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35. Franssen RFW, Bongers BC, Vogelaar FJ, Janssen-Heijnen MLG. Feasibility of a teleprehabilitation program in high-risk patients with colon or rectal cancer undergoing elective
surgery: a feasibility study. Periop Med. 2022;11:28.
36. Ferreira V, Agnihotram RV, Bergdahl A, etal. Maximizing patient adherence to Prehabilitation:
gastrointestinal cancer surgery: what do the patients say? Supp Care Cancer. 2018;26:2717–23.
37. McDonald S, Yates D, Durrand JW, et al. Exploring patient attitudes to behaviour change
before surgery to reduce peri-operative risk: preferences for short- vs. long-term behaviour
change. Anaesthesia. 2019;74:1580–8.
38. Barberan-Garcia A, Cano I, Bongers BC, etal. Digital support to multimodal communitybased Prehabilitation: gastrointestinal cancer surgery: looking for optimization of health value
generation. Front Oncol. 2021;11:662013.
39. Blumenau Pedersen M, Saxton J, Birch S, et al. The use of digital technologies to support home-based prehabilitation prior to major surgery: a systematic review. Surgeon.
2023;S1479-666X(23):00060–4.
40. Schierbeck G.Prehabilitation as novel paradigm shift in cancer care. Semin Oncol Nurs.
2022;38:151327.
41. NHS. Appointments in general practice. 2023. england.nhs.uk/cancer/faster- diagnosis/.
Accessed 28 Jun 2023.
42. Steffens D, Delbaere K, Young J, etal. Evidence on technology-driven preoperative exercise
interventions: are we there yet? Br J Anaesth. 2020;125:646–9.
43. Waller E, Sutton P, Rahman S, et al. Prehabilitation with wearables versus standard of care
before major abdominal cancer surgery: a randomised controlled pilot study. Surg Endosc.
2022;36:1008–17.
44. Lau CSM, Chamberlain RS.Prehabilitation programs improve exercise capacity before and
after surgery in gastrointestinal cancer surgery patients: a meta-analysis. J Gastroint Surg.
2020;24:2829–37.
45. Mareschal J, Hemmer A, Douissard J, etal. Surgical Prehabilitation in patients with gastrointestinal cancers: impact of unimodal and multimodal programs on postoperative outcomes and
prospects for new therapeutic strategies-a systematic review. Cancers (Basel). 2023;15(6):1881.
J. Lambert et al.
Chapter 6
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Efcacy ofPrehabilitation inAbdominal
Cancer Surgery
LaraEdbrooke, ShazaAbo, andLindaDenehy
Introduction
Colorectal cancer is the third most common form of cancer and the second leading
cause of cancer-related death globally [1]. Major surgical resection, with or without
neoadjuvant treatment (chemo/radiotherapy), is the only curative treatment option.
However, surgery is not without risk. Despite its excellent survival benet, this
treatment carries a signicant burden to patients and the health care system, as many
surgical patients develop short—and/or long-term complications [2]. Death within
30days after surgery is the third leading cause of death worldwide [3], and onequarter of patients suffer major postoperative complications such as respiratory
infections [4]. This risk is predominantly driven by a subgroup of high-risk patients
(as detailed below), where approximately 12% of patients and 12% of surgical procedures (predominantly major abdominal surgery) account for more than 80% of
postoperative complications [5].
L. Edbrooke (*)
Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
e-mail: larae@unimelb.edu.au
L. Denehy
Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
Department of Health Services Research, The Peter MacCallum Cancer Centre,
Melbourne, VIC, Australia
e-mail: l.denehy@unimelb.edu.au
S. Abo
Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
Department of Physiotherapy, The Peter MacCallum Cancer Centre,
Melbourne, VIC, Australia
e-mail: shaza.abo@unimelb.edu.au
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_6
81© The Author(s), under exclusive license to Springer Nature
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It is anticipated that the number of patients with increased surgical risk will
increase three-fold over the next 30years, due to a rising number of patients over
50years receiving surgery, adversely impacting healthcare budgets. This is driven
by an ageing global population, with associated increased co-morbid disease, and
the prevalent use of neoadjuvant therapy (chemotherapy/radiotherapy before surgery) that deconditions patients before cancer surgery [6].
L. Edbrooke etal.
Whole Body Prehabilitation
Prehabilitation modies the preoperative deconditioned state by improving the
physiologic capacity of patients to withstand the stressor of major surgery.
