COMMENTARY

Prehabilitation Before Gastrointestinal Cancer Surgery: What Is the Evidence?

Alex Macario, MD, MBA

Disclosures

January 04, 2018

With the desire by physicians and nurses to optimize the care of the surgical patient, and with outcomes of such care publicly reported, there is great desire for interventions that will improve the quality of recovery of a patient after surgery.

For example, shorter lengths of hospital stays and fewer complications can occur with Enhanced Recovery After Surgery protocols that include carbohydrate drinks 2 hours before surgery, minimally invasive approaches, avoidance of large volumes of intravenous fluids, early mobilization with food and drink intake, and avoiding (or early removal of) drains and tubes.

Another intervention receiving increasing attention is prehabilitation. This has gained positive attention for a variety of surgery types including orthopedics and bariatric surgery, each of which has its own literature and would be too large to review here. Instead, we will focus this viewpoint on interventions for patients with gastrointestinal (GI) cancer.

Prehabilitation Interventions Prior to GI Cancer Surgery

The MEDLINE, PubMed, Embase, CINAHL, Cochrane, and Google Scholar databases were searched for publications between 2006 and September 2016 that evaluated interventions related to preoperative optimization of patients with GI cancer.[1] The possible interventions included exercise, nutritional support, hematinic optimization, and smoking cessation.

Outcomes of interest from review of the selected articles included fitness at the end of the prehabilitation before surgery, postoperative morbidity and mortality, length of hospital stay, markers of functional fitness such as cardiopulmonary exercise, quality-of-life measures, transfusions, and levels of compliance with the prehabilitation interventions themselves.

A formal meta-analysis could not be performed because of the heterogeneity in study design and interventions. In other words, each study was sufficiently different from the others that the results could not be aggregated. The available published studies are also hampered by inadequate sample sizes and lack of uniform endpoints.

Of the 544 studies identified, 20 were included in the qualitative analysis. Two trials (a total of 164 participants undergoing elective colorectal cancer surgery) investigated the impact of a month-long program of physical exercise (combination of aerobic and resistance training), nutritional assessment and whey protein supplementation, as well as anxiety-reduction techniques, including breathing exercises.

The primary outcome was change in functional walking capacity, as measured by the 6-minute walk test at baseline and 4-8 weeks after surgery. Compliance rates were 45% and 78%. Both trials identified a statistically significant improvement in functional walking capacity in the intervention groups but were underpowered to demonstrate any difference in postoperative complication rates and hospital length of stay.

The authors also looked at single-intervention studies. Seven trials only studied preoperative exercise lasting anywhere from 21 to 74 days. Although compliance with treatment varied significantly (16%-97%), the studies found improved preoperative fitness. But this does not necessarily translate to better postoperative clinical outcomes such as decreased complications or length of stay.

The four trials of preoperative iron replacement only had a variety of different interventions (two were oral iron supplements and two were intravenous iron infusions), and two studies included nonanemic patients. Because of the heterogeneity of interventions, results of these trials need to be interpreted with caution.

Similar heterogeneity was found in the nutritional optimization protocols (five trials) that included whey protein supplementation or supplemental liquid diet of 750-1000 mL daily of Impact® (Ajinomoto Co., Tokyo, Japan/Novartis, Berne, Switzerland), or 400 mL daily of Nutridrink® Protein (N. V. Nutricia, Warsaw, Poland) over a preoperative period ranging from 3 to 14 days.

Preoperative smoking cessation for at least 2 weeks reduced the incidence of postoperative complications in patients awaiting esophagogastric surgery in one study. Another study suggested that the duration of smoking cessation was more meaningful than the total amount of smoking in the past, with the incidence of severe morbidity in patients who abstained from smoking for >91 days being equivalent to nonsmokers.

To summarize, the authors concluded that although some of the small studies are supportive of prehabilitation interventions, there are not enough data to make a conclusion about the integration of prehabilitation in GI cancer surgery as a bundle of care.

Viewpoint

The prehabilitation concept is to optimize preoperative functional capacity in preparation for surgery. Analogous perhaps to an athlete training for a competition, the idea is to prepare the mind and body for the stress of surgery and recovery. This can be difficult to accomplish because there may be time pressure to get the surgery done expeditiously within 4-6 weeks to optimize outcome and to initiate adjuvant therapy. Also, it may be difficult for a patient to fully immerse in a prehabilitation program as the patient may be dealing with the emotional and practical side effects (eg, impact of a medical leave at the workplace) of a new diagnosis requiring surgery.

Nonetheless, patients may ask, "What can I do to prepare myself for surgery?" Although exercise was the main component of initial prehabilitation programs, the precise type varies by study and includes walking, cycling, jogging, swimming, or a step trainer. The devil is in the details, and whether aerobic, stretching, resistance, or muscle strengthening exercises and their duration (studies have looked at 2-8 weeks) best suits a patient prior to surgery is unknown.

Older patients with a reduced functional capacity and a sedentary lifestyle may have difficulty completing exercise regimens before surgery. If the exercise intervention is not customized to the patient, then low compliance will result. Another issue, of course, is whether and for how long to continue exercise after the surgery itself.

More recently, prehabilitation programs have added: (1) dietician assessment of nutritional status followed by protein supplementation if appropriate; and (2) psychological support via training the patient with relaxation and breathing exercises as anxiety reduction measures. The value of both of these elements of prehabilitation programs remains unknown because available clinical studies are heterogeneous in inclusion criteria, precise intervention, and endpoints.

As for iron deficiency, even though it can impair functional capacity, increase lethargy, and may be helpful to treat in other disorders and surgeries, trials investigating the treatment of iron deficiency in GI cancer surgery are inadequate to draw conclusions.

How best to deliver prehabilitation is confounded by many variables such as the frailty of the patient and the type of the surgery planned. Unfortunately, there is a lot more to know about prehabilitation before it can become part of evidence-based everyday practice. Ideally, coordination of care would address reversible comorbid diseases at the same time as the workup of the surgical disease.

Although prehabilitation has the potential to improve outcomes in GI cancer surgery, prospective randomized trials with controls are needed that examine standardized structured interventions, outcome measures of functional capacity, and related clinical endpoints important to patients.

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