Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews.

BACKGROUND: The certainty that prehabilitation improves postoperative outcomes is not clear. The objective of this umbrella review (i.e. systematic review of systematic reviews) was to synthesise and evaluate evidence for prehabilitation in improving health, experience, or cost outcomes. METHODS: We performed an umbrella review of prehabilitation systematic reviews. MEDLINE, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Joanna Briggs Institute's database, and Web of Science were searched (inception to October 20, 2020). We included all systematic reviews of elective, adult patients undergoing surgery and exposed to a prehabilitation intervention, where health, experience, or cost outcomes were reported. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. Primary syntheses of any prehabilitation were stratified by surgery type. RESULTS: From 1412 titles, 55 systematic reviews were included. For patients with cancer undergoing surgery who participate in any prehabilitation, moderate certainty evidence supports improvements in functional recovery. Low to very low certainty evidence supports reductions in complications (mixed, cardiovascular, and cancer surgery), non-home discharge (orthopaedic surgery), and length of stay (mixed, cardiovascular, and cancer surgery). There was low to very low certainty evidence that exercise prehabilitation reduces the risk of complications, non-home discharge, and length of stay. There was low to very low certainty evidence that nutritional prehabilitation reduces risk of complications, mortality, and length of stay. CONCLUSIONS: Low certainty evidence suggests that prehabilitation may improve postoperative outcomes. Future low risk of bias, randomised trials, synthesised using recommended standards, are required to inform practice. Optimal patient selection, intervention design, and intervention duration must also be determined.

Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity?

PURPOSE OF REVIEW: A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation. RECENT FINDINGS: All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening. SUMMARY: There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.

Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are multimodal evidenced-based care pathways for optimal recovery. Central to ERAS is integration of perioperative nutrition care into the overall management of the patient. This study describes changes to perioperative nutrition care after implementation of an ERAS program, and identifies factors that affect compliance to ERAS care elements and short-term postoperative outcomes. METHODS: Data were prospectively collected from patients undergoing elective colorectal surgery at 6 hospitals in Alberta, Canada, from 2013-2017. Compliance to nutrition care elements (nutrition risk screening, preoperative carbohydrate loading, early postoperative oral feeding, and mobilization) was recorded before ERAS implementation (pre-ERAS group, n = 487) and with ERAS implementation (ERAS group, n = 3536). Logistic regression identified factors that affect compliance to care elements, length of hospital stay (LOS), and postoperative complications. RESULTS: A total of 4023 patients were included. The rate of nutrition risk screening improved from 9% (pre-ERAS group) to 74% (ERAS group); 12% were at nutrition risk. Compliance increased for preoperative carbohydrate loading (4%-61%), early postoperative oral feeding (P < .001), and mobilization (P < .001). In multivariable logistic regression, nutrition risk independently predicted low overall compliance (<70%) to ERAS care elements (odds ratio [OR] 2.77; 95% CI, 2.11-3.64; P < .001) and a trend for LOS >5 days (OR 1.40; 95% CI, 1.00-1.96; P = .052). Low compliance to ERAS (<70%) predicted postoperative complications (OR 2.69; 95% CI, 2.23-3.24; P < .001). CONCLUSION: ERAS implementation positively impacted the adoption of standardized perioperative nutrition care practices. Nutrition risk screening identified patients less able to comply with postoperative nutrition care elements and who had longer LOS.

Food Is Medicine: A Qualitative Analysis of Patient and Institutional Barriers to Successful Surgical Nutrition Practices in an Enhanced Recovery After Surgery Setting.