Prehabilitation is commonly delivered as a multimodal intervention bundle tailored to the individual and comprising medical optimisation for example, assessment of haematinics and treatment including iron infusions (as appropriate),
smoking cessation, patient education delivered by the multidisciplinary team
(including pain management, the importance of early mobilisation), exercise,
nutrition and psychological support [7]. Enhanced recovery after surgery (ERAS)
protocols are multimodal perioperative care pathways designed to achieve early
recovery after surgical procedures [8]. Even though they have a different structure
they usually include preoperative counselling, preoperative nutrition (including
avoidance of strict perioperative fasting, and carbohydrate loading up to 2h preoperatively), standardised anaesthetic and analgesic regimens (epidural and nonopioid analgesia) and early mobilisation. Often, both are included in the care package
of ERAS Plus.
Randomised Trials
In a multicentre trial in colorectal cancer surgery (n=251), participants were randomised to receive 4weeks of supervised, multimodal prehabilitation or standard
care (ERAS pathway with no additional nutrition, exercise or psychological counselling). Prehabilitation included exercise, nutrition, psychosocial support, and
smoking cessation (if required). The number of severe complications was signicantly lower (OR 0.47 [95%CI 0.26–0.87]; p=0.02), along with fewer medical
complications (e.g., respiratory) compared with standard care (OR 0.48 [95%CI
0.26–0.89]; p=0.02). Between-group 6-min walk test distance, 4weeks postoperatively, was not signicantly different. Unfortunately, the trial was ceased early due
to the COVID-19 pandemic and did not reach its powered sample size [9].
Systematic reviews and meta-analyses [10–18] similarly support multidisciplinary prehabilitation to reduce operative risks and improve postoperative patient
outcomes, although not all aspects of patient recovery have been found to be
6 Efcacy ofPrehabilitation inAbdominal Cancer Surgery
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signicant. Given the large number of trials in prehabilitation in the past 10 years
McIsaac et al. performed an overview of systematic reviews which included 55
reviews examining the efcacy of prehabilitation [19]. Moderate-certainty evidence
(GRADE) favouring prehabilitation (either uni—or multimodal) to improve functional recovery was reported the 6-min walk test (6MWT). However, evidence certainty in favor of prehabilitation over standard care for the outcomes of complications,
discharge destination and hospital length of stay was graded low to very low
certainty.
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Respiratory Prehabilitation
Depending on postoperative pulmonary complications (PPC) denition, incidence
can range from 10 to 60% [4, 20]. PPCs are associated with worse postoperative
outcomes including prolonged length of hospital stay [4], hospital readmissions
[21], and worse quality of life [22]. As occurs with prehabilitation in general, respiratory education and training should be provided prior to surgery to target prevention of PPC [23]. Nearly 50% of all PPCs develop within the rst two postoperative
days, with many developing on the rst day [24]. Deep breathing exercises, coughing instruction and the reasons these are important can be explained to patients in
the preoperative period.
Boden etal. compared usual care with one 30-min face to face education session
prior to surgery delivered within existing preadmission clinics. The patient education session included an explanation of surgical impact on the lungs, deep breathing
instruction, and practise. This randomised trial of 440 patients reported a halving of
PPC after major abdominal surgery (adjusted hazard ratio 0.48, 95% condence
interval 0.30 to 0.75, p=0.001), reduced 12-month mortality in patients who did not
develop a PPC and found the intervention cost effective [25, 26]. These results are
supported in a meta-analysis (n=1345) that provides moderate certainty evidence
for respiratory physiotherapy in reducing PPC [27].
Inspiratory Muscle Training (IMT)
Inspiratory muscle training (IMT) is strength training specically targeting the skeletal muscles responsible for inspiration.A load on the inspiratory muscles is generated through a mouth-held device [28]. The efcacy of IMT [29] as a breathing
technique taught preoperatively is supported for patients undergoing cardiac and
thoracic surgery [10] but to date no trials have reported efcacy in the colorectal
surgical population. In patients with oesophageal cancers IMT is recommended
pre- operatively due to the demonstrated benets in improving pulmonary function [30].
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L. Edbrooke etal.
Who Needs Prehabilitation?
Modiable risk factors (deconditioning, malnutrition, psychological distress)
impact surgical outcomes. Deconditioning: Physical tness predicts complications
after major cancer surgery [31, 32]. Neoadjuvant therapy, chemo—and/or radiotherapy prior to major surgery, further impairs functional capacity, and importantly
this may be offset with exercise-based prehabilitation [33]. Malnutrition: About
26% of hospitalised patients are malnourished, and a greater proportions (39%) of
patients are nutritionally at-risk. In abdominal cancer surgery, 44% of patients are
malnourished, with associated increased hospital length of stay complications or
death after surgery [34].
