020 with remote or telehealth intervention adaptations. Recruitment ended on December 31, 2021. Over the 16-month recruitment period, a total of 77 participants were recruited.

CONCLUSIONS

Prehabilitation represents an opportunity to maximize functional capacity and improve surgical outcomes. The study will provide guidance and contribute to the evidence on the integration of prehabilitation into standard care using adaptive models of health care delivery including telehealth.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTR 12620000409976; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378974&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/41101.

Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity?

The literature evaluating the effect of prehabilitation programmes on postoperative outcomes and quality of life of patients with gynaecological cancer undergoing surgery was reviewed. Databases including Pubmed, Medline, EMBASE (Ovid) and PsycINFO were systematically searched to identify studies evaluating the effect of prehabilitation programmes on patients with gynaecological cancer. Both unimodal and multimodal prehabilitation programmes were included encompassing physical exercise and nutritional and psychological support. Primary outcomes were surgical complications and quality of life. Secondary outcomes were anthropometric changes and adherence to the prehabilitation programme. Seven studies fulfilled the inclusion criteria, comprising 580 patients. Included studies were nonrandomised prospective studies (n = 4), retrospective studies (n = 2) and one case report. Unimodal programmes and multimodal programmes were included. In patients with ovarian cancer, multimodal prehabilitation resulted in significantly reduced hospital stay and time to chemotherapy. In patients with endometrial and cervical cancer, prehabilitation was associated with significant weight loss, but had no significant effects on surgical complications or mortality. No adverse events of the programmes were reported. Evidence on the effect of prehabilitation for patients with gynaecological cancer is limited. Future studies are needed to determine the effects on postoperative complications and quality of life.

Unresolved issues in perioperative nutrition: A narrative review

Surgical patients are at an increased risk of negative outcomes if they are malnourished or at risk of malnutrition preoperatively. Optimisation of nutritional status should be a focus throughout the perioperative continuum to promote improved surgical outcomes. Enhanced Recovery after Surgery (ERAS) protocols are increasingly applied in the surgical setting but are not yet widespread. This narrative review focused on areas of perioperative nutrition that are perceived as controversial or are lacking in agreement. A search for available literature was conducted on 1 March 2022 and relevant high-quality articles published since 2015 were considered for inclusion. Most malnutrition screening tools are not specific to the surgical population except for the Perioperative Nutrition Screen (PONS) although more large-scale initiatives are needed to improve the prevalence of preoperative nutrition screening. Poor muscle health is common in patients with malnutrition and further exacerbates negative health outcomes indicating that prevention, detection and treatment is of high importance in this population. Although a lack of consensus remains for who should receive preoperative nutritional therapy, evidence suggests a positive impact on muscle health. Additionally, postoperative nutritional support benefits surgical outcomes, with some patients requiring enteral and/or parenteral feeding routes and showing benefit from immunonutrition. The importance of nutrition extends beyond the time in hospital and should remain a priority post-discharge. The impact of individual or personalised nutrition based on select patient characteristics remains to be further investigated. Overall, the importance of perioperative nutrition is evident in the literature despite select ongoing areas of contention.

Optimized perioperative management (fast-track, ERAS) to enhance postoperative recovery in elective colorectal surgery

Aim

This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).

Methods

With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.

Results

An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimization of concurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.

Conclusion

Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Tailoring prehabilitation to address the multifactorial nature of functional capacity for surgery

Mounting evidence suggests that recovery begins before the surgical incision. The pre-surgery phase of recovery - the preparation for optimal surgical recovery - can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson & Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualized and coordinated care from medical, nutritional, psychosocial, and exercise services. This article is protected by copyright. All rights reserved.

Perioperative Risk Stratification and Modification

This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.

'Fit for surgery': The relationship between cardiorespiratory fitness and postoperative outcomes

New Findings

What is the topic of this review?

The relationships and physiological mechanisms underlying the clinical benefits of cardiorespiratory fitness (CRF) in patients undergoing major intra‐abdominal surgery.

What advances does it highlight?

Elevated CRF reduces postoperative morbidity/mortality, thus highlighting the importance of CRF as an independent risk factor. The vascular protection afforded by exercise prehabilitation can further improve surgical risk stratification and postoperative outcomes.

