EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults.

BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research.

Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.

Prehabilitation in patients awaiting liver transplantation.

BACKGROUND: Frailty, malnutrition and sarcopenia lead to a significant increase in morbidity and mortality before and after liver transplantation (LT). Prehabilitation attempts to optimize physical fitness of individuals before major surgeries. To date, little is known about its impact on patients awaiting LT. AIMS: The aim of our scoping review was to describe whether prehabilitation in patients awaiting LT is feasible and safe, and whether it leads to a change in clinical parameters before or after transplantation. METHODS: We performed a systematic review of the literature from 1946 to November 2023 to identify prospective studies and randomized controlled trials of adult LT candidates who participated in an exercise training program. RESULTS: Out of 3262 citations initially identified, six studies were included. Studies were heterogeneous in design, patient selection, intervention, duration, and outcomes assessed. All studies were self-described as pilot or feasibility studies and had a sample size ranging from 13 to 33. Two studies were randomized controlled trials. Two study restricted to patients with cirrhosis who were eligible for liver transplantation or on the transplant list. Exercise programs lasted between 6 and 12 weeks. In terms of feasibility, proportion of eligible patients that were recruited was between 54 and 100%. Program completion ranged between 38 and 90%. Interventions appeared safe with 9 (9.2%) adverse events noted. In the intervention group, improvements were generally noted in peak oxygen consumption and workload, 6-min walking distance, and muscle strength. One study suggested a decrease in post-transplant hospital length of stay. CONCLUSIONS: Overall, it appears that prehabilitation with exercise training is feasible, and safe in patients awaiting LT. Higher quality and larger studies are needed to confirm its impact on pre- and post-transplantation-related outcomes.

Cancer symptom burden negatively affects health-related quality of life in patients undergoing prehabilitation prior to liver resection: results from a 12-week randomized controlled trial.

TAKE HOME MESSAGE: Cancer symptoms negatively affect health-related quality of life (HRQoL) in patients with cancer awaiting liver resection. Prehabilitation maintained HRQoL after surgery. Future studies should test whether relieving cancer symptoms can improve HRQoL.

Preoperative multimodal prehabilitation before elective colorectal cancer surgery in patients with WHO performance status I or II: randomized clinical trial.

BACKGROUND: Multimodal prehabilitation is a promising adjunct to the current surgical treatment pathway for colorectal cancer patients to further improve postoperative outcomes, especially for high-risk patients with low functional capacity. The aim of the present study was to test the effect of prehabilitation on immediate postoperative recovery. METHOD: The study was designed as a RCT with two arms (intervention and control). The intervention consisted of 4 weeks of multimodal prehabilitation, with supervised physical training, nutritional support and medical optimization. The control group received standard of care. A total of 40 patients with colorectal cancer (WHO performance status I or II) undergoing elective surgery with curative intent were included. The primary outcome was postoperative recovery within the first 3 postoperative days, measured by Quality of Recovery-15, a validated questionnaire with a scoring range between 0 and 150 and a minimal clinically relevant difference of 8. RESULTS: In total, 36 patients were analysed with 16 in the intervention group and 20 in the control group. The mean age of the included patients was 79 years. The overall treatment effect associated with the intervention was a 21.9 (95% c.i. 4.5-39.3) higher quality of recovery-15 score during the first 3 postoperative days compared to control, well above the minimal clinically relevant difference. CONCLUSION: Four weeks of multimodal prehabilitation prior to elective curative intended colorectal cancer surgery in patients with WHO performance status I or II was associated with a clinically relevant improvement in postoperative recovery.Registration number: NCT04167436 (http://www.clinicaltrials.gov).

Prehabilitation: Who can benefit?

Prehabilitation is an intervention that occurs between cancer diagnosis and the start of an acute treatment. It involves physical, nutritional, and psychological assessments to establish a baseline functional level and provide targeted interventions to improve a person's health and prevent future impairments. Prehabilitation has been applied to surgical oncology and has shown positive results at improving functional capacity, reducing hospital stay, decreasing complications, and enhancing health-related quality of life. The importance of collaboration between various healthcare professionals and the implementation of multimodal interventions, including exercise training, nutrition optimization, and emotional support is discussed in this manuscript. The need for screening and assessment of conditions such as sarcopenia, frailty, or low functional status in order to identify patients who would benefit the most from prehabilitation is vital and should be a part of all prehabilitation programs. Exercise and nutrition play complementary roles in prehabilitation, enhancing anabolism and performance. However, in the presence of malnutrition and sarcopenia, exercise-related energy expenditure without sufficient protein intake can lead to muscle wasting and further deterioration of functional capacity, thus special emphasis on nutrition and protein intake should be made in these cases. Finally, the challenges and the need for a paradigm shift in perioperative care are discussed to effectively implement personalized prehabilitation programs.

