Exercise prehabilitation in elective intra-cavity surgery: A role within the ERAS pathway? A narrative review

Sex-Specific Cardiometabolic Determinants of Postoperative Atrial Fibrillation After Cardiac Surgery

BACKGROUND

Cardiometabolic diseases increase the risk of postoperative atrial fibrillation (POAF), a complication leading to higher long-term risk of major cardiovascular events (MACE). It remains unknown whether the effect of these risk factors differs according to sex. We sought to evaluate the sex-specific predictors of POAF after coronary artery bypass grafting (CABG).

METHODS

In a prospective registry of patients undergoing isolated CABG, we compared predictors of POAF between sexes with logistic regression models. Because of high prevalence of abdominal obesity in women, > 80% having a waist circumference (WC) ≥ 88 cm, median WC values were used to define abdominal obesity (men ≥ 102 cm, women ≥ 100 cm).

RESULTS

This analysis included 6177 individuals (17% women). Mean age was 65.6 ± 8.9 years. POAF occurred in 32% of men and 28% of women (P < 0.05). Compared with men, women with POAF had similar WC; higher prevalence of hypertension and diabetes; lower high-density lipoprotein (HDL)-cholesterol; and higher glucose, triglyceride, low- density lipoprotein (LDL)-cholesterol, and C-reactive protein levels (all P < 0.05). After adjustment, age and abdominal obesity were associated with POAF in both sexes (P < 0.05). The interaction of WC with sex suggested a worse impact of WC on POAF risk among women (adjusted odds ratio [OR], 1.97; 95% confidence interval [CI], 1.48-2.62 vs in men 1.33; 95% CI, 1.17-1.50; P for interaction = 0.01).

CONCLUSIONS

Abdominal obesity is a major predictor of POAF in both sexes, with higher risk in women. These results emphasize the need for enhanced strategies to manage abdominal obesity and its cardiometabolic consequences in the general population and the potential to develop sex-specific preventive interventions to reduce risk of POAF.

Prehabilitation to Enhance Vascular Surgery Outcomes: A Narrative Review

Prehabilitation, an emerging strategy, prepares patients for elective surgery by encouraging healthy behaviors, including physical exercise and healthy nutrition, while providing psychological support, to improve postoperative outcomes and foster healthier lifestyles. Despite growing interest, there is little research on prehabilitation. Specifically, studies involving prehabilitation in vascular surgery are heterogeneous with small sample sizes. This review aimed to investigate the reported positive impact of prehabilitation on vascular surgery patients, discuss prehabilitation models, highlight prehabilitation program-associated challenges, and suggest appropriate interventions. Prehabilitation improves physical fitness, reduces postoperative complications, and enhances overall recovery. Multimodal prehabilitation programs can positively impact vascular surgery patients, with benefits including improved cardiovascular fitness, reduced postoperative complications, shorter postoperative hospital stays, enhanced overall recovery, and improved quality of life. The currently reported prehabilitation programs are heterogeneous, with limitations regarding patient adherence and lack of long-term outcomes, posing challenges to their widespread adoption. Overall, prehabilitation shows promise for improving vascular surgery outcomes and fostering long-term healthy behaviors. The systematic implementation of prehabilitation in vascular surgery care pathways, overcoming reported limitations, and integrating multimodal prehabilitation into routine preoperative care hold potential benefits. This review underscores the need for high-quality research to establish best practices in prehabilitation and integrate them into the standard of care for vascular surgery patients.

LUNA EMG as a Marker of Adherence to Prehabilitation Programs and Its Effect on Postoperative Outcomes among Patients Undergoing Cytoreductive Surgery for Ovarian Cancer and Suspected Ovarian Tumors

BACKGROUND

Prehabilitation is a novel strategy in preoperative management. The aim of this study was to investigate the effect of prehabilitation programs on peri- and postoperative outcomes and to verify if LUNA EMG has the capacity to monitor compliance with prehabilitation programs.