The “Higher-Risk” Surgical Patient
These patients are typically older, have multiple comorbidities and functional limitations including deconditioning, malnutrition and sarcopenia (muscle wasting),
and may be frail [35]. Frailty is a multidimensional clinical syndrome characterised
by reduced physiological reserve against stressors due to age-related disability.
However, a common denition (and measurement) of frailty is lacking. Frailty is
associated with poor treatment tolerance, adverse postoperative outcomes, and
higher risk of mortality; and these factors worsen with more severe frailty. The role
of prehabilitation in frail individuals has not been extensively studied but in general
the current evidence is supportive of prehabilitation to improve function in this
patient group. Frail patients may need more prolonged intervention (more than
4–5weeks) to experience functional gains [36].
The Impact ofNeo-Adjuvant Cancer Treatments
Patients receiving neo-adjuvant treatments may also be at higher risk.Chemo/radiotherapy related side effects including nausea, vomiting, diarrhoea and fatigue are
common and impact nutrition, weight, body composition, and functional status [37,
38]. These contribute further to the development of adverse events and inordinately
high cost of care [39]. In the EMPOWER trial participants were randomised to
receive either hospital-based exercise or routine care,post-neoadjuvant treatment
and prior to surgery. Adherence was high with participants attending 91% of scheduled sessions.Exercise capacity improved signicantly following the intervention
(between-group mean difference (95% CI) for the change in oxygen uptake (VO
at anaerobic threshold (AT) = 2.9 mL/kg/min (0.8 to 5.1), p =0.011) [40]. Pilot
studies demonstrate safety, feasibility, and trends towards positive outcomes
)
2
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favouring prehabilitation in rectal cancer surgery [41]; however, further high- quality
research is required regarding the efcacy of prehabilitation during neoadjuvant
therapies prior to abdominal cancer surgery.
Stepped Care
Escalating interventions can be individualised to the severity of risk and to the
patient’s response. Current recommendations are to provide stepped, individualised
interventions based on risk assessment (Fig.6.1, adapted from Macmillan Cancer
Support) [42]. Not all centres use this stepped approach and it may need modication depending on the demographics of the population referred for prehabilitation.
This model of prehabilitation care shows three levels of stepped multimodal
prehabilitation: Universal, Targeted and Specialised prehabilitation and was developed by an international working group for the Macmillan Cancer Support group in
partnership with the Royal College of Anaesthetists and the National Institute of
Health Research (UK) [42]. Universal prehabilitation targets all patients and
focuses on educating patients and improving patient self-efcacy and empowerment before surgery. Patients (with a family member or friend) may receive education from content experts, with presentations on their surgical pathway, the
importance of exercise, physical activity, nutrition, stress reduction, pain management and oral and respiratory care. This may be delivered face to face or by webinar
Fig. 6.1 Prehabilitation model of care (adapted from Macmillan Cancer Support)
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L. Edbrooke etal.
or videos supported with written educational materials. Patients may also be taught
the principles of ERAS and encouraged to participate in their care journey. Risk
factor triggers can identify patients requiring Targeted or Specialised Care levels of
prehabilitation, centred on exercise, nutritional and psychological support. Research
to assess outcomes from the Universal component of prehabilitation has not yet
been undertaken.
Patients receiving Targeted prehabilitation are commonly prescribed an individual exercise programme, consisting of aerobic exercise and strength training.
Exercise prescription and progression follow the American College of Sports
Medicine guidelines and FITT (Frequency, Intensity, Type and Time) principles
to achieve progressive overload and maximise gains [43]. Aerobic exercise is
performed as continuous or interval training—commonly using a treadmill or
stationary cycling. Resistance training involves upper and lower limb exercises of
the major muscle groups using machines, resistance bands, body weight, or freeweights. This is often prescribed at moderate intensity initially, with the aim to
progress towards higher intensities. Intensity may be prescribed and exercise progressed based on ndings from the patient’s cardiopulmonary exercise test
(CPET) using maximal heart rate at the point of peak oxygen uptake (HR max at
VO
), or using the Borg scale (aiming to start at 3–4/10 ‘somewhat hard’
2 peak
level) [44].