Abstract

Surgery accounts for 7.7% of all deaths globally and the number of procedures is increasing annually. A patient's ‘fitness for surgery’ describes the ability to tolerate a physiological insult, fundamental to risk assessment and care planning. We have evolved as obligate aerobes that rely on oxygen (O₂). Systemic O₂ consumption can be measured via cardiopulmonary exercise testing (CPET) providing objective metrics of cardiorespiratory fitness (CRF). Impaired CRF is an independent risk factor for mortality and morbidity. The perioperative period is associated with increased O₂ demand, which if not met leads to O₂ deficit, the magnitude and duration of which dictates organ failure and ultimately death. CRF is by far the greatest modifiable risk factor, and optimal exercise interventions are currently under investigation in patient prehabilitation programmes. However, current practice demonstrates potential for up to 60% of patients, who undergo preoperative CPET, to have their fitness incorrectly stratified. To optimise this work we must improve the detection of CRF and reduce potential for interpretive error that may misinform risk classification and subsequent patient care, better quantify risk by expressing the power of CRF to predict mortality and morbidity compared to traditional cardiovascular risk factors, and improve patient interventions with the capacity to further enhance vascular adaptation. Thus, a better understanding of CRF, used to determine fitness for surgery, will enable both clinicians and exercise physiologists to further refine patient care and management to improve survival.

Multimodal prehabilitation in older adults before major abdominal surgery: a systematic review and meta-analysis

PURPOSE

Multimodal prehabilitation aims to prepare frail older patients for major surgery. The objective of this review is to determine the benefits of pre-operative multimodal prehabilitation compared to standard care in older patients.

METHODS

Data sources included MEDLINE, EMBASE, CENTRAL, CINAHL and PsychINFO. They were searched from inception to September 2021. Only randomized controlled trials (RCT) with an average study population age ≥ 65 that had undergone major abdominal operation with at least two components (physical, nutritional, psychological) of prehabilitation programs were included.

RESULTS

Nine RCTs were included with a total of 823 patients, of whom 705 completed the study with 358 undergoing prehabilitation and 347 were controls. Significantly lower complications were observed in the prehabilitation group compared to control (OR 0.67; 95% CI 0.46 to 0.99; p = 0.04; I² = 32%). A significant increase in 6-min walking distance (6MWD) from baseline to immediately prior to surgery (mean difference 35.1 m; 95%CI 11.6-58.4; p = 0.003; I² = 67%) and 8 weeks post-surgery (mean difference 44.9 m; 95%CI 6.0-83.8; p = 0.02; I² = 75%) was noted in the prehabilitation group. No difference was observed in length of stay (OR 0.59; 95% CI - 0.23 to 1.40; p = 0.16; I² = 91%) or 30-day emergency department visit (OR 0.72; 95% CI 0.41 to 1.26; p = 0.25; I² = 0%). Patient reported outcome measures were not significantly different.

CONCLUSIONS

Amongst older patients, multimodal prehabilitation increases peri-operative functional capacity and may potentially decrease post-operative complications. Future studies should continue to focus on older patients who are frail as this is the group that prehabilitation would likely have a clinically significant impact on.

Finding value with prehabilitation in older persons receiving surgery

PURPOSE OF REVIEW

Patients presenting for surgery are increasingly older and frail. Prehabilitation offers the best hope of preemptive functional optimisation to improve postoperative outcomes. Systematic reviews and meta-analyses show signals of improved function and reduced complications and length of stay, but are hampered by small trials with heterogeneous nature of interventions.

RECENT FINDINGS

The value proposition for prehabilitation is strengthened by applying the following considerations to the evidence. Multimodal prehabilitation programmes incorporating elements of exercise, nutrition, and psychological preparation have a sound physiological basis and will help standardise care delivery and evidence gathering. Targeting prehabilitation resources at high-risk patients may yield higher returns. Effective prehabilitation programmes must be individualised and pragmatic to address known barriers to adherence. The evidence for functional improvement is clear and this aligns with the values of older patients. A comprehensive analysis of value incorporates functional, quality of life, and cost outcomes in addition to conventional morbidity and mortality measures.

SUMMARY

Multimodal prehabilitation delivered by a multidisciplinary team improves functional outcomes following surgery. Function is an integral part of multidimensional value assessment including clinical and experiential measures. Future value enhancements include addressing frailty and overcoming barriers through targeted programme design.

Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities

Global demand for major surgery is rising as a consequence of a growing, ageing population and clinically applicable approaches to perioperative risk reduction have never been needed more. Prehabilitation aims to optimise aerobic capacity and address modifiable risk factors prior to surgery to improve postoperative outcomes. Given the inherently high-risk nature of vascular surgery and the frequently high-acuity, frail, vascular surgical population, the potential to introduce an intervention into the surgical pathway that may reduce postoperative complications cannot be overlooked. The aim of this article is to examine the current evidence base for prehabilitation in patients awaiting vascular surgery, and to summarise the potential benefits, pitfalls, and practicalities of this emerging perioperative intervention. There is a paucity of high-quality research specifically aimed at prehabilitation for patients undergoing vascular surgery, both peripheral and aortic, making it difficult to draw definitive conclusions upon which to base a change in practice. Currently, evidence is taken from small, often single-centre heterogenous studies that vary significantly from each other, meaning that the optimal exercise regimen for patients awaiting vascular surgery has yet to be defined. Establishing the impact of prehabilitation on outcomes for vascular patients is important as the effectiveness of preoperative exercise training is likely to vary between surgical interventions and patient populations. However, extrapolation from other cohorts is possible and indeed forms the basis of many current prehabilitation programmes. Given the success of prehabilitation in other surgical groups, it has potential to become an important future research target for patients awaiting vascular surgery.

Technical efficiency evaluation of colorectal cancer care for older patients in Dutch hospitals

BACKGROUND

Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors.

METHODS

Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians' judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores.

RESULTS

Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001).

CONCLUSION

This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care.

Muscle weakness as an additional criterion for grading sarcopenia-related prognosis in patients with cancer

Background

Low muscle strength has been pointed out as a key characteristic of sarcopenia, but the prognostic significance of muscle function next to reduced skeletal muscle mass (SMM) in patients with cancer has been scantily investigated.

Methods

Data on muscle strength by handgrip (HG) dynamometry and total‐body SMM estimated by bioelectrical impedance analysis (BIA) of Italian and German patients with cancer observed prospectively until death or censoring were analysed (N = 1076). Patients were stratified in four risk categories based on low HG (<10th percentiles of age and gender‐specific normative values) and low total‐body SMM according to SMM index cutoffs (<10.75 and <6.75 kg/m² in men and women, respectively).

Results

During a median follow‐up of 58 months [25th–75th percentile, 37–60], 566 patients had died. Patients presenting low HG in combination or not with low SMM were characterised by shorter median survival (12.7 vs. 27.2 months, respectively; p < 0.001) compared to those with low SMM/normal HG and normal SMM/normal HG (>60 months for both). After adjusting for sex, age, body mass index and percentage of weight loss, disease's stage, performance status and type of cancer, compared to reference category (normal HG and SMM; N = 210) the hazard ratios were: low SMM/normal HG (N = 342), 0.83 [95% confidence interval, CI, 0.67–1.02] (p = 0.073); normal SMM/low HG (N = 158), 1.19 [95% CI, 1.07–1.32] (p = 0.002); low SMM/low HG (N = 366), 1.39 [95% CI, 1.27–1.53] (p < 0.001).

Conclusions

Muscle weakness was found to be a more powerful predictor of survival than BIA‐estimated SMM and should be considered as an additional key feature of sarcopenia in patients with cancer.

Low muscle strength has been pointed out as a key characteristic of sarcopenia, but the prognostic significance of muscle function next to reduced skeletal muscle mass (SMM) in patients with cancer has been scantily investigated. Muscle weakness was found to be a more powerful predictor of survival than SMM and should be considered as additional key feature of sarcopenia in patients with cancer.

Measuring the human immune response to surgery: multiomics for the prediction of postoperative outcomes

PURPOSE OF REVIEW

Postoperative complications including infections, cognitive impairment, and protracted recovery occur in one-third of the 300 million surgeries performed annually worldwide. Complications cause personal suffering along with a significant economic burden on our healthcare system. However, the accurate prediction of postoperative complications and patient-targeted interventions for their prevention remain as major clinical challenges.

RECENT FINDINGS

Although multifactorial in origin, the dysregulation of immunological mechanisms that occur in response to surgical trauma is a key determinant of postoperative complications. Prior research, primarily focusing on inflammatory plasma markers, has provided important clues regarding their pathogenesis. However, the recent advent of high-content, single-cell transcriptomic, and proteomic technologies has considerably improved our ability to characterize the immune response to surgery, thereby providing new means to understand the immunological basis of postoperative complications and to identify prognostic biological signatures.