METHODS

A total of seventy patients with suspected ovarian cancer were recruited between April 2021 and September 2022 and were divided into a prehabilitation group (36 patients) or a control group (34 patients). A LUNA EMG device was utilized to monitor muscle strength and tension.

RESULTS

Within the prehabilitation group, we observed a significant increase in the 6-Minute Walk Test distance by 17 m (median, IQR: 0-42.5, p < 0.001) and a significant increase in muscle strength measured with LUNA EMG. In comparison to the control group, the prehabilitation group showed fewer complications according to the Clavien-Dindo classification (47.2% vs. 20.6%, p = 0.02) and shorter postoperative hospital stays (median 5.0 days [IQR: 4.0-6.2] vs. 7.0 days [IQR: 6.0-10.0], p < 0.001).

CONCLUSION

Prehabilitation has a positive effect on physical capacity and muscle strength and is associated with a reduction in the number of complications after surgery. LUNA EMG can be a useful tool for monitoring patients' adherence to prehabilitation programs.

The effect of preoperative rehabilitation on the prevention of postoperative ileus in colorectal cancer patients

PURPOSE

Previous research suggests that the preoperative rehabilitation of colorectal cancer patients can reduce postoperative ileus. However, the evidence is insufficient and further research is warranted. This study aimed to investigate whether short-term preoperative rehabilitation, both on an outpatient and inpatient basis, can reduce the incidence of postoperative ileus after colorectal cancer surgery.

METHODS

This was a retrospective cohort study that drew on data from multicenter electronic medical records. Patients with stage 1-3 colorectal cancer who underwent surgery and postoperative rehabilitation were included. The incidence of postoperative ileus was compared between patients who received short-term preoperative rehabilitation and those who did not. Propensity score adjustment using inverse probability weighting and subgroup analysis by type of surgery was performed.

RESULTS

Four thousand seventy-six eligible patients (43.4% female; mean age 75.1 ± 10.9 years) were included; 1914 (47.0%) received short-term preoperative rehabilitation. The preoperative rehabilitation group had a significantly lower incidence of postoperative ileus than the no preoperative rehabilitation group (pre-adjustment: 5.5% vs. 9.9%, p < 0.001; post-adjustment: 5.2% vs. 9.0%, p < 0.001). Therefore, preoperative rehabilitation was significantly associated with a lower incidence of postoperative ileus (OR: 0.554, 95% CI: 0.415-0.739, p < 0.001). In an adjusted analysis of surgery type subgroups, the incidence of postoperative ileus was significantly lower in the preoperative rehabilitation group for all types of surgery.

CONCLUSION

Our study showed that short-term preoperative rehabilitation for patients with stage 1-3 colorectal cancer, both with inpatients and outpatients, significantly reduces the incidence of postoperative ileus.

The clinical effect and safety of new preoperative fasting time guidelines for elective surgery: a systematic review and meta-analysis

BACKGROUND

Traditional fasting and no drinking schemes (fasting for 8-12 hours and no drinking for 4-6 hours) affect the metabolism of the body. The new guidelines put forward by the American Association of Anesthesiologists (fasting for 6 hours, no drinking for 2 hours) obviously reduce the time of fasting and no drinking, but the clinical efficacy and safety need to be further confirmed. In this study, a meta-analysis of randomized controlled trials (RCTs) using the new guidelines and traditional protocols was conducted to provide an evidence-based foundation for elective surgery.

METHODS

The articles were searched in PubMed, EBSCO, MEDLINE, Science Direct, Cochrane Library, CNKI, China Biomedical Resources Database, Wanfang Database, Weipu, and Western Biomedical Journal Literature Database. RCTs related to fasting before surgery during the screening period were selected. Chinese and English search keywords included elective surgery, preoperative, fasting and no drinking, patient comfort, thirst, hunger, collapse, hypoglycemia, preoperative gastric volume, preoperative gastric juice pH, and intraoperative gastric volume. The RevMan 5.3 software provided by Cochrane collaboration network was used to evaluate the quality of included documents. Two professionals independently screened the literature, extracted data, and assessed the risk of bias.