BACKGROUND: Close adherence to the Enhanced Recovery After Surgery (ERAS) program is associated with improved outcomes. A nutrition-focused qualitative analysis of patient experience and of ERAS implementation across our province was conducted to better understand the barriers to successful adoption of ERAS nutrition elements. METHODS: Enrolled colorectal patients (n = 27) were asked to describe their surgical experience. Narrative interviews (n = 20) and focus groups (n = 7) were transcribed verbatim and analyzed inductively for food and nutrition themes. Qualitative data sources (n = 198 documents) collected throughout our implementation of ERAS were categorized as institutional barriers that impeded the successful adoption of ERAS nutrition practices. RESULTS: We identified patient barriers related to 3 main themes. The first theme, Mistaken nutrition facts & beliefs, describes how information provision was a key barrier to the successful adoption of nutrition elements. Patients held misconceptions and providers tended to provide them with contradictory nutrition messages, ultimately impeding adequate food intake and adherence to ERAS elements. The second theme, White bread is good for the soul?, represents a mismatch between prescribed medical diets and patient priorities. The third theme, Food is medicine, details patient beliefs that food is healing; the perception that nutritious food and dietary support was lacking produced dissatisfaction among patients. Overall, the most important institutional barrier limiting successful adoption of nutrition practices was the lack of education for patients and providers. CONCLUSION: Applying a patient-centered model of care that focuses on personalizing the ERAS nutrition elements might be a useful strategy to improve patient satisfaction, encourage food intake, correct previously held beliefs, and promote care adherence.

High dose amino acid administration achieves an anabolic response in type 2 diabetic patients that is independent of glycaemic control: A randomized clinical trial.

BACKGROUND & AIMS: Surgical stress provokes protein catabolism and hyperglycaemia that is enhanced in patients with type 2 diabetes (T2DM), and increases perioperative morbidity. This study hypothesized that perioperative administration of high dose intravenous (IV) amino acids (AA) will augment protein balance in T2DM patients receiving tight plasma glucose control via continuous IV insulin compared to standard plasma glucose control via subcutaneous (SC) insulin sliding scale. METHODS: Eighteen patients with well-controlled T2DM (HbA1C% < 7.1) undergoing colorectal surgery were assigned randomly to receive standard glucose control (6-10 mmol/l, SC insulin, n = 9) or tight glucose control (4-6 mmol/l, IV insulin, n = 9). Both groups received general anaesthesia and epidural analgesia. AA (1 ml/kg h Aminoven™ 10%, ∼2.4 g/kg d) were infused via a peripheral vein for two 3-h periods: at the beginning of surgery and in the post-operative care unit. Whole-body protein and glucose kinetics were assessed by stable isotope tracers, L-[1-13C]leucine and [6,6-2H2]glucose. RESULTS: Whole-body protein balance was positive after surgery in all patients. Since protein synthesis, breakdown and leucine oxidation were comparable in both groups, whole body protein balance was not different (p = 0.605). Tight glucose control suppressed endogenous glucose production (EGP, p < 0.001) and increased glucose clearance (p < 0.001) compared to standard glucose control during both study periods. No episode of hypoglycaemia occurred in either group. CONCLUSION: High-dose perioperative AA administration under optimal anti-catabolic care with epidural analgesia was effective in achieving a positive protein balance in T2DM patients undergoing surgery that was independent of glycaemic control strategy. Continuous IV insulin maintained normoglycaemia by inhibiting EGP and increasing glucose clearance. Improved glucose control, without a pronounced increase in protein balance with the intravenous insulin regimen, suggests perioperative protein metabolism may be less sensitive to insulin than is glucose.

Pearls of optimizing nutrition and physical performance of older adults undergoing cancer therapy.

As the global population continues to age, the prevalence of cancer is increasing, with more than half of new cancer diagnoses occurring in those aged 65years and older. As a result of improved oncological care, a greater number of older patients undergo treatment, either chemoradiotherapy or surgery or both. The older oncology patient is not part of a homogenous group; chronological age poorly describes the health status of an individual. Comprehensive geriatric assessment (CGA) identifies domains, assessed by a multidisciplinary team, that should be considered to guide appropriate oncological treatment decisions. This paper will focus on two aspects of the CGA: the assessment of nutrition and functional status of the older patient with cancer. Optimization of both diet and physical activity may help patients improve their tolerance to oncological treatments and health-related quality of life (HRQOL). Beginning with definitions of frailty, sarcopenia, cachexia, and malnutrition, this paper will suggest standardized screening, diagnostic and interventional procedures to identify and treat these conditions in the older oncology patient.

