Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study

A cross-sectional survey of prehabilitation among surgeons and anesthesiologists

BACKGROUND

Prehabilitation, which includes nutritional and exercise therapies, is recommended for patients before surgery to improve physical and cognitive functions. This study aimed to identify the awareness, understanding, and issues among surgeons and anesthesiologists regarding the implementation of prehabilitation.

METHODS

We conducted a survey on prehabilitation targeting surgeons and anesthesiologists working at a university hospital and two private hospitals. The survey collection period was set for 1 month, commencing on February 5, 2024. Descriptive statistics were employed to summarize the characteristics of the participants.

RESULTS

A total of 254 surgeons and 49 anesthesiologists from three hospitals participated, with a response rate of 61.7%. Regarding the understanding of prehabilitation, 16.7% of anesthesiologists and only 2% of surgeons had a good grasp of its content. When enquired about the necessity of prehabilitation, 100% of anesthesiologists indicated it as necessary or somewhat necessary, whereas 98.7% of surgeons responded similarly. Several barriers to the implementation of prehabilitation were identified, with the most common reason being the busy schedule of outpatient services.

CONCLUSION

This study highlights that while both surgeons and anesthesiologists recognize the importance of prehabilitation, significant challenges exist in its practical implementation. This underscores the need for simple explanatory tools for patients, the introduction of remote care options, and simple orders to relevant departments, which are essential and require multidisciplinary collaboration.

Exploring the acceptability of and adherence to prehabilitation and rehabilitation in patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND AND AIMS

Prehabilitation combines exercise, nutritional, and psychological interventions administered before surgery to improve patient outcomes. This comprehensive review and meta-analysis examined the feasibility, adherence, and effectiveness of prehabilitation in frail, high-risk individuals undergoing major abdominal surgery.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Web of Science, MEDLINE, Embase, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) databases to identify relevant studies evaluating prehabilitation programs published between 2010 and 2023, either as observational studies or randomized clinical trials (RCTs).

RESULTS

The 23 articles (13 RCTs and 10 observational studies) included 1849 older male and female patients aged 68.7 ± 7.2 years. Nineteen of the included studies reported on adherence to prehabilitation programmes, which was generally good (>75%) over different models, settings, and durations. Factors such as patients' desire for expedited surgery, self-assessment of fitness, personal and professional obligations, health issues, holidays, and advancement of surgery dates negatively affected adherence to prehabilitation programmes. When compared with rehabilitation or standard pre- and post-surgical care, prehabilitation was associated with a 25%, albeit not statistically significant reduction in postoperative complications, according to data from 14 studies reporting on postoperative complications (OR 0.75, 95% CI 0.48 to 1.17, P = 0.43; I2 = 65%). Prehabilitation has been found to improve the 6-min walk test significantly by 29.4 m (MD +29.4 m, 95% CI 5.6 to 53.3, P = 0.02; I2 = 39%), compared with rehabilitation or standard pre- and post-surgical care.

CONCLUSION

Prehabilitation was acceptable to patients, with good adherence, and improved physical function.

Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review

PURPOSE

The purpose of this systematic review is to better understand access to, acceptance of and adherence to cancer prehabilitation.

METHODS

MEDLINE, CINAHL, PsychINFO, Embase, Physiotherapy Evidence Database, ProQuest Medical Library, Cochrane Library, Web of Science and grey literature were systematically searched for quantitative, qualitative and mixed-methods studies published in English between January 2017 and June 2023. Screening, data extraction and critical appraisal were conducted by two reviewers independently using Covidence™ systematic review software. Data were analysed and synthesised thematically to address the question 'What do we know about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?' The protocol is published on PROSPERO CRD42023403776 RESULTS: Searches identified 11,715 records, and 56 studies of variable methodological quality were included: 32 quantitative, 15 qualitative and nine mixed-methods. Analysis identified facilitators and barriers at individual and structural levels, and with interpersonal connections important for prehabilitation access, acceptance and adherence. No study reported analysis of facilitators and barriers to prehabilitation specific to people from ethnic minority communities. One study described health literacy as a barrier to access for people from socioeconomically deprived communities.

CONCLUSIONS

There is limited empirical research of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.

IMPLICATIONS FOR CANCER SURVIVORS

To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual characteristics and attention given to structural factors, such as staff training. Interpersonal connections are proposed as a fundamental ingredient for successful prehabilitation.

[Adapted physical activity as part of the pre-habilitation program]

Adapted physical activity (APA) is one of the pillars of prehabilitation. The creation and personalization of an APA program is based on an assessment carried out by the APA teacher, who identifies the patient's obstacles and levers. The aim of this personalized program assessment is to support the person being cared for in adopting a more active and less sedentary lifestyle, and to ensure that these changes have a positive impact on their health. Relying on resources in the city and on the patient's caregivers are all ways of reinforcing the patient's adherence to APA.

Preparing for colorectal surgery: a feasibility study of a novel web-based multimodal prehabilitation programme in Western Canada

AIM

Prehabilitation for colorectal cancer has focused on exercise-based interventions that are typically designed by clinicians; however, no research has yet been patient-oriented. The aim of this feasibility study was to test a web-based multimodal prehabilitation intervention (known as PREP prehab) consisting of four components (physical activity, diet, smoking cessation, psychological support) co-designed with five patient partners.