RESULTS

A total of 6 studies were included. The incidence of hunger in patients undergoing elective surgery in the experimental group and control group was significantly different [Z=3.90; relative risk (RR) =0.58; 95% confidence interval (CI): 0.44, 0.76; P<0.0001]. The incidence of thirst was significantly different between the experimental group and control group (Z=7.22; RR =0.21; 95% CI: 0.13, 0.32; P<0.00001).

DISCUSSION

Meta-analysis results confirmed that the new guidelines can significantly reduce the hunger and thirst of patients, improve their satisfaction after surgery, and can be applied clinically.

Prehabilitation in rectal surgery: a narrative review

AIM

Neoadjuvant chemotherapy (NACRT) can make decompensated patients more vulnerable prior to rectal surgery. Prehabilitation is an intervention which enhances functional capacity to withstand the stress of surgery. The aim of this review was to evaluate the impact of prehabilitation for patients undergoing rectal surgery on physical fitness and clinical outcomes and to establish feasibility of prehabilitation.

METHODS

An analysis of the literature was conducted of PubMed, the Cochrane Library, MEDLINE, EMBASE and ScienceDirect. Articles were initially included based on their title and abstracts reviewed. Full-text copies of those selected were obtained for confirmation of inclusion.

RESULTS

Eight studies were included. Heterogenicity was observed in the structure of exercise programmes. Improvements in physical fitness were observed in six studies. One study demonstrated a statistically significant improvement in quality of life. The prehabilitation programmes were shown to be feasible, with high completion rates. No adverse events were reported. There was limited data regarding the impact of prehabilitation on postoperative outcomes.

CONCLUSION

Current evidence on prehabilitation in rectal surgery has considerable heterogenicity in both structure of programmes and outcome measures. Standardisation is required for future evaluation of the impact on outcomes. A trimodal approach of exercise, nutritional and psychological interventions has been employed in similar programmes, and should be used in rectal surgery. The intervention should be tailored to the patient and environment. This review highlights the benefits, safety and feasibility of prehabilitation and provides a platform for consensus-building for international trials.

30-day Major Adverse Cardiac Events (MACE) after elective bariatric surgery: the development and validation of the Bari-MACE clinical predictive tool

BACKGROUND

Major adverse cardiac events (MACEs) after bariatric surgery are poorly understood yet are thought to be associated with significant morbidity and mortality.

OBJECTIVES

To evaluate the prevalence and clinical impact of short-term, 30-day MACE and to develop a pragmatic clinical predictive MACE scoring tool.

SETTING

This retrospective study was conducted using all the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited center data from 2015 to 2019.

METHODS

Primary Roux-en-Y and sleeve gastrectomy procedures were included, and prior revisional surgeries and emergency surgeries were excluded. Multivariable logistic regression modeling was used to examine the risk factors associated with 30-day MACE. Using forward regression, a Bari-MACE clinical prediction model was generated.

RESULTS

A total of 750,498 patients were included in our analysis of which 959 (.1%) experienced a MACE. MACE patients were older (54.0 ± 11.5 yr versus 44.4 ± 12.0 yr, P < .0001), and comprised a higher proportion of males (36.3% versus 20.4%, P < .0001) and patients of White racial status (74.0% versus 71.6%, P < .0001). The MACE cohort also had a higher body mass index (46.6 ± 9.7 kg/m² versus 45.2 ± 7.8 kg/m², P < .0001), higher rates of sleep apnea (56.8% versus 38.2%, P < .0001), and a higher proportion of insulin-dependent diabetes (26.1% versus 8.4%, P < .0001) than non-MACE patients. Derivation of our clinical predictive Bari-MACE scoring model revealed 12 variables associated with development of MACE with a specificity of 97.8% using a 55-point threshold.