Impact of Dietary Counseling on Health-Related Quality of Life in Patients with Cancer Awaiting Hepato-Pancreato-Biliary Surgery.

We examined the effectiveness of dietary counseling performed within a trimodal prehabilitation study for patients with cancer awaiting hepato-pancreato-biliary (HPB) surgery. Additionally, we explored relationships between nutritional status and health-related quality of life (HRQoL). The dietary intervention aimed to achieve a protein intake of 1.5 g/kg/day and reduce nutrition-impact symptoms. Patients received dietary counseling 4 weeks prior to surgery (prehabilitation group); the rehabilitation group just before surgery. We used 3-day food journals to calculate protein intake and the abridged Patient-generated Subjective Global Assessment questionnaire (aPG-SGA) to determine nutritional status. We utilized the Functional Assessment of Cancer Therapy-General questionnaire to measure HRQoL. Sixty-one patients participated in the study (30 = prehabilitation). Dietary counseling achieved a significant increase in preoperative protein intake (+0.3 ± 0.1 g/kg/day, P = 0.007), with no change in the rehabilitation group. Dietary counseling did not mitigate a significant increase in aPG-SGA postoperatively (prehabilitation: +5.8 ± 1.0; rehabilitation: +3.3 ± 1.0; P < 0.05). aPG-SGA was predictive of HRQoL (ß = -1.77, P < 0.0001). HRQoL remained unchanged in both groups over the study period. Dietary counseling within a HPB prehabilitation program improves preoperative protein intake, but not aPG-SGA, which is predictive of HRQoL. Future studies should examine whether specialized medical management of nutrition-impact symptoms would improve HRQoL outcomes within a prehabilitation model.

Strategies for optimal perioperative outcomes in gastric cancer.

Cancer and surgery represent a major stress on the human body. Any condition that prevents patients from tolerating the physiological stress is a risk factor for poor outcome. There is a need to identify these impairments early in the process with a simple screening, followed by assessments that provide a holistic picture of the patient. The proposed path of multimodal prehabilitation acts synergistically with enhanced recovery after surgery care to achieve optimal patient outcomes.

From Theory to Practice: An International Approach to Establishing Prehabilitation Programmes.

Purpose: This article focuses on the following:The importance of prehabilitation in people with cancer and the known and hypothesised benefits.Exploration of the principles that can be used when developing services in the absence of a single accepted model of how these services could be established or configured.Description of approaches and learning in the development and implementation of prehabilitation across three different countries: Canada, the Netherlands and the United Kingdom, based on the authors' experiences and perspectives. Recent Findings: Practical tips and suggestions are shared by the authors to assist others when implementing prehabilitation programmes. These include experience from three different approaches with similar lessons.Important elements include the following: (i) starting with a small identified clinical group of patients to refine and test the delivery model and demonstrate proof of concept; (ii) systematic data collection with clearly identified target outcomes from the outset; (iii) collaboration with a wide range of stakeholders including those who will be designing, developing, delivering, funding and using the prehabilitation services; (iv) adapting the model to fit local situations; (v) project leaders who can bring together and motivate a team; (vi) recognition and acknowledgement of the value that each member of a diverse multidisciplinary team brings; (vii) involvement of the whole team in prehabilitation prescription including identification of patients' levels of risk through appropriate assessment and need-based interventions; (viii) persistence and determination in the development of the business case for sustainable funding; (ix) working with patients ambassadors to develop and advocate for the case for support; and (x) working closely with commissioners of healthcare. Summary: Principles for the implementation of prehabilitation have been set out by sharing the experiences across three countries. These principles should be considered a framework for those wishing to design and develop prehabilitation services in their own areas to maximise success, effectiveness and sustainability.

Patients' perspectives of prehabilitation as an extension of Enhanced Recovery After Surgery protocols.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) and prehabilitation programs are evidence-based and patient-focused, yet meaningful patient input could further enhance these interventions to produce superior patient outcomes and patient experiences. We conducted a qualitative study with patients who had undergone colorectal surgery under ERAS care to determine how they prepared for surgery, their views on prehabilitation and how prehabilitation could be delivered to best meet patient needs. METHODS: We conducted semistructured interviews with adult patients who had undergone colorectal surgery under ERAS care within 3 months after surgery. Patients were enrolled between April 2018 and June 2019 through purposive sampling from 1 hospital in Alberta. The interview transcripts were analyzed independently by a researcher and a trained patient-researcher using inductive thematic analysis. RESULTS: Twenty patients were interviewed. Three main themes were identified. First, waiting for surgery: patients described fear, anxiety, isolation and deterioration of their mental and physical states as they waited passively for surgery. Second, preparing would have been better than just waiting: patients perceived that a prehabilitation program could prepare them for their operation if it addressed their emotional and physical needs, provided personalized support, offered home strategies, involved family and included surgical expectations (both what to expect and what is expected of them). Third, partnering with patients: preoperative preparation should occur on a continuum that meets patients where they are at and in a partnership that respects patients' expertise and desired level of engagement. CONCLUSION: We identified several patient priorities for the preoperative period. Integrating these priorities within ERAS and prehabilitative programs could improve patient satisfaction, experiences and outcomes. Actively engaging patients in their care might alleviate some of the anxiety and fear associated with waiting passively for surgery.

Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery.

BACKGROUND: Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery. METHODS: In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien-Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34). RESULTS: Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03-1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34. CONCLUSION: DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.

ESPEN practical guideline: Clinical nutrition in surgery.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery: A Randomized Controlled Trial.

OBJECTIVE: To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery. SUMMARY BACKGROUND DATA: Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown. METHODS: This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. RESULTS: Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/d (-0.01 to 0.01)] or peak cough flow [-0.002 L/min/d (-0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23-1.99)]. CONCLUSIONS: In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02131844.

Prehabilitation: metabolic considerations.

PURPOSE OF REVIEW: The major components of ERAS attenuate the inflammatory response and modulate metabolism in direction of sparing body protein and preserving function. However, these perioperative interventions might have limited effectiveness on postoperative outcomes if preoperative risk factors are not addressed and optimized. RECENT FINDINGS: The preoperative metabolic perturbations characterized by insulin resistance and sarcopenia might predispose patients to a higher degree of postoperative catabolism. High-risk populations for such metabolic disturbances include elderly and frail patients, and patients with metabolic syndrome. Research on the effect of prehabilitation on perioperative metabolism is limited, but recent findings suggest that interventions designed to improve insulin sensitivity prior to surgery might represent a promising therapeutic target to minimize surgical complications. SUMMARY: The present paper will discuss the metabolic implications of modulating preoperative risk factors with elements of multimodal prehabilitation, such as exercise training and nutrition.

Development of a clinical pathway for enhanced recovery in colorectal surgery: a Canadian collaboration

Summary: Enhanced Recovery After Surgery (ERAS) is a model of care that was introduced in the late 1990s by a group of surgeons in Europe. The model consists of a number of evidence-based principles that support better outcomes for surgical patients, including improved patient experience, reduced length of stay in hospital, decreased complication rates and fewer hospital readmissions. A number of Canadian surgical care teams have already adopted ERAS principles and have reported positive outcomes. Arising from the Canadian Patient Safety Institute's Integrated Patient Safety Action Plan for Surgical Care Safety, and with support from numerous partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. We discuss the development of a multidisciplinary clinical pathway for elective colorectal surgery to help guide Canadian clinicians.

Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework.

The field of cancer survivorship has significantly advanced person-centered care throughout the cancer continuum. Within cancer survivorship, the last decade has seen remarkable growth in the investigation of prehabilitation comprising pre-treatment interventions to prevent or attenuate the burden of oncologic therapies. While the majority of evidence remains in the surgical setting, prehabilitation is being adapted to target modifiable risk factors that predict poor treatment outcomes in patients receiving other systemic and localized anti-tumor treatments. Here, we propose a multiphasic approach for prehabilitation across the cancer continuum, as a conceptual framework, to encompass the variability in cancer treatment experiences while adopting the most inclusive definition of the cancer survivor.

The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients.

INTRODUCTION: Treatment delay may have detrimental effects on cancer outcomes. The impact of longer delays on colorectal cancer outcomes remains poorly described. The objective of this study was to determine the effect of delays to curative-intent surgical resection on survival in colorectal cancer patients. METHODS: All adult patients undergoing elective resection of primary non-metastatic colorectal adenocarcinoma from January 2009 to December 2014 were reviewed. Treatment delays were defined as the time from tissue diagnosis to definitive surgery, categorized as < 4, 4 to < 8, and ≥ 8 weeks. Primary outcomes were 5-year disease-free (DFS) and overall survival (OS). Statistical analysis included Kaplan-Meier curves and Cox regression models. RESULTS: A total of 408 patients were included (83.2% colon;15.8% rectal) with a mean follow-up of 58.4 months (SD29.9). Fourteen percent (14.0%) of patients underwent resection < 4 weeks, 40.0% 4 to < 8 weeks, and 46.1% ≥ 8 weeks. More rectal cancer patients had treatment delay ≥ 8 weeks compared with colonic tumors (69.8% vs. 41.4%, p < 0.001). Cumulative 5-year DFS and OS were similar between groups (p = 0.558; p = 0.572). After adjusting for confounders, surgical delays were not independently associated with DFS and OS. CONCLUSIONS: Treatment delays > 4 weeks were not associated with worse oncologic outcomes. Delaying surgery to optimize patients can safely be considered without compromising survival.

Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care.

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.