METHOD

A longitudinal, two-armed (website without or with coaching support) feasibility study of 33 patients scheduled for colorectal surgery 2 weeks or more from consent (January-September 2021) in the province of British Columbia, Canada. Descriptive statistics analysed a health-related quality of life questionnaire (EQ5D-5L) at baseline (n = 25) and 3 months postsurgery (n = 21), and a follow-up patient satisfaction survey to determine the acceptability, practicality, demand for and potential efficacy in improving overall health.

RESULTS

Patients had a mean age of 52 years (SD 14 years), 52% were female and they had a mean body mass index of 25 kg m-2 (SD 3.8 kg m-2). Only six patients received a Subjective Global Assessment for being at risk for malnutrition, with three classified as 'severely/moderately' malnourished. The majority (86%) of patients intended to use the prehabilitation website, and nearly three-quarters (71%) visited the website while waiting for surgery. The majority (76%) reported that information, tools and resources provided appropriate support, and 76% indicated they would recommend the PREP prehab programme. About three-quarters (76%) reported setting goals for lifestyle modification: 86% set healthy eating goals, 81% aimed to stay active and 57% sought to reduce stress once a week or more. No patients contacted the team to obtain health coaching, despite broad interest (71%) in receiving active support and 14% reporting they received 'active support'.

CONCLUSION

This web-based multimodal prehabilitation programme was acceptable, practical and well-received by all colorectal surgery patients who viewed the patient-oriented multimodal website. The feasibility of providing active health coaching support requires further investigation.

Changes in Self-Reported and Device-Measured Physical Activity Before Abdominal Resection Surgery: A Meta-Analysis

OBJECTIVE

To determine the effect of interventions on physical activity levels of patients awaiting abdominal resection surgery using self-reported as well as device-measured outcome measures.

DATA SOURCE

PubMed and EMBASE databases were searched on the 18th of April 2023 up to April 2023 for studies on interventions to promote physical activity during the preoperative phase.

REVIEW METHODS

Studies were included if pre- and post-intervention physical activity was measured between diagnosis and abdominal surgery. Risk of bias was assessed by the Physiotherapy Evidence Database (PEDro) assessment tool for trials. Meta-analyses were performed to assess the effect of the pre-surgery activity promoting interventions on self-reported and device-measured physical activity.

RESULTS

Seventeen studies were included in the analysis with 452 subjects in the intervention groups. The random-effect meta-analysis showed a moderate improvement in intervention groups measures in pre-surgery physical activity levels compared to the baseline (SMD = 0.67, [CI = 0.30;1.03], I2 = 79%). The self-reported subgroup meta-analysis showed the largest increase in performed physical activity, (SMD = 0.78, [CI = 0.4;1.15], I2 = 79%) whilst non-significant increase was shown in the device-measured subgroup (SMD = 0.16, [CI = -0.64;0.97], I2 = 58%).

CONCLUSION

Increasing physical activity in the preoperative phase is feasible. Self-reported physical activity outcome measures show larger effects compared to device-measured outcome measures. More high-quality research should be performed utilizing objective measures.

[Pre-rehabilitation of oncological patients before extensive abdominal and thoracic surgery: a literature review]

Surgery is one of the leading treatment methods of patients with primary or recurrent malignant neoplasms in the thoracic or abdominal cavity. Extensive abdominal interventions are accompanied by such adverse outcomes as blood loss, hypoxia, inflammation, blood clotting abnormality, emotional and cognitive disorders, that increases the incidence of serious complications and worsens the treatment outcome and life quality in weakened oncological patients. Multimodal pre-rehabilitation before surgery can significantly decrease the incidence and severity of postoperative complications. The rehabilitation complex includes exercise therapy, nutritional and psychological support, smoking cessation and pharmacotherapy. Currently, there are a number of questions facing rehabilitation specialists and oncologists, that are related to the determination of pre-rehabilitation optimal timing and process duration, the choice of specific physical exercises, determining the load intensity. This review presents a current view on understanding of surgical stress in extensive abdominal interventions, its effect on the oncological process course, summarizes the experience of last years in choosing pre-rehabilitation program taking into account pathogenetic mechanisms of surgical stress and individual patient's characteristics. Special attention is paid to the comparison of physical exercises' various types, their action mechanisms at different stages of pathological process, the issues of load dosing during pre-rehabilitation activities.

Prehabilitation in colorectal cancer surgery improves outcome and reduces hospital costs

INTRODUCTION

Increasing evidence suggests that multimodal prehabilitation programs reduce postoperative complication rates and length of stay. Nevertheless, prehabilitation is not standard care yet, also as financial consequences of such programs are lacking. Aim of this study was to analyse clinical outcomes and effects on hospital resources if prehabilitation is implemented for patients who are planned for colorectal surgery.

MATERIALS AND METHODS

Patients undergoing elective colorectal surgery and who received either prehabilitation or standard care between January 2017 and March 2022 in a regional Dutch hospital were included. Outcome parameters were length of hospital stay, 30-day postoperative complications, 30-day ICU admission, readmission rates and hospital costs.

RESULTS

A total of 196 patients completed prehabilitation whereas 390 patients received standard care. Lower overall complication rates (31 % vs 40 %, p = 0.04) and severe complication rates (20 % vs 31 %, p = 0.01) were observed in the prehabilitation group compared to standard care. Length of stay was shorter in the prehabilitation group (mean 5.80 days vs 6.71 days). In hospital cost savings were €1109 per patient, while the calculated investment for prehabilitation was €969.

CONCLUSION

Implementation of a multimodal prehabilitation program in colorectal surgery reduces postoperative complication rates, length of stay and hospital costs.

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.