Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

Abstract

ObjectiveTo determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.DesignSystematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).SettingSecondary care.ParticipantsPatients (≥18 years) undergoing major elective surgery (curative or palliative).InterventionsAny intervention administered in the preoperative period with the aim of improving postoperative outcomes.Outcomes and measuresPrimary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.Review methodsTwo authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.Results178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: −1.81 days, 95% CI −2.31 to −1.31; −2.11 days, 95% CI −3.07 to −1.15; −1.67 days, 95% CI −2.31 to −1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).ConclusionsSome prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.PROSPERO registration numberCRD42015019191.

Unplanned readmission after carotid stenting versus endarterectomy: analysis of the United States Nationwide Readmissions Database

“…When examining baseline characteristics, we found a significantly higher risk ratio for readmission in octogenarian and older patients, male patients, patients on Medicaid, and patients with higher APR-DRG mortality, APR-DRG severity of illness, and Elixhauser Comorbidity Index scores, largely in agreement with previous smaller studies17 18 24 25 as well as studies restricted to Medicare beneficiaries 15 16. Our data would therefore suggest that for prevention of readmission, targeting octogenarian and older patients, those with higher comorbidities, and patients on Medicaid might be a worthwhile strategy, although evidence for preadmission intervention in surgical patients remains sparse 26…”

“…15 16 Our data would therefore suggest that for prevention of readmission, targeting octogenarian and older patients, those with higher comorbidities, and patients on Medicaid might be a worthwhile strategy, although evidence for preadmission intervention in surgical patients remains sparse. 26 We then examined adverse events and outcomes during the initial admission for revascularization that might predict a higher risk for readmission. We identified acute renal failure, acute respiratory failure, and non-routine discharge as predictors for readmission after both CAS and CEA in asymptomatic patients; in symptomatic patients, hematoma and cardiac events were additional adverse events that predicted readmission.…”

Strategies for optimal perioperative outcomes in gastric cancer

“…18 Cessation interventions for smoking and excess alcohol use should also be provided, 17 as both factors are associated with poor wound healing and increased risk of postoperative complications. [19][20][21][22] Finally, preoperative anaemia increases risk of perioperative morbidity and mortality, 23 and should be corrected where possible. Notably, routine preoperative administration of intravenous iron in anaemic patients is now being challenged due to evidence that it does not reduce the likelihood of blood transfusion or risk of death perioperatively.…”

“…However, in more recent times, it has expanded to a multimodal holistic approach which includes: (1) structured and personalized aerobic and resistance, (4) cessation of adverse health habits (e.g., alcohol abuse, smoking). 19,45 An additional benefit is the empowerment of patients, who will be able to play a more active role in coping with their disease going into surgery.…”

“…ERAS clinical care pathways have become standard practice in the management of many gastrointestinal cancers 17,18 as they reduce length-of-stay, surgical stress responses, costs-of-care, and postoperative morbidity. 51 However, ERAS pathways focus on the intraor postoperative recovery period, 19 and their full benefit has not T A B L E 1 Simple screening in the surgical office for malnutrition, low functional capacity, and anxiety and depression…”