A Narrative Review About Prehabilitation in Surgery: Current Situation and Future Perspectives

Cognitive prehabilitation for older adults undergoing elective surgery: a systematic review and narrative synthesis

Background

Perioperative cognitive maintenance and protection in older adults is an important patient safety imperative. In addition to foundational care, one area of growing interest is integrating cognitive prehabilitation into the surgical trajectory. This review aimed to evaluate the effectiveness and safety of cognitive prehabilitation on cognitive functional capacity and postoperative cognitive outcomes among older adults undergoing elective surgery.

Methods

The MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, CBM, CNKI, WANFANG, and VIP databases were systematically searched up to September 5, 2024, to identify randomized controlled trials published for English or Chinese. Two authors independently completed the study selection process, data extraction process and methodological quality assessment. The Patient, Intervention, Comparison, Outcome, Study design framework was used to construct the search strategy. The predefined primary outcomes of interest included the incidence of postoperative delirium (POD) and the incidence of delayed neurocognitive recovery (dNCR). The quality of the studies was evaluated by the PEDro scale. Owing to the small number of trials and clinical and methodological diversity, a narrative synthesis was undertaken in accordance with the Synthesis Without Meta-analysis guidelines. This study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system.

Results

Six studies were analysed. These trials involved 645 total participants, with 316 in the intervention group (mean age, 66.0-73.8 years; 38.4-77.8% male) and 329 in the comparator group (mean age, 67.5-72.6 years; 31.8-88.9% male). The effects of preoperative cognitive training on reducing the incidence of dNCR, the incidence of POD, the length of hospital stay and the incidence of postsurgical complications as well as improving postoperative global cognitive function and activities of daily living are quite uncertain. The results of this study should be interpreted with caution owing to the limited number of trials and low to very low certainty of evidence.

Conclusion

Current evidence on the effectiveness and safety of cognitive prehabilitation on cognitive and noncognitive outcomes in older patients undergoing elective surgery is limited and unclear.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277191, Identifier CRD42021277191.

Utility guideline and considerations for the novel Hugo™ RAS (robotic-assisted surgery) system in colorectal surgery: surgical outcomes and initial experience in a tertiary center

PURPOSE

A novel robotic platform-Hugo™ RAS (robotic-assisted surgery) system-has been introduced with several innovations that may prove advantageous for surgeons, such as an open console and four interchangeable modular arms. Our study aims to evaluate this platform's safety, efficacy, and potential impact on the surgical treatment of colorectal pathology.

METHODS

Patients underwent robotic-assisted colorectal procedures with the Hugo™ RAS system at the General University Hospital of Elche from October 2023 to July 2024. Patient characteristics, intraoperative and postoperative variables, and robotic technical issues were recorded.

RESULTS

Forty consecutive patients were included (14 right, 13 left, and 8 rectum neoplasms; 4 left diverticulitis; and 1 ileocecal Crohn's disease). The patients' characteristics were as follows: median age, 69.5 years; 24 males and 16 females; 45% ASA III-IV; and Charlson Comorbidity Index > 5:42.5%. We recorded four medical (2 anemia, 1 phlebitis, and 1 admission to the intensive care unit) and three surgical (1 hematoma of the incision, 1 intestinal occlusion, and 1 dehiscence of the anastomosis) postoperative complications. We had no conversions neither open nor laparoscopic surgery. The average hospital stay was 3 days, with no mortality or readmission.

CONCLUSIONS

The Hugo™ RAS system is safe and feasible for colorectal procedures. The modularity of the arms provides the versatility of configurations adjusted depending on the patient's body features and the surgeon's preferences and greater adaptability to operating rooms. The open console is highly comfortable and ergonomic for the surgeon, allowing communication with the operating room environment.

TRIAL REGISTRATION

NCT06512480.

Home-based prehabilitation improves physical conditions measured by ergospirometry and 6MWT in colorectal cancer patients: a randomized controlled pilot study

PURPOSE/BACKGROUND

Prehabilitation aims to improve physical condition in the preoperative period and, therefore, decrease the loss of cardiopulmonary capacity postoperatively, with the aim of reducing complications and promoting an early recovery. This study aims to evaluate the impact of home-based prehabilitation on the physical condition of patients treated surgically for colorectal cancer.

METHODS

A prospective and randomized clinical study was conducted on 60 patients during two periods from October 2018 to February 2019 and from September 2019 to September 2020, in a single university hospital. Patients were randomized into two study groups (30 per group): prehabilitation vs. standard care. Changes in physical condition, measured at diagnosis, the day before surgery, and at 6-8 weeks after surgery using the cardiopulmonary exercise testing (CPET) and the 6-minute walk test (6MWT) were evaluated.

RESULTS

Prehabilitation reduced postoperative complications (17.4% vs. 33.3%, p = 0.22) and hospital stay (5.74 vs. 6.67 days, p = 0.30). 6MWT showed a significant improvement in the prehabilitation group (+78.9 m). Six weeks after surgery, prehabilitation showed a significant improvement in the 6MWT (+68.9 m vs. -27.2 m, p = 0.01). Significant differences were also observed in the ergospirometry between the diagnosis and postoperative study (+0.79 METs vs. -0.84 METs, p = 0.001). A strong correlation was observed between CPET and 6MWT (0.767 (p < 0.001)).

CONCLUSION

Home prehabilitation achieved lower overall postoperative complications than standard care and reached significant improvements in 6MWT and CET. A strong correlation was observed between CET and 6MWT, which allows validation of 6MWT as a valid and reliable measure of functional exercise capacity in colorectal patients when other, more specific and expensive tests are not available.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov in August 2018 with registration number https://clinicaltrials.gov/study/NCT03618329?cond=Prehabilitation%20cancer&term=arroyo&distance=50&rank=1  (NCT03618329). Initial results published in Supportive Care in Cancer: Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic. DOI: https://doi.org/10.1007/s00520-021-06343-1 .

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic

Background

Surgery remains the first curative treatment for colorectal cancer. Prehabilitation seems to attenuate the loss of lean mass in the early postoperative period. However, its long-term role has not been studied. Lockdown due to the COVID-19 pandemic has forced to carry out the prehabilitation program at home. This study aimed to assess the effect of home prehabilitation on body composition, complications, and hospital stay in patients undergoing oncological colorectal surgery.

Methods

A prospective and randomized clinical study was conducted in 20 patients operated of colorectal cancer during COVID-19 lockdown (13 March to 21 June 2020) in a single university clinical hospital. Patients were randomized into two study groups (10 per group): prehabilitation vs standard care. Changes in lean mass and fat mass at 45 and 90 days after surgery were measured using multifrequency bioelectrical impedance analysis.

Results

Prehabilitation managed to reduce hospital stay (4.8 vs 7.2 days, p = 0.052) and postoperative complications (20% vs 50%, p = 0.16). Forty-five days after surgery, the loss of lean mass decreased (1.7% vs 7.1%, p = 0.17). These differences in lean mass were attenuated at 90 days; however, the standard care group increased considerably their fat mass compared to the prehabilitation group (+ 8.72% vs − 8.16%).

Conclusions

Home prehabilitation has proven its effectiveness, achieving an attenuation of lean mass loss in the early postoperative period and a lower gain in fat mass in the late postoperative period. In addition, it has managed to reduce hospital stays and postoperative complications.

Registration number

This article is part of an ongoing, randomized, and controlled clinical trial approved by the ethics committee of our hospital and registered in ClinicalTrials.gov in August 2018 with registration number NCT03618329.