CONCLUSION

Thirty-day major adverse cardiac events after elective bariatric surgery are rare, occurring in approximately .1% of all patients, but are associated with significant morbidity and mortality. Using the MBSAQIP, we developed a Bari-MACE clinical predictive tool to risk-stratify patients with the aim to better guide perioperative care and foster improved surgical outcomes.

SupPoRtive Exercise Programmes for Accelerating REcovery after major ABdominal Cancer surgery trial (PREPARE-ABC): Study protocol for a multicentre randomized controlled trial

BACKGROUND

Exercise programmes can increase cardiopulmonary reserve and functional capacity prior to surgery and can improve clinical, functional and survival outcomes after a colorectal cancer diagnosis. However, the impact of pre- and postoperative exercise on postoperative recovery outcomes and longer-term health-related quality of life are unknown; thus, there is a need for high-quality randomized controlled trials.

METHOD

SupPoRtive Exercise Programmes for Accelerating REcovery after major Abdominal Cancer surgery (PREPARE-ABC) is a three-arm multicentre randomized controlled trial with internal pilot. The primary objective is to assess the effects of pre- and postoperative exercise on surgical outcomes and longer-term health-related quality of life in cancer patients undergoing colorectal resection. The aim of PREPARE-ABC is to randomize 1146 patients at the individual level (1:1:1) to hospital-supervised exercise, home-supported exercise or treatment as usual. The primary outcomes are short-term (30-day) morbidity, assessed using the Clavien-Dindo classification, and longer-term health-related quality of life, assessed using the Medical Outcomes Study Health Questionnaire (36-item Short-Form Survey [SF-36]). Secondary outcomes include cardiopulmonary fitness, physical activity behaviour change, psychological health status and cost-effectiveness. A process evaluation of intervention delivery and usual care also will be undertaken.

DISCUSSION

This is the first UK-based definitive randomized controlled trial to investigate the effects of pre- and postoperative exercise on short-term postoperative health outcomes and longer-term health-related quality of life in colorectal cancer patients. The trial will yield robust clinical and cost-effectiveness data to underpin clinical guidance on how exercise programmes should be implemented in the routine management of patients undergoing major colorectal cancer surgery.

Auditory and Visual Stimulation for Abdominal Postoperative Patients Experiencing Enhanced Recovery After Surgery (ERAS)

The Enhanced Recovery After Surgery program can reduce postoperative complications, hospital stay, and overall costs in patients, although the evidence for physical intervention with patients is still lacking. This study provides visual and auditory physical interventions to patients in order to explore the effects of Enhanced Recovery After Surgery following abdominal surgery. The study group consisted of patients who had undergone laparoscopic cholecystectomy, radical resection of gastric cancer, or radical resection of colon cancer; we randomly divided them into a control group and a visual and auditory intervention group. We then monitored the bowel sound frequency and time of the first anal self-exsufflation for both groups after surgery. We found that compared with the control group, patients who had undergone laparoscopic cholecystectomy and radical gastrectomy who received auditory intervention had increased bowel sound frequency and a shorter time until first anal self-exsufflation. In addition, patients with colon cancer who received both auditory and visual stimulation had increased bowel sounds and shorter time until the first anal self-exsufflation. These results suggest that visual and auditory interventions significantly improve patients' gastrointestinal function, shorten the hospitalization period, and reduce complications after operation.

The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway

Background

There is compelling support for implementing prehabilitation to optimize perioperative risk factors and to improve postoperative outcomes. However, there is limited evidence studying the application of multimodal prehabilitation for patients with breast cancer.

Objective

To determine the feasibility of multimodal prehabilitation as part of the breast cancer treatment pathway.

Design

This was a prospective, cohort observational study. Breast cancer patients undergoing surgery were recruited. They were assigned to an intervention or control group according to patient preference.

Setting

UK prehabilitation center.

