Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery

Abstract

Background: Surgery is a major physiologic stress comparable to intense exercise. Diminished cardiopulmonary reserve is a major predictor of poor outcomes. Current preoperative workup focuses mainly on identifying risk factors, however little attention is devoted to improving cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a “surgical marathon” similar to the preparation of an athlete. Study Design: The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in four activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. We prospectively collected demographic, intraoperative (first hour), and postoperative data for patients enrolled in MSHOP undergoing major abdominal surgery. Statistical analysis was performed using 2:1 propensity score matching to compare the MSHOP group (N=40) to emergency (N=40) and elective, non-MSHOP (N=76) patients. Results: Overall, 70% of MSHOP patients complied with the program. Age, gender, ASA classification, and BMI did not differ significantly between groups. One hour intraoperatively, MSHOP patients showed improved systolic and diastolic blood pressures and lower heart rate (Figure). There was a significant reduction in Clavien-Dindo class 3–4 complications in the MSHOP group (30%) compared to the non-prehabilitation (38%) and emergency (48%) groups (p=0.05). This translated to total hospital charges averaging $75,494 for the MSHOP group, $97,440 for the non-prehabilitation group, and $166,085 for the emergency group (p < 0.001). Conclusion: Patients undergoing prehabilitation prior to colectomy showed positive physiologic effects and experienced fewer complications. The average savings of $21,946 per patient represents a significant cost offset for a prehabilitation program, and should be considered for all patients undergoing surgery.

Patients’ and healthcare workers’ recommendations for a surgical patient safety checklist – a qualitative study

“…Combining patient's surgical safety checklist with existing programs such as the ERAS program might improve patient's compliance to the program as well as further reduce complications, and hospitalisation time. Several surgical complication prevention programs are based on providers giving information and patients adhering to the programs [6,7,[13][14][15]19]. The aim for a patient's surgical safety checklist is to encourage patients to take more responsibility for their own safety, by ensuring that they have received and understood the information provided to them as well as helping them to prepare before and after surgery.…”

“…Patients are rarely informed in a timely manner about the benefits of lifestyle changes [6] and most patients participating in this study believed it was too late to change lifestyle weeks before surgery. If patients optimise their own health before surgery by exercising, improving nutritional status, or discontinuing smoking, alcohol and other substances they can reduce complications [6,7,30,31]. A major study on orthopaedic patients found that ceasing smoking six to eight weeks before surgery could reduce overall complications from 56 to 18% [32].…”

“…The World Health Organisation (WHO) and European patient organisations endorse patient involvement in safety [1,2]. Patient involvement in self-care and safety is widely discussed [1,[3][4][5][6][7]. Patients are willing to participate, but this depends largely on the healthcare system creating opportunities that promote and allow patient involvement [2,5,8].…”

“…Prehabilitation and Enhanced Recovery after Surgery (ERAS) is a multidisciplinary and multimodal perioperative program designed to optimise patient health before surgery, increase awareness in certain elements within the intraoperative phase as well as enhancing patient recovery and rehabilitation. With patient compliance, these programs have shown reductions up to 50% in complications, and 42% in mortality in patients [7,19]. Further, one study having designed and implemented a patient checklist after colorectal surgery showed reduction of readmissions from 28% to 20% [16].…”

Preventive Cardio-Oncology: The Time Has Come

“…Should we advocate for initiating cardio-oncology prehabilitation before patients undergo chemotherapy, radiation, or surgery? In the overall surgical world, exercise or nutritional prehabilitation (initiated before surgery) seems to improve outcomes and lower healthcare costs compared to waiting for rehabilitation (initiated after surgery) alone (124)(125)(126)(127)(128)(129)(130)(131)(132)(133)(134)(135)(136)(137). Clinical trials are underway to further define the prehabilitation period (before surgical therapy) as optimal for fitness intervention (138)(139)(140).…”