It is recommended that exercise sessions include behaviour change strategies,
including setting of personalised goals. Patients are commonly also prescribed a
home exercise programme, aiming to work towards the guidelines of achieving
150 min of moderate-intensity physical activity per week [45]. Individualised
dietary advice is given dependent on the patient’s anthropometric and nutritional
assessment ndings and this advice can include education to optimise nutrition to
achieve adequate energy and protein intake, oral protein supplementation, and
enteral or parenteral nutrition, if required. Immunonutrition,providing nutrients in
larger amounts than required to regulate immune activities, is not used consistently
but is shown to reduce postoperative complications (infections, anastomotic leak)
and hospital length of stay following gastrointestinal cancer surgery [46].
Psychological support during prehabilitation is aimed at helping patients prepare for
surgery and addresses any factors which may impact on the ability to engage with
additional aspects of the prehabilitation programme. Psychological interventions
may include psycho-education, stress management, problem solving, motivational
therapy, and cognitive behavioural approaches [47].Screening and risk assessment
are needed to use this model wisely and to direct resources to those most in need of
prehabilitation. Table6.1 describes commonly used screening and assessment measures to risk stratify patients to receive Universal, Targeted or Specialized
prehabilitation.
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Table 6.1
Commonly used screening and assessment tools
Surgical Risk Tool Interpretation
Postoperative
complications
Exercise capacity Cardiopulmonary exercise test (gold
Physical activity
(exercise is a
sub-category [64])
Performance status Australia-modied Karnofsky
Physical function Sit-to-stand (STS)—30 [68] or 60s,
Skeletal muscle Handgrip strength (HGS),
Malnutrition Malnutrition Screening Tool [73]
Sarcopenia (muscle
loss)
Frailty Clinical Frailty Scale [77]
Anxiety and
depression
Clavien-Dindo classication [57]
Postoperative morbidity survey
(POMS) [58]
Days alive and at home up to
30daysafter surgery [59]
standard) [60]
6-min walk test [61]
Incremental shuttle walk test [61]
Patient-reported—Duke Activity
Status Index [32]
Accelerometry
International Physical Activity
Questionnaire-Short Form [65]
PerformanceStatus [67]
5 times chair stand (5-CTS) [69]
quadriceps dynamometry [72]
Patient-GeneratedSubjective Global
Assessment [74]
SARC-F: Strength, assistance
walking, rise from chair, climb
stairs, falls history [75]
Bioimpedance appendicular lean
mass (ALM) [71, 76]
CT scan (muscle mass third lumbar
vertebra)
Fried’s Frailty Phenotype [78]
Generalised anxiety disorder
(GAD-7 item) [79]
Patient health questionnaire
(PHQ-9) [80]
Hospital Anxiety and Depression
Scale [81]
Graded I-V (death). Major
complications ≥ III
POMS—9 domains of morbidity
(presence/absence)
Greater
complicationsareassociated with
peak oxygen uptake (VO
<15mL/kg/min or anaerobic
threshold <11mL/kg/min [62]
< 400m greater risk [63]
Range 0—58.2 (≤ 34 greater
complication risk)
3days×8h/daywear time is valid
[66]
Meeting guidelines yes/no and
continuous variable
(weeklymetabolic equivalent of
task minutes)
0–100 (higher scoresindicate
better function)
30s STS <12 (females) <14
(males)is below average for 60–64
yand associated with higher falls
risk [70]; 5-CTS>15s=at risk/
probablesarcopenia [71]
HGS <27kg males <16kg
females=at risk/probable
sarcopenia [71]
0–1=low risk, 2=moderaterisk,
3–5=high risk
Typical range 0–35; A =wellnourished; B=moderate/
suspected; C=severe malnutrition
Score 0–10 (higher
score=increasedprobability of
sarcopenia)
ALM <20kg male <15kg
femaleat risk/probable sarcopenia
Local standards sarcopenia
1 (very t) to 9 (terminally ill)≥5
indicate frailty
0–21: 0–4 minimal, 5–9 mild,
10–14 moderate, 15–21 severe
0–27: 0–4 minimal, 5–9 mild,
10–14 moderate, 15–19
moderately severe, 20–27 severe
0–21:0–7 no, 8–10 mild, 11–14
moderate, 15–21 severe
peak)
2
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Table 6.1 (continued)
Surgical Risk Tool Interpretation
PROMS
Health-related
quality of life
Fatigue Functional Assessment of Chronic
PREMS NHS National Cancer Patient
Risks are assessed and managed in conjunction with medical optimisation, pain management,
smoking cessation (if required); PREMS patient-reported experience measures, PROMS patientreported outcome measures, Euro-Qol European organisation for research and treatment of cancer
quality of life questionnaire;
European Organisation for Research
and Treatment of Cancer Quality of
Life Questionnaire-Core 30 [82]/
EuroQoL (EQ-5D-5L) [83]
Illness Therapy-Fatigue [84]
Experience Survey [85]
0–100 (higher scoresrepresent
higher physical function, quality
of life or symptoms, according to
respective scales)
0–52 (<30 indicates severe fatigue)