Participants

A total of 75 patients were referred during the study period. Forty eight patients (64%) did not participate; 20 of those opted to be in the control group. Twenty four patients engaged with prehabilitation and returned completed questionnaires. In total, 44 patients were included in the analysis.

Interventions

The program consisted of supervised exercise, nutritional advice, smoking cessation, and psychosocial support.

Outcome Measures

Feasibility was determined by the center's ability to deliver the program. This was measured by the number of patients who wanted to access the service, compared with those able to. Service uptake, patient satisfaction, and project costs were recorded. Patient‐reported outcomes (PROs) and the use of healthcare resources were also evaluated.

Results

A total of 61 patients (81%) wanted to participate; 24 (32%) were able to partake and return questionnaires. Reasons for nonparticipation included surgery within weeks, full‐time commitments, and transportation difficulties. A total of 25 (93%) prehabilitation patients recorded high satisfaction with the program. There was a significant reduction in anxiety among prehabilitation patients. There were no significant improvements in the other PROs. There were no changes to hospital length of stay, readmissions, and complications.

Conclusions

Multimodal prehabilitation is a feasible intervention. Logistical challenges need to be addressed to improve engagement. These results are limited and would require a larger sample to confirm the findings. Work on a thorough cost‐benefit analysis is also required.

Effect of preparative rehabilitation on recovery after cardiac surgery: A systematic review

BACKGROUND

Physical prehabilitation (preparative rehabilitation) programs may have beneficial effects on enhancing physical strength and functional status before surgery, but their effects on postoperative recovery are unclear.

OBJECTIVES

This systematic review investigated the effectiveness of physical prehabilitation programs before cardiac surgery on postoperative recovery and other perioperative outcomes.

METHODS

We searched for reports of randomised controlled trials of any prehabilitation programs that included physical activity or an exercise training component in adults undergoing elective cardiac surgery, published in any language, from six bibliographic databases (last search on June 20, 2019). We assessed trials for risk of bias, overall certainty of evidence and quality of intervention reporting using the Cochrane Risk of Bias Assessment Tool, GRADE system and the Template for Intervention Description and Replication checklist and guide, respectively.

RESULTS

All 7 studies (726 participants) were at high risk of bias because of lack of blinding. The quality of prehabilitation reporting was moderate because program adherence was rarely assessed. The timing of prehabilitation ranged from 5 days to 16 weeks before surgery and from face-to-face exercise prescription to telephone counselling and monitoring. We found uncertain effects of prehabilitation on postoperative clinical outcomes (among the many outcomes assessed): perioperative mortality (Peto odds ratio 1.30, 95% confidence interval [CI] 0.28 to 5.95; I²=0%; low-certainty evidence) and postoperative atrial fibrillation (relative risk 0.75, 95% CI 0.38 to 1.46; I²=50%; very low-certainty evidence). However, prehabilitation may improve postoperative functional capacity and slightly shorten the hospital stay (mean difference -0.66 days, 95% CI -1.29 to -0.03; I²=45%; low-certainty evidence).

CONCLUSION

Despite the high heterogeneity among physical prehabilitation trials and the uncertainty regarding robust clinical outcomes, physical prehabilitation before cardiac surgery seems to enhance selected postoperative functional performance measures and slightly reduce the hospital length of stay after cardiac surgery.

Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis

BACKGROUND

Prehabilitation has emerged as a strategy to prepare patients for elective abdominal cancer surgery with documented improvements in postoperative outcomes. The aim of this study was to assess the evidence for prehabilitation interventions of relevance to the older adult.

METHODS

Systematic searches were conducted using MEDLINE, Web of Science, Scopus, CINAHL and PsychINFO. Studies of preoperative intervention (prehabilitation) in patients undergoing abdominal cancer surgery reporting postoperative outcomes were included. Age limits were not set as preliminary searches revealed this would be too restrictive. Articles were screened and selected based on PRISMA guidelines, and assessment of bias was performed. Qualitative, quantitative and meta-analyses of data were conducted as appropriate.

