Prehabilitation boosts functional status in esophagogastric surgery patients

Last Updated: 2018-09-14

By Marilynn Larkin

NEW YORK (Reuters Health) - Prehabilitation improves perioperative functional capacity in patients undergoing esophagogastric surgery, researchers have found.

"Prehabilitation is a structured, personalized intervention that utilizes the perioperative period to optimize patients' functional status," Dr. Francesco Carli of McGill University Health Center in Montreal told Reuters Health. "The main components are exercise, nutrition, and anxiety-coping interventions."

"Each component of the program should be individualized and administered by a specialist and should consider baseline functional status, comorbidities, and the type of surgery or cancer treatment," he said by email.

"In patients with esophagogastric cancer, physical and nutritional status are potentially modifiable factors that impressively impact on post-operative outcome and cancer care," he noted. "We therefore thought that prehabilitation would have a compelling rationale in this clinically challenging population."

Dr. Carli and colleagues randomized 68 patients awaiting elective esophagogastric resection for cancer at McGill to prehabilitation - a preoperative program of exercise and nutrition optimization - or usual care. Patients in the prehabilitation group were a mean age of 67.3 and 69% were men; the mean age of control group participants was 68 and 80% were men.

The primary outcome was change in functional capacity over time, measured as the difference in absolute change in 6-minute walking distance (6MWD) between baseline and the preoperative visit, and between baseline and the postoperative visit. A significant change was defined as an improvement or a deterioration of 20 meters from baseline.

As reported online September 5 in JAMA Surgery, 51 (of 68) patients were included in the primary analysis. The median duration of prehabilitation was 36 days, whereas the median preoperative period in the control group was 51 days.

Twenty participants (77%) had prehabilitation during neoadjuvant chemotherapy, 11 of whom (55%) started prehabilitation before medical treatment. Overall compliance with prehabilitation was 63%. No exercise-related adverse events were reported.

Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean 6MWD change, 36.9 m vs. 22.8 m) and after surgery (mean 6MWD change, 15.4 m vs. 81.8 m).

There were no statistically significant differences between groups with respect to number and severity of complications, length of hospital stay, emergency department visits, or readmission rates.

"In our seven-year experience in different cancer populations, no adverse effects of prehabilitation were detected," Dr. Carli said. "Being safe and effective, all patients could potentially benefit from this intervention. Since data are mounting that deconditioned patients are the ones who benefit most, targeting high-risk populations could represent a compelling strategy for clinical implementation of prehabilitation programs."

"Prehabilitation should be continued after surgery, to both maintain physical status and be prepared for the next treatment step," he added. "In fact, since cancer care is a multi-phasic journey, continuing a conditioning intervention after surgery may not be considered as a rehabilitation after surgery, but rather, as prehabilitation to adjuvant therapy."

Dr. Michael Englesbe of the University of Michigan, coauthor of a related editorial, told Reuters Health that "every patient should train for surgery."

"Patients should set recovery goals, train before surgery and resume training following surgery to facilitate reaching these goals," he said by email. "These programs save money and improve lives."

However, "they take time for health care providers to implement and operate," he noted. "Reimbursement for this additional work will be critical to develop sustainable programs."

"Blue Cross and Blue Shield of Michigan is piloting a program that reimburses providers for (their) time," he added. "This is an exciting step forward."

SOURCE: http://bit.ly/2MuyNBO and http://bit.ly/2MuzE5u

JAMA Surg 2018.