##'Prehab' Boosts Fitness Before Upper Gi Surgery

###'Prehab' Boosts Fitness Before Upper Gi Surgery | MIDDAY

Patients who underwent prehabilitation prior to elective surgery for esophagogastric cancer had significantly better functional capacity before and after surgery, a small randomized trial showed.

Preoperatively, 6-minute walk distance (6MWD) increased by 121 feet versus baseline in patients assigned to prehabilitation as compared with a decrease of almost 75 feet in the control group. Four to 8 weeks after surgery, 6MWD remained 50 feet more than baseline in the prehabilitation group versus a decrease of almost 270 feet from baseline in the control group.

"This randomized clinical trial demonstrated prehabilitation-induced significant improvement in physical status among patients undergoing surgery for malignant gastroesophageal lesions," Francesco Carli, MD, DPhil, of McGill University Health Center in Montreal, and co-authors concluded in an article published online in JAMA Surgery. "Further investigation is required to determine the optimal modality of the intervention and its effect on overall oncologic outcomes."

"Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum," they added.

Though supportive of prehabilitation prior to cancer surgery, the results are not definitive because of issues related to the study design, said Raja Flores, MD, of Mount Sinai Health System in New York City. The study involved a total of 51 evaluable patients, and the intervention and control groups were not well balanced with regard to baseline characteristics. As such, the results should be interpreted cautiously.

Nonetheless, a precedence exists for beneficial effects of prehabilitation, and the study by Carli and colleagues adds to the evidence.

"The idea of prehabilitation is very important," Flores told Medpage Today. "We learned that in the lung volume reduction study [for chronic obstructive pulmonary disease, COPD]. It showed that preoperative, prehabilitation really made a big difference in outcome. I think that will work in esophageal surgery, but this study, itself does not prove that. You need a bigger study with more patients to show that, but this study does point you in that direction."

The authors acknowledged that the concept of prehabilitation before cancer surgery and other types of operations is not new, but the benefits have yet to be established in patients undergoing upper gastrointestinal surgery. However, physician and nutritional studies have been recognized as potentially modifiable factors in esophagogastric cancer.

Investigators designed a randomized trial to investigate the effectiveness of prehabilitation to prevent physical decline in patients undergoing elective upper gastrointestinal surgery. They hypothesized that prehabilitation would improve functional capacity throughout the perioperative period.

The study involved adults referred for elective surgical management of nonmetastatic esophagogastric cancer. Patients with significant comorbidities, unstable cardiac conditions, severe COPD,or ASA physical status class 4-5 were excluded. Patients were randomized to a structured prehabilitation program that addressed functional capacity and nutritional status.

The prehabilitation program included individualized, home-based exercise training, consultations with a kinesiologist, aerobic activities, strengthening activities, dietary assessments and advice, and prescription nutritional supplements as needed to maintain daily protein intake and total energy requirements. The control group received conventional preoperative care with no specific interventions.

The primary outcome was functional outcome, as defined by 6MWD, assessed at baseline, before surgery, and 4 to 8 weeks after surgery. The median duration of prehabilitation was 36 days, and the median preoperative period in the control group was 51 days. Data analysis included 51 evaluable patients, 26 randomized to prehabilitation and 25 to the control group.

The 6MWD changed significantly in both groups but in different directions. Between-group differences achieved statistical significance at both the preoperative and postoperative assessments (P<0.001). The authors reported that 62% of patients assigned to prehabilitation had improved functional capacity at the preoperative assessment, and the improvement was maintained at the follow-up assessment. Surgical and oncologic outcomes (such as receipt of planned chemotherapy) did not differ significantly between the two groups.

The authors of an accompanying editorial credited the McGill group with leading a scientific investigation of prehabilitation that "has convinced many clinicians that prehabilitation benefits patients." However, they also noted the differences between a clinical trial setting and the realities of routine clinical practice.

"In other words, patients are not randomized in standard practice, and physicians may intuitively prescribe prehabilitation for those patients whom they believe stand to benefit the most," wrote Michael J. Englesbe, MD, of the University of Michigan in Ann Arbor, and co-authors. "In addition, it is often unrealistic to delay a patient's medical care to undergo a prehabilitation program, especially for patients with time-sensitive, surgically amenable conditions.

"Diverse patients, diverse stakeholders, and diverse financing strategies contribute to a complex milieu for care and impeded the acceptance and implementation of prehabilitation. More pragmatic, population-based studies of prehabilitation are essential to prove its effect and drive care transformation."

The authors reported having no relevant relationships with industry. Authors of the editorial also reported having no relevant relationships with industry.

2018-06-13T17:17:24-0400

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