NEW YORK (Reuters Health) – Prehabilitation was not associated with a large decrease in complications among patients undergoing non-bariatric abdominal or pelvic surgery, a systematic review reveals.
“Prehabilitation is the concept that optimizing a patient prior to surgery can improve outcomes,” Drs. Mike Liang of McGovern Medical School at UTHealth and Nicole Lyons, a recent graduate of the school, told Reuters Health. “However, unlike traditional ‘preoperative optimization’ such as improving the treatment of underlying medical conditions, prehabilitation includes interventions that require substantial patient engagement,” such as exercise, and in some cases, dietary changes and smoking cessation.
“Unfortunately, in our systematic review, there did not appear to be a difference in short-term or long-term surgical outcomes,” they said by email. “One of the randomized controlled trials was our trial on prehabilitation with ventral hernia repair (in which) patients were able to demonstrate improved surgical outcomes with prehabilitation which consisted of an intensive preoperative exercise and diet program.”
Some trials were able to demonstrate success because of the program’s duration and intensity, and patient compliance, they noted. “Most programs were only a relatively short four weeks, while others, such as ours, were up to six months.”
Drs. Liang, Lyons and colleagues searched the literature for randomized controlled trials of prehabilitation before non-bariatric abdominal or pelvic surgery.
As reported in the Journal of the American College of Surgeons, 14 RCTs involving 982 patients met the inclusion criteria; 502 patients underwent a prehabilitation program. The studies were heterogenous and assessed several surgical subspecialties, prehabilitation techniques, and outcomes.
Most studies (71%) had an period of four weeks or less; nonetheless, compliance was poor, with <75% compliance in four of the seven studies that reported it (range 16% -98%).
Five studies examined surgical site infections and none found a difference with or without prehabilitation (intervention 0-16% vs. control 0-13%).
Most (69%) found prehabilitation did not reduce postoperative complications (intervention 9%-63% vs. 13%-80%).
However, five of seven studies using the 6-minute walk test as an outcome showed improvement in the intervention group, suggesting prehabilitation improves functional status.
Drs. Liang and Lyons said, “Challenges for these programs include: identifying the right patients who might find the greatest benefit; the types of surgeries included; and the types of programs. Patients who are overweight or obese, those with poor underlying physical fitness, and those who smoke might be considered patients with the greatest potential benefit.”
Dr. Jonathan Whiteson, associate professor of rehabilitation medicine at NYU Langone’s Rusk Rehabilitation in New York City, commented in an email to Reuters Health, “I agree with some of the review’s findings – specifically, that due to the variability in the studies included in the systematic review, the data carry little weight in supporting recommendations for future practice.”
“Prehabilitation has been shown to be effective for cardiothoracic and orthopedic surgery,” he said, “and the supporting literature includes more robust and consistent pre-habilitation protocols. To affirm or refute the hypothesis that prehabilitation for non-bariatric abdominal surgery improves outcomes, larger scale prospective randomized trials are required.”
“While prehabilitation might be considered pre-surgical activity/exercise, other lifestyle factors are crucial and are part of any rehabilitation protocol, pre- or post-surgical,” he noted. “These include diet/nutrition, weight loss, glycemic control, tobacco cessation, pulmonary/chest therapy (breathing exercises etc.), alcohol cessation, sleep hygiene, stress management, patient education, medication and lifestyle compliance. These elements must be included in any study looking at non-bariatric abdominal surgery outcomes.”
“For now until the definitive study is completed, care must be individualized and optimization of pre-surgical health must be emphasized to patients, caregivers, surgeons and surgical teams alike if we are to improve post-operative outcomes,” he added. “Particular emphasis must be made to prehabilitation program compliance.”
SOURCE: https://bit.ly/2Fn49MN Journal of the American College of Surgeons, online July 23, 2020.