1
|
Kovoor JG, Nann SD, Barot DD, Garg D, Hains L, Stretton B, Ovenden CD, Bacchi S, Chan E, Gupta AK, Hugh TJ. Prehabilitation for general surgery: a systematic review of randomized controlled trials. ANZ J Surg 2023; 93:2411-2425. [PMID: 37675939 DOI: 10.1111/ans.18684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/23/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Prehabilitation seeks to optimize patient health before surgery to improve outcomes. Randomized controlled trials (RCTs) have been conducted on prehabilitation, however an updated synthesis of this evidence is required across General Surgery to inform potential Supplementary discipline-level protocols. Accordingly, this systematic review of RCTs aimed to evaluate the use of prehabilitation interventions across the discipline of General Surgery. METHODS This study was registered with PROSPERO (CRD42023403289), and adhered to PRISMA 2020 and SWiM guidelines. PubMed/MEDLINE and Ovid Embase were searched to 4 March 2023 for RCTs evaluating prehabilitation interventions within the discipline of General Surgery. After data extraction, risk of bias was assessed using the Cochrane RoB 2 tool. Quantitative and qualitative data were synthesized and analysed. However, meta-analysis was precluded due to heterogeneity across included studies. RESULTS From 929 records, 36 RCTs of mostly low risk of bias were included. 17 (47.2%) were from Europe, and 14 (38.9%) North America. 30 (83.3%) investigated cancer populations. 31 (86.1%) investigated physical interventions, finding no significant difference in 16 (51.6%) and significant improvement in 14 (45.2%). Nine (25%) investigated psychological interventions: six (66.7%) found significant improvement, three (33.3%) found no significant difference. Five (13.9%) investigated nutritional interventions, finding no significant difference in three (60%), and significant improvement in two (40%). CONCLUSIONS Prehabilitation interventions showed mixed levels of effectiveness, and there is insufficient RCT evidence to suggest system-level delivery across General Surgery within standardized protocols. However, given potential benefits and non-inferiority to standard care, they should be considered on a case-by-case basis.
Collapse
Affiliation(s)
- Joshua G Kovoor
- University of Sydney, Sydney, New South Wales, Australia
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Silas D Nann
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Dwarkesh D Barot
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Devanshu Garg
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Lewis Hains
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Erick Chan
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Aashray K Gupta
- University of Sydney, Sydney, New South Wales, Australia
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Engel D. Setting Up a Prehabilitation Unit: Successes and Challenges. Semin Oncol Nurs 2022; 38:151334. [PMID: 35995631 DOI: 10.1016/j.soncn.2022.151334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVE The goal of this article is to provide a pragmatic approach to implementing a prehabilitation pathway and service guide. DATA SOURCES The article presents data from peer-reviewed scientific articles (ie, reviews and original studies) and narrative reviews, as well as professional insights and experiences of the author in setting up a prehabilitation clinic. CONCLUSION Successful setup of a prehabilitation unit is highly feasible and rewarding, if led by enthusiastic idealists who work in cooperation with a passionate multidisciplinary team (MDT) with clear vision to collectively improve patient outcomes and experiences. It requires a well-integrated MDT to deliver a successful prehabilitation service. IMPLICATIONS FOR NURSING PRACTICE Nurses are the supporting pillar in many areas of the health care system. The field of prehabilitation is no exception to this with the mainstay contribution nursing provides. A combination of patient care, medical knowledge, and administrative capabilities are required to modify the perioperative pathway and introduce the concept of prehabilitation. Nursing staff are ideally positioned to be strong advocates to developing and delivering an effective MDT prehabilitation clinical pathway.
Collapse
Affiliation(s)
- Dominique Engel
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada; Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
3
|
Ng P, Lee JKD, Tan KY. Finding value with prehabilitation in older persons receiving surgery. Curr Opin Support Palliat Care 2022; 16:19-24. [PMID: 34812752 DOI: 10.1097/spc.0000000000000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Kok Yang Tan
- Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| |
Collapse
|
4
|
Shukla A, Granger CL, Wright GM, Edbrooke L, Denehy L. Attitudes and Perceptions to Prehabilitation in Lung Cancer. Integr Cancer Ther 2021; 19:1534735420924466. [PMID: 32447995 PMCID: PMC7249590 DOI: 10.1177/1534735420924466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Prehabilitation to maximize exercise capacity before
lung cancer surgery has the potential to improve operative tolerability and
patient outcomes. However, translation of this evidence into clinical practice
is limited. Aims: To determine the acceptability and perceived
benefit of prehabilitation in lung cancer among thoracic surgeons.
Procedure: 198 cardiothoracic surgeons within Australia and New
Zealand were surveyed to evaluate their attitudes and perceived benefits of
prehabilitation in lung cancer. Results: Response rate was 14%. A
moderate proportion of respondents reported that there is a need to refer lung
resection patients to preoperative physiotherapy/prehabilitation, particularly
high-risk patients or those with borderline fitness for surgery. 91% of surgeons
were willing to delay surgery (as indicated by cancer stage/type) to optimize
patients via prehabilitation. The main barriers to prehabilitation reported were
patient comorbidities and access to allied health professionals, with 33%
stating that they were unsure who to refer to for prehabilitation in thoracic
surgery. This is despite 60% of the cohort reporting that pulmonary
rehabilitation is available as a preoperative resource. 92% of respondents
believe that further research into prehabilitation in lung cancer is warranted.