RESULTS

Thirty-three studies (3962 patients) were included. Interventions included exercise, nutrition, psychological input, comprehensive geriatric assessment and optimization, smoking cessation and multimodal (two or more interventions). Nine studies purposely selected high-risk, frail or older patients. Thirty studies were at moderate or high risk of bias. Ten studies individually reported benefits in complication rates, with meta-analyses for overall complications demonstrating significant benefit: multimodal (risk difference -0·1 (95 per cent c.i. -0·18 to -0·02); P = 0·01, I2  = 18 per cent) and nutrition (risk difference -0·18 (-0·26 to -0·10); P < 0·001, I2  = 0 per cent). Seven studies reported reductions in length of hospital stay, with no differences on meta-analysis.

CONCLUSION

The conclusions of this review are limited by the quality of the included studies, and the heterogeneity of interventions and outcome measures reported. Exercise, nutritional and multimodal prehabilitation may reduce morbidity after abdominal surgery, but data specific to older patients are sparse.

Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum

PURPOSE

Pectus excavatum is a common chest wall deformity amenable to surgical correction, most commonly by a technique known as the Nuss Procedure. The surgery is associated with significant postoperative pain and lengthy hospital stays. We hypothesized that a standardized enhanced recovery after surgery (ERAS) pathway would result in significantly reduced length of stay (LOS) and reduced levels of postoperative pain without an increase in readmissions or emergency department (ED) visits.

METHODS

We instituted a pectus excavatum ERAS program at a high-volume academic center. Our ERAS protocol standardized perioperative exercise and pharmacologic regimens, pre- and post-operative education, and early return to activity. We conducted a retrospective review of all patients undergoing the Nuss procedure from 2015 to 2018. ERAS was implemented at the mid-point of the study period, and pre- and post-protocol patients were compared in our analysis. The primary outcome measure was LOS. The secondary outcomes included pain scores, incidence of urinary retention, and readmissions or ED visits.

RESULTS

One hundred nine patients were included in this study (51 patients pre-ERAS and 58 post-ERAS). The average length of hospitalization prior to implementation of ERAS was 3.49 and after the implementation 2.90 (p = 0.0007). The implementation of ERAS showed a trend of decreasing readmissions and emergency department visits, but this did not reach statistical significance. There was a statistically significant decrease in both requirement for urinary catheter placement and pain scores on postoperative day 0.

CONCLUSIONS

Implementation of ERAS for the Nuss procedure leads to a significant reduction in LOS, early pain scores, and urinary catheter usage, without an increase in post-operative ED visits and hospital readmissions. An ERAS protocol should be utilized in this patient population.

TYPE OF STUDY

Retrospective comparative study.

TYPE OF EVIDENCE

Level III.

Gerofit Prehabilitation Pilot Program: Preparing Frail Older Veterans for Surgery

Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. We present data from our prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort. The infrastructure of the existing Veterans Affairs (VA) Gerofit health and exercise program was used to create our pilot. Pilot patients were screened for risk of postoperative functional decline, assessed for baseline physical function, enrolled in a personalized exercise program, and prepared to transition into the hospital for surgery. Patients (n = 9) completed an average of 17.7 prehabilitation sessions. After completing the program, 55.6% improved in ≥2 of the 5 fitness assessments completed. Postoperative outcomes including complications, 30-day mortality, and 30-day readmissions were better than predicted by the National Surgical Quality Improvement Program Surgical Risk Calculator. We have obtained institutional support for implementing similar prehabilitation programs at VA hospitals nationally through our designation as a VA Patient Safety Center for Inquiry. This is the first multi-institutional prehabilitation program for frail, older Veterans and represents an essential step toward optimizing surgical care for this vulnerable population.