Local standards patient experience
L. Edbrooke etal.
Controversies inPrehabilitation
While prehabilitation as a ‘package of care’ is shown to improve patient outcomes,
the components included vary between centres. The denition of prehabilitation
also varies, for example the inclusion of the medical optimisation of anaemia and
smoking cessation could be considered to be standard medical care but are often
included in the prehabilitation package. In the McIsaac overview, only four reviews
(7%) delineated how prehabilitation was dened to inform review inclusion eligibility [19]. Risk stratication is important before surgery but many different tools are
used to assess risk such as the National Surgical Quality Improvement Program
(NSQIP) calculator, American Society of Anesethesiologists’ (ASA) classication,
and the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk
index. However, these tools do not take into account the social determinants of
health which are shown to impact recovery outcomes [48].
In colorectal cancer the length of prehabilitation interventions requires additional research. What is the minimum period preoperatively needed to be effective?
The prehabilitation intervention time needed to enhance patient tness is debated in
the literature with variations between a minimum of 2weeks or 4weeks of intervention remaining a controversy [37]. This may be dependent on the patient preoperative condition and the cancer surgery planned. For example, the more frail and
deconditioned patients may need a longer prehabilitation intervention.
Whilst most research involves combined aerobic and resistance exercise interventions there is a need for further research regarding optimal exercise intervention
types, according to individual needs and surgery type, which are feasible to deliver
during the prehabilitation period. The most common components included in prehabilitation are aerobic, resistance and respiratory training with nutrition intervention
commonly added [37]. With a focus on pre-operative aerobic tness, a comparative
review of prehabilitation prior to abdominal cancer surgery found three out of four
included studies reported signicant increases in VO
at AT or VO
2
high-intensity interval training interventions. In contrast, neither study of
following
2 peak
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moderate- intensity exercise training reported signicant changes in aerobic tness
[49]. However, others report signicant outcomes for moderate intensity activity.
One study compared high to moderate intensity interval training in 42 patients
before surgery for colorectal cancer and found both improved short term VO
[50].
peak
2
Prehabilitation publications also vary regarding the setting of interventions,
home or hospital based, supervised or unsupervised. The consensus regarding
supervised exercise interventions is that they are superior to unsupervised in impact
on both adherence to exercise and outcomes of tness and/or strength [51]. Home
based exercises can be supervised using video conferencing or web based real time
methods [52].
Finally, the reporting of interventions and measurement of specic outcomes is
variable. In the McIsaac overview, only thirty-ve (64%) reviews reported the duration of prehabilitation [19]. Guidelines regarding reporting are needed to improve
comparisons between trials and a core set of outcomes that are measured will allow
greater combinations of trials in future meta-analyses.
Case Reports
These cases were accessed from our centre where prehabilitation is included as
usual care in abdominal cancer surgery. Each case detailed below attended ‘surgery
school’ as part of the Universal approach to prehabilitation. This online education
session, including question and answer time, from the multidisciplinary team
included topics what to expect; pain management; optimising muscle and nutrition;
the role of exercise and the importance of respiratory care and early mobilisation;
and preparing psychologically for surgery. Education followed respiratory prehabilitation principles to reduce the risk of postoperative complications (covering
active deep breathing, cough, oral care, understanding your surgery and recovery,
getting out of bed and head of bed elevation; aCOUGH). Both patients were edu-
cated about the importance of performing Active Cycle of Breathing Techniques
(ACBT) in the pre—and early postoperative periods.
Case 1—Mr. D
Mr. D is a 72-year-old man with a non-English speaking background who lives with
his wife. An ex-smoker, he had previously worked as a gardener and enjoys 3–4
standard alcoholic drinks per day. His past history includes mild osteoarthritis in
both hips and hypertension.
Following reporting to his GP some swallowing difculties and a sensation of
pressure in his chest, Mr. D underwent investigations and was diagnosed with an
oesophageal squamous cell carcinoma. He was scheduled for high-risk surgery, an
oesophagectomy, following 6weeks of neoadjuvant chemoradiotherapy. Key points
along Mr. D’s prehabilitation pathway are summarised in Fig.6.2. As part of his
surgical consultation, he was referred to prehabilitation by his surgical team, due to
the high risk of the planned procedure. His Duke Activity Status Index (DASI) score
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