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Skořepa P, Ford KL, Alsuwaylihi A, O'Connor D, Prado CM, Gomez D, Lobo DN. The impact of prehabilitation on outcomes in frail and high-risk patients undergoing major abdominal surgery: A systematic review and meta-analysis. Clin Nutr 2024; 43:629-648. [PMID: 38306891 DOI: 10.1016/j.clnu.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND & AIMS Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving surgical outcomes. The aim of this systematic review and meta-analysis was to determine the impact of prehabilitation on postoperative outcomes in frail and high-risk patients undergoing major abdominal surgery. METHODS Embase, Medline, CINAHAL and Cochrane databases were searched from January 2010 to January 2023 for randomised clinical trials (RCTs) and observational studies evaluating unimodal (exercise) or multimodal prehabilitation programmes. Meta-analysis was limited to length of stay (primary end point), severe postoperative complications (Clavien-Dindo Classification ≥ Grade 3) and the 6-minute walk test (6MWT). The analysis was performed using RevMan v5.4 software. RESULTS Sixteen studies (6 RCTs, 10 observational) reporting on 3339 patients (1468 prehabilitation group, 1871 control group) were included. The median (interquartile range) age was 74.0 (71.0-78.4) years. Multimodal prehabilitation was applied in fifteen studies and unimodal in one. Meta-analysis of nine studies showed a reduction in hospital length of stay (weighted mean difference -1.07 days, 95 % CI -1.60 to -0.53 days, P < 0.0001, I2 = 19 %). Ten studies addressed severe complications and a meta-analysis suggested a decline in occurrence by up to 44 % (odds ratio 0.56, 95 % CI 0.37 to 0.82, P < 0.004, I2 = 51 %). Four studies provided data on preoperative 6MWT. The pooled weighted mean difference was 40.1 m (95 % CI 32.7 to 47.6 m, P < 0.00001, I2 = 24 %), favouring prehabilitation. CONCLUSION Given the significant impact on shortening length of stay and reducing severe complications, prehabilitation should be encouraged in frail, older and high-risk adult patients undergoing major abdominal surgery.
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Affiliation(s)
- Pavel Skořepa
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic; 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic. https://twitter.com/PavelSkorepa
| | - Katherine L Ford
- Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Canada; Department of Kinesiology & Health Sciences, University of Waterloo, Waterloo, Canada. https://twitter.com/KathFord_RD
| | - Abdulaziz Alsuwaylihi
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dominic O'Connor
- School of Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK. https://twitter.com/Dom_OConnor1
| | - Carla M Prado
- Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Canada. https://twitter.com/DrCarlaPrado
| | - Dhanny Gomez
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ke Y, Ng RRG, Elangovan S, Leong YH, Goh ZH, Graves N, Shannon NB, Abdullah HR. Prehabilitation programs - a systematic review of the economic evidence. Front Med (Lausanne) 2023; 10:1281843. [PMID: 38105890 PMCID: PMC10722222 DOI: 10.3389/fmed.2023.1281843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Prehabilitation, which involves improving a patient's physical and psychological condition before surgery, has shown potential benefits but has yet to be extensively studied from an economic perspective. To address this gap, a systematic review was conducted to summarize existing economic evaluations of prehabilitation interventions. Methods The PRISMA Protocols 2015 checklist was followed. Over 16,000 manuscripts were reviewed, and 99 reports on preoperative interventions and screening tests were identified, of which 12 studies were included in this analysis. The costs are expressed in Pounds (GBP, £) and adjusted for inflation to December 2022. Results The studies were conducted in Western countries, focusing on specific surgical subspecialties. While the interventions and study designs varied, most studies demonstrated cost savings in the intervention group compared to the control group. Additionally, all cost-effectiveness analysis studies favored the intervention group. However, the review also identified several limitations. Many studies had a moderate or high risk of bias, and critical information such as time horizons and discount rates were often missing. Important components like heterogeneity, distributional effects, and uncertainty were frequently lacking as well. The misclassification of economic evaluation types highlighted a lack of knowledge among physicians in prehabilitation research. Conclusion This review reveals a lack of robust evidence regarding the economics of prehabilitation programs for surgical patients. This suggests a need for further research with rigorous methods and accurate definitions.
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Affiliation(s)
- Yuhe Ke
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Roderica Rui Ge Ng
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Shalini Elangovan
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yun Hao Leong
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Zhao Han Goh
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Nicholas B. Shannon
- Duke-NUS Medical School, Singapore, Singapore
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hairil Rizal Abdullah
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Jain SR, Kandarpa VL, Yaow CYL, Tan WJ, Ho LML, Sivarajah SS, Ng JL, Chong CXZ, Aw DKL, Foo FJ, Koh FHX. The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis. World J Surg 2023; 47:86-102. [PMID: 36184673 DOI: 10.1007/s00268-022-06761-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Sneha Rajiv Jain
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Vasundhara Lakshmi Kandarpa
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Clyve Yu Leon Yaow
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Winson JianHong Tan
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Leonard Ming Li Ho
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Sharmini Su Sivarajah
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jia Lin Ng
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Cheryl Xi Zi Chong
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Darius Kang Lie Aw
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Fung Joon Foo
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Frederick Hong Xiang Koh
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore.
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