Prehabilitation

Fit-4-Surgery: Exercise interventions and outcome following surgery 
Professor Mike Grocott
Lecture Abstract: 2014 Conference

Physical fitness is an important determinant of perioperative outcome: less fit patients have higher incidences of morbidity and mortality after major surgery.  Although the early work in this area was from Australia, the keenest proponents (and most of the evidence base) now derive from the UK.  Early studies focused on using physical fitness measures, commonly derived from cardiopulmonary exercise testing, as risk indices to guide intra- and post-operative care.  Increasingly the focus is on shared decision making with comprehensive provision of information to patients and their carers, to inform a decision that is specific to an individual patient’s condition and context.  “Prehabilitation” physical training programs have been proposed as an intervention to improve postoperative outcome and useful data are beginning to reach the journals.

An additional variable is the use of neoadjuvant treatments (chemo- and/or radio- therapy) prior to cancer surgery.  Recent data suggests that such approaches may cause harm to physical fitness, which in turn translates into adverse clinical outcome.  It may therefore be that, in some patients, the tumour regression benefits of such treatments may be outweighed by the harms of diminished physical fitness.  The period of recovery between neoadjuvant treatments and surgery may offer an opportunity for physical training in some groups of patients who would otherwise routinely progress urgently to surgery (e.g. major cancer surgery).

The complex interaction between physical fitness, neoadjuvant interventions and physical training in individual patients undergoing cancer surgery is likely to be an important area of research and clinical innovation in the coming years. Prescription of neoadjuvant regimens based on knowledge of likely responses, both tumour regression and harm to physical fitness, offers the opportunity to substantially improve outcomes.

The period around the time of surgery is characterized by increased focus on personal health along with multiple interactions with healthcare professionals and may provide a particular opportunity for improving health in general, and physical fitness in particular.  In particular they may offer an opportunity to embed sustained changes in behavior at a time when patients are particularly focused on health improving behavior.  Pre- and post- operative exercise interventions are likely to be of benefit to patients.

References

1. Pearse RM, Holt PJ, Grocott MP.  Managing perioperative risk in patients undergoing elective non-cardiac surgery.  BMJ  2011;343:d5759

2. Grocott MP, Pearse RM.  Prognostic studies of perioperative risk: robust methodology is needed.  British Journal of Anaesthesia  2010;105(3):243-5

3. West M, Jack S, Grocott MP.  Perioperative cardiopulmonary exercise testing in the elderly.  Best Practice and Research in Clinical Anaesthesiology  2011;25(3):427-37

4. Hennis PJ, Meale PM, Grocott MP.  Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery.  Postgraduate Medical Journal  2011;87(1030):550-7

5. Colson M, Baglin J, Bolsin S, Grocott MP.  Cardiopulmonary exercise testing predicts 5 yr survival after major surgery.  British Journal of Anaesthesia 2012;109(5):735-41

6. Jack S, West M, Grocott MP.  Perioperative exercise training in elderly subjects. Best Practice and Research in Clinical Anaesthesiology  2011;25(3):461-72

7. O'Doherty AF, West M, Jack S, Grocott MP.  Preoperative aerobic exercise training in elective intra-cavity surgery: a systematic review.  British Journal of Anaesthesia  2013;110(5):679-89

8. West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MPW, Jack S.  The effect of prehabilitation on objectively measured physical fitness following neoadjuvant treatment in preoperative rectal cancer patients – a blinded interventional pilot study. British Journal of Anaesthesia (in press)

9. West MA, Loughney L, Barben CP, Sripadam R, Kempf GJ, Grocott MPW, Jack S.  The effects of neoadjuvant chemoradiotherapy on physical fitness and morbidity in rectal cancer surgery patients.  European Journal of Surgical Oncology (in press)

10. Jack S, West MA, Raw D, Marwood S, Ambler G, Cope TM, Shrotri M, Sturgess RP, Calverley PMA, Grocott MPW.  The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery.  European Journal of Surgical Oncology 2014;40(10):1313-20

11.  Burke SM, Brunet J, Sabiston CM, Jack S, Grocott MP, West MA. Patients' perceptions of quality of life during active treatment for locally advanced rectal cancer: the importance of preoperative exercise.  Support Care Cancer 2013;21(12):3345-53