SUMMARY

The comprehensive and single-cell characterization of the human immune response to surgery has significantly advanced our ability to predict the risk of postoperative complications. Multiomic modeling of patients' immune states holds promise for the discovery of preoperative predictive biomarkers, ultimately providing patients and surgeons with actionable information to improve surgical outcomes. Although recent studies have generated a wealth of knowledge, laying the foundation for a single-cell atlas of the human immune response to surgery, larger-scale multiomic studies are required to derive robust, scalable, and sufficiently powerful models to accurately predict the risk of postoperative complications in individual patients.

[Implementation of fast-track measures in colorectal resections : A survey among members of the DGAI]

PURPOSE

The fast-track (FT) concept is a multimodal, interdisciplinary approach to perioperative patient care intended to reduce postoperative complications. Despite good evidence implementation seems to need improvement, whereby almost all studies focused on the implementation of surgical modules regardless of the interdisciplinary aspect. Adherence to the anesthesiological measures (prehabilitation, premedication, volume and temperature management, pain therapy), on the other hand, has been insufficiently studied. To assess the status quo a survey on the implementation of anesthesiological FT measures was conducted among members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) to analyze where potential for improvement exists.

METHODS

Using the SurveyMonkey® online survey tool, 28 questions regarding perioperative anesthesiological care of colorectal surgery patients were sent to DGAI members in order to analyze adherence to FT measures.

RESULTS

While some of the FT measures (temperature management, PONV prophylaxis) are already routinely used, there is a divergence between current recommendations and clinical implementation for other components. In addition to premedication, interdisciplinary measures (prehabilitation) and measures that affect multiple interfaces (operating theatre, recovery room, ward), such as volume management or perioperative pain management, are particularly affected.

CONCLUSION

The anesthesiological recommendations of the FT concept are only partially implemented in Germany. This particularly affects the interdisciplinary components as well as measures at the operating theatre, recovery room and ward interfaces. The establishment of an interdisciplinary FT team and interdisciplinary development of SOPs can optimize adherence, which in turn improves the short-term and long-term outcome of patients.

Feasibility and Efficiency of the BEFORE (Better Exercise and Food, Better Recovery) Prehabilitation Program

Prehabilitation has been postulated as an effective preventive intervention to reduce postoperative complications, particularly for elderly patients with a relatively high risk of complications. To date, it remains to be determined whether prehabilitation increases physical capacity and reduces postoperative complications. The aim of this study was to assess the feasibility of a 4-week multimodal prehabilitation program consisting of a personalized, supervised training program and nutritional intervention with daily fresh protein-rich food for colorectal cancer patients aged over 64 years prior to surgery. The primary outcome was the feasibility of this prehabilitation program defined as ≥80% compliance with the exercise training program and nutritional intervention. The secondary outcomes were the organizational feasibility and acceptability of the prehabilitation program. A compliance rate of ≥80% to both the exercise and nutritional intervention was accomplished by 6 patients (66.7%). Attendance of ≥80% at all 12 training sessions was achieved by 7 patients (77.8%); all patients (100%) attended ≥80% of the available training sessions. Overall, compliance with the training was 91.7%. Six patients (66.7%) accomplished compliance of ≥80% with the nutritional program. The median protein intake was 1.2 (g/kg/d). No adverse events occurred. This multimodal prehabilitation program was feasible for the majority of patients.

Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer

Prehabilitation is a clinical model that introduces components of rehabilitation to patients prior to undergoing intensive medical interventions, such as surgery, in order to optimize function and improve tolerability to the intervention. Cancer care introduces a continuum of sequential or concurrent intensive anti-neoplastic medical interventions that are known to be detrimental to a patient's function. Prehabilitation evidence has grown across several areas of oncology care delivery demonstrating that a multi-modal rehabilitative intervention, delivered prior to oncology-direct therapies, leads to better functional outcomes and improves important endpoints associated with surgery and cancer treatment. This commentary article provides a brief history of the emergence of prehabilitation in cancer care delivery, reviews the current evidence base and guidelines for prehabilitation, and offers insights for future implementation of this model as a standard in oncology care. A prehabilitation program is an optimal starting point for most patients undergoing anti-neoplastic therapy as it serves as a gateway to improving functional outcomes throughout the cancer continuum. Future research in prehabilitation should aim to reach beyond measuring functional outcomes and to explore the impact of this model on important disease treatment endpoints such as tumor response to oncology-directed treatment, impact on treatment-related toxicities, and disease progression.