Physical therapy prehabilitation on a reverse total shoulder replacement candidate: a case study

[Purpose] The purpose of this report is to describe the PT evaluation, prehab interventions, and outcomes of a patient pursuing reverse total shoulder replacement (rTSR) for pain reduction and functional gains. [Participant and Methods] A 62-year-old male self-referred to PT two months before his right rTSR. His chief complaints were right shoulder pain, stiffness, and functional impairment due to rotator cuff tendon tears and shoulder arthritis. He demonstrated poor posture, limited ROM, decreased strength, and diminished function. The PT prehab program consisted of an initial encounter followed by six treatment sessions across approximately one month. [Results] On the last visit, the patient's pain had meaningfully decreased along with improved posture, AROM, and muscle strength producing a clinically significant improvement in function resulting in the postponing of his rTSR. On a three months follow-up, the patient had maintained or improved in his test and measures and functional outcomes. He expressed satisfaction with the prehab outcomes and that he had indefinitely postponed his rTSR. [Conclusion] PT prehab program improved pre-operative measures on pain, posture, joint mobility, muscle strength, and function on a patient who had been scheduled for rTSR surgery. PT prehab program may delay the need for rTSR surgery.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.

Prehabilitation is better than cure

PURPOSE OF REVIEW

With a continuously growing number of older patients undergoing major surgical procedures, reliable parameters practicable in perioperative routine revealing those patients at risk are urgently needed. Recently, the concept of 'prehabilitation' with its key elements exercise, nutrition and psychological stress reduction especially in frail patients is attracting increasing attention.

RECENT FINDINGS

Literature search revealed a huge amount of publications in particular within the last 12 months. Although a single definition of both frailty and prehabilitation is still to be made, various players in the perioperative setting obviously are becoming increasingly convinced about a possible benefit of the program - referring to different components and measures performed. Although physiologically advantages seem obvious, there is hardly any reliable data on clinical outcomes resulting from properly performed studies. This applies especially to octogenarians; thus those at risk for adverse events the concept originally addresses.

SUMMARY

Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients. However, further studies on effectiveness in a highly heterogeneous population and agreement on a common concept are mandatory before a final judgement can be given.

Clinical efficiency of prehabilitation program in patients undergoing coronary artery bypass grafting

Aim.To evaluate clinical efficacy of high-intensity exercise training included in the prehabilitation program for elective coronary artery bypass grafting (CABG).

Methods. 38 male patients were included in the study before on-pump CABG. After fulfilling the inclusion/exclusion criteria, patients were randomized into two groups: Group 1 patients (n = 20) underwent supervised treadmill exercise, and Group 2 patients (n = 18) were referred to surgery without any exercise training. Patients underwent a 7-day exercise training with daily measurements of hemodynamic parameters and electrocardiogram (ECG) monitoring. The load intensity was measured with cardiopulmonary exercise testing and accounted for 80% of the maximal oxygen uptake. Postoperative complications were recorded in the in-hospital period and analyzed. Quality of life indicators were measured by the SF-36 standard version 7–10 days prior to surgery and on days 7-10 of the postoperative period. Adherence to drug and non-drug therapy was assessed during the 6-month follow-up.

Results.There was a significantly lower incidence of postoperative complications during the in-hospital period in patients undergoing prehabilitation program with supervised high-intensity exercise training, compared with patients without any exercise training (p = 0.002). Group 1 patients had reliably better mental health (MH) scores compared with Group 2 patients (48.9±7.60 vs. 39.1±6.80 scores, respectively; p = 0.03) on days 7–10 after CABG. Six months after the CABG, patients who underwent prehabilitation exercise training were less likely to resume smoking than patients without any exercise training (p = 0.04). The tendency towards improved adherence to drug therapy and compensation in arterial hypertension has been determined among Group 1 patients.

Conclusion. Exercise training included in the prehabilitation program proved to be safe and effective in terms of improved clinical outcomes after CABG, quality of life and adherence to treatment in this group of patients.