Protein intakes are associated with reduced length of stay: a comparison between Enhanced Recovery After Surgery (ERAS) and conventional care after elective colorectal surgery.

Background: Protein can modulate the surgical stress response and postoperative catabolism. Enhanced Recovery After Surgery (ERAS) protocols are evidence-based care bundles that reduce morbidity.Objective: In this study, we compared protein adequacy as well as energy intakes, gut function, clinical outcomes, and how well nutritional variables predict length of hospital stay (LOS) in patients receiving ERAS protocols and conventional care.Design: We conducted a prospective cohort study in adult elective colorectal resection patients after conventional (n = 46) and ERAS (n = 69) care. Data collected included preoperative Malnutrition Screening Tool (MST) score, 3-d food records, postoperative nausea, LOS, and complications. Multivariable regression analysis assessed whether low protein intakes and the MST score were predictive of LOS.Results: Total protein intakes were significantly higher in the ERAS group due to the inclusion of oral nutrition supplements (conventional group: 0.33 g · kg-1 · d-1; ERAS group: 0.54 g · kg-1 · d-1; P < 0.02). This group difference in protein intake was maintained in a multivariable model that controlled for differences between baseline and surgical variables (P = 0.001). Oral food intake did not differ between the 2 groups. The ERAS group had shorter LOS (P = 0.049) and fewer total infectious complications (P = 0.01). Nausea was a predictor of protein intake. Nutrition variables were independent predictors of earlier discharge after potential confounders were controlled for. Each unit increase in preoperative MST score predicted longer LOSs of 2.5 d (95% CI: 1.5, 3.5 d; P < 0.001), and the consumption of ≥60% of protein requirements during the first 3 d of hospitalization was associated with a shorter LOS of 4.4 d (95% CI: -6.8, -2.0 d; P < 0.001).Conclusions: ERAS patients consumed more protein due to the inclusion of oral nutrition supplements. However, total protein intake remained inadequate to meet recommendations. Consumption of ≥60% protein needs after surgery and MST scores were independent predictors of LOS. This trial was registered at clinicaltrials.gov as NCT02940665.

Prehabilitation with Whey Protein Supplementation on Perioperative Functional Exercise Capacity in Patients Undergoing Colorectal Resection for Cancer: A Pilot Double-Blinded Randomized Placebo-Controlled Trial.

BACKGROUND: A previous comprehensive prehabilitation program, providing nutrition counseling with whey protein supplementation, exercise, and psychological care, initiated 4 weeks before colorectal surgery for cancer, improved functional capacity before surgery and accelerated functional recovery. Those receiving standard of care deteriorated. The specific role of nutritional prehabilitation alone on functional recovery is unknown. OBJECTIVE: This study was undertaken to estimate the impact of nutrition counseling with whey protein on preoperative functional walking capacity and recovery in patients undergoing colorectal resection for cancer. DESIGN: We conducted a double-blinded randomized controlled trial at a single university-affiliated tertiary center located in Montreal, Quebec, Canada. Colon cancer patients (n=48) awaiting elective surgery for nonmetastatic disease were randomized to receive either individualized nutrition counseling with whey protein supplementation to meet protein needs or individualized nutrition counseling with a nonnutritive placebo. Counseling and supplementation began 4 weeks before surgery and continued for 4 weeks after surgery. MAIN OUTCOME MEASURE: The primary outcome was change in functional walking capacity as measured with the 6-minute walk test. The distance was recorded at baseline, the day of surgery, and 4 weeks after surgery. A change of 20 m was considered clinically meaningful. RESULTS: The whey group experienced a mean improvement in functional walking capacity before surgery of +20.8 m, with a standard deviation of 42.6 m, and the placebo group improved by +1.2 (65.5) m (P=0.27). Four weeks after surgery, recovery rates were similar between groups (P=0.81). CONCLUSION: Clinically meaningful improvements in functional walking capacity were achieved before surgery with whey protein supplementation. These pilot results are encouraging and justify larger-scale trials to define the specific role of nutrition prehabilitation on functional recovery after surgery.

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

BACKGROUND: The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. METHODS: A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. RESULTS: Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥ 20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. -21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). CONCLUSION: Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.