Conclusion: The benefits of prehabilitation for the oncology
population have been well documented in the literature over recent years and
this is reflected in the perceptions surgeons had on the benefits of
prehabilitation for their patients. This survey demonstrates an interest among
cardiothoracic surgeons in favor of prehabilitation, and therefore further
research and demonstration of its benefit is needed in lung cancer to facilitate
implementation into practice.
Collapse
Affiliation(s)
- Anna Shukla
- The University of Melbourne, Melbourne, Victoria, Australia.,St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine L Granger
- The University of Melbourne, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Gavin M Wright
- St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Lara Edbrooke
- The University of Melbourne, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Linda Denehy
- The University of Melbourne, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Minnella EM, Baldini G, Quang ATL, Bessissow A, Spicer J, Carli F. Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care. J Cardiothorac Vasc Anesth 2021; 35:3255-3264. [PMID: 33752968 DOI: 10.1053/j.jvca.2021.02.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy. DESIGN Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery. SETTING Single center, tertiary university hospital. PARTICIPANTS Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned. INTERVENTIONS At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs. MEASUREMENTS AND MAIN RESULTS Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101). CONCLUSIONS A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.
Collapse
Affiliation(s)
- Enrico Maria Minnella
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Anh Thy Le Quang
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amal Bessissow
- Department of Medicine, Division of Internal Medicine, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, Division of Thoracic Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
6
|
Fulop A, Lakatos L, Susztak N, Szijarto A, Banky B. The effect of trimodal prehabilitation on the physical and psychological health of patients undergoing colorectal surgery: a randomised clinical trial. Anaesthesia 2020; 76:82-90. [PMID: 32761611 DOI: 10.1111/anae.15215] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
Abstract
Prehabilitation aims to increase the endurance capacity of patients who are awaiting major surgery. However, there are no studies investigating the implementation of this demanding and expensive intervention in low-income countries. This study aimed to assess the impact of a 4-week trimodal prehabilitation program on the physical and psychological health of patients waiting for colorectal surgery compared with a control group managed according to enhanced recovery after surgery principles supplemented by nutritional care. This study was a single-centre, randomised controlled trial. The primary outcome measures for the physical aspects were 6-minute walking distance (6MWD) and incentive spirometry, whereas the psychological elements were measured using the 36-item short form survey questionnaire and the hospital anxiety and depression score. In total, data from 149 patients were analysed (77 in the prehabilitation group and 72 in the control group). At the time of surgery, patients in the prehabilitation group had improved 6MWD and incentive spirometry compared with the control group (median (IQR [range]) percentage improvement 131% (112-173 [68-376]) vs. 107% (99-120 [63-163]); p < 0.001 and 113% (100-125 [75-200]) vs. 100% (100-112 [86-167]); p < 0.001 respectively). Patients in the prehabilitation group also had reduced anxiety scores compared with the control group (mean (SD) anxiety score (4 (3) vs. 5 (3) respectively; p = 0.032). However, these effects did not translate into improvements in postoperative mortality and morbidity, or a reduction in duration of hospital stay. Trimodal (physical, emotional and nutritional) prehabilitation is able to improve functional status as well as some parameters of emotional and physical well-being of patients waiting for colorectal surgery.
Collapse
Affiliation(s)
- A Fulop
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - L Lakatos
- Department of Surgery, St. Borbala Hospital, Tatabanya, Hungary
| | - N Susztak
- Department of Surgery, St. Borbala Hospital, Tatabanya, Hungary
| | - A Szijarto
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - B Banky
- Department of Surgery, St. Borbala Hospital, Tatabanya, Hungary
| |
Collapse
|
7
|
|
8
|
Prehabilitation May Help Mitigate an Increase in COVID-19 Peripandemic Surgical Morbidity and Mortality. Am J Phys Med Rehabil 2020; 99:459-463. [PMID: 32324618 PMCID: PMC7253050 DOI: 10.1097/phm.0000000000001452] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
As physicians specializing in rehabilitation medicine consider sequelae from the novel coronavirus pandemic that began in 2019, one issue that should be top of mind is the physiologic effect that large-scale social distancing had on the health of patients in general but, more specifically, on preoperative patients who had their surgeries delayed or will have newly scheduled procedures during the peripandemic period. Predictably, as the virus becomes less prevalent, there will be a tremendous motivation to move forward with scheduling operations from both patient care and institutional perspectives. However, one can anticipate a pandemic-related increase in surgical morbidity and mortality above prepandemic levels, particularly in older or medically frail patients evenif they did not have a novel coronavirus (i.e., COVID-19) infection. Therefore, now is the time to consider for patients awaiting surgery a wider adoption of prehabilitation—physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.
Collapse
|