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- 1. COLLECTIVE REVIEW Prehabilitation among Patients Undergoing Non-Bariatric Abdominal Surgery: A Systematic Review Nicole B Lyons, MD, Karla Bernardi, MD, MS, Oscar A Olavarria, MD, Naila Dhanani, MD, Puja Shah, BS, Julie L Holihan, MD, MS, Tien C Ko, MD, FACS, Lillian S Kao, MD, MS, FACS, Mike K Liang, MD, MS, FACS Nearly half of individuals in Western society will undergo abdominal or pelvic surgery in their lifetime.1 After abdominal surgery, 30% of patients will suffer postoper- ative complications such as surgical site infections.2-5 These complications affect the patient (quality of life and morbidity), healthcare system (cost and chronic dis- ease), and hospitals (cost and space).6,7 Patients at greatest risk for major complications are pa- tients with comorbid conditions, including those with poor physical fitness and overweight or obese patients. Two-thirds of individuals in the US are overweight (BMI 25-30 kg/m2 ) or obese (BMI > 30 kg/m2 ). Among these high-risk patients, the risk of developing a postoper- ative complication ranges from 30% to 80%.2-5,8,9 Current perioperative strategies to improve outcomes focus primarily on immediate perioperative care. Enhanced recovery after surgery (ERAS) programs have changed how patients are handled perioperatively, and are associated with a lower overall morbidity and shorter hospital stay.10 The ERAS program uses a set of protocols before, during, and after surgery such as pre-surgery edu- cation and counseling, early mobilization, removal of drains, and oral intake to improve outcomes. However, ERAS does not include a preoperative exercise component or “prehabilitation.” New guidelines state that prehabili- tation may be beneficial when used in conjunction with ERAS and may improve postoperative outcomes.11 Another program is Strong for Surgery, which includes checklists that are integrated into the preoperative phase to screen patients for risk factors that may lead to compli- cations. These checklists target 8 areas including nutri- tion, glycemic control, and smoking cessation. In November 2018, prehabilitation was added to the check- lists included in Strong for Surgery.12 Strong for Surgery defines prehabilitation as “a process of improving the functional capability of a patient before a surgical procedure.” Prehabilitation programs can include several interventions for preoperative optimiza- tion including smoking cessation, nutritional optimiza- tion, physical activity, pulmonary rehabilitation, and stress reduction.4 There does not seem to be a generally accepted criterion or definition for what must be included for it to be considered a prehabilitation program. Benefits of prehabilitation have been demonstrated in select surgi- cal patients, such as those undergoing cardiothoracic, or- thopaedic, or bariatric surgery.13 Preoperative physical conditioning improved physical function, pulmonary function, and decreased hospital length of stay in random- ized trials among patients undergoing cardiac and ortho- paedic surgery.13,14 Preoperative weight loss has also been shown to decrease the risk of cardiovascular and thrombo- embolic events, operative duration, and surgical compli- cations with bariatric surgery.15 However, generalizability to patients undergoing nonbariatric abdominal surgery remains unknown. This review aimed to assess whether a prehabilitation program focusing on exercise has positive effects on postoperative clinical or functional outcomes after nonbariatric abdominal or pel- vic surgery. METHODS A review of the literature using PubMed, EMBASE, and Cochrane Library was performed following Preferred Reporting Items for Systematic reviews and Meta- Analysis (PRISMA) Guidelines. Articles published be- tween September 1, 1976 and June 22, 2019 were reviewed. The following search term strategy was used: ("preoperative optimization" OR "weight loss" OR "exer- cise" OR "nutritional counseling" OR "prehabilitation" Drs Bernardi and Lyons contributed equally to this work. Disclosure information: Nothing to disclose. Presented at Surgical Infection Society 39th Annual Meeting, Coronado, CA, June 2019. Received May 13, 2020; Revised June 7, 2020; Accepted June 24, 2020. From the Department of Surgery (Lyons, Bernardi, Olavarria, Dhanani, Shah, Holihan, Ko, Kao, Liang) and the Center for Surgical Trials and Ev- idence-Based Practice (Bernardi, Liang), University of Texas Health Science Center at Houston, Houston, TX. Correspondence address: Nicole B Lyons, MD, 6431 Fannin St, Houston TX 77030. email: lyons.nicole.b@gmail.com 480 ª 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jamcollsurg.2020.06.024 ISSN 1072-7515/20
- 2. OR "preoperative training" OR "smoking cessation" OR "tobacco cessation" OR "glucose control" OR "glycemic control" OR "diabetic counseling" OR "incentive spirom- etry" OR "respiratory muscle training" OR "pulmonary prehabilitation" OR "incentive spirometer exercise" OR "inspiratory muscle training") AND ("prior to surgery" OR "before surgery" OR "preoperative"). Reference lists of the selected manuscripts were reviewed in the search for additional articles. Two independent reviewers reviewed all articles (KB and NBL). Inclusion criteria were randomized controlled trials regarding abdominal and pelvic surgery that evaluated patients who were involved in a prehabilitation program. Although prehabi- litation can include several interventions, such as smoking cessation and nutritional optimization, for the purpose of this review, prehabilitation was defined as any exercise program before surgical intervention. Studies were included if they were focused on adults (over age 18), hu- man subjects, and were published in the English language. Studies were limited to only intra-abdominal and pelvic surgery, but did not include procedures that were per- formed solely for cosmetic purposes, such as panniculec- tomy. Only elective or semi-elective procedures were included, as patients needed time to complete the preha- bilitation program. There was no limit on date of publi- cation used for this review. Exclusion criteria included: articles without an exercise regimen as part of the prehabilitation program or bariatric surgery procedures, because the primary goal of prehabi- litation in these procedures differs from that in other intra-abdominal surgery. When articles analyzing the same or overlapping patient populations and outcomes were identified, the most recent article was included. Sys- tematic reviews and meta-analyses were reviewed to ensure articles they selected were also included in our review. All studies included were appraised using the Critical Appraisal Skills Programme (CASP) evaluation tool for internal and external validity.16 A CASP score was calcu- lated for each of the randomized controlled trials, with a maximum score of 22. The studies were divided into categories based on their score: high quality was a score 15, moderate was a score of 14 to 10, and low quality was a score 9. These categories were devised by the authors. For each manuscript included, the primary and second- ary outcomes used for each study, number of patients, country of origin, surgical specialty, details on the preha- bilitation program, and complications were extracted. The outcomes of length of stay (LOS), 6-minute walk test (6MWT), and Clavien-Dindo grading were extracted, because LOS, functional status, and complications have shown improvement in other specialties using prehabilita- tion. Due to substantial clinical heterogeneity, no meta- analysis could be performed, so cumulative ranges of sta- tistics were reported instead. RESULTS In total, 2,105 manuscripts were identified from the initial PubMed, EMBASE, and Cochrane library search. Two articles identified from other sources were also included. After duplicates were removed, 396 manuscripts remained. Of these, 161 manuscripts were excluded based on review of their titles, and 235 remained for abstract re- view (Fig. 1). Twenty-eight manuscripts were reviewed, and 14 were included in the systematic review. Quality assessment and description of included studies Twelve randomized controlled trials were identified through the initial literature search and 2 more from searching the study references; all 14 underwent a full- text review. Assessment of risk of bias and the methodol- ogy of the studies was included in Table 117-30 along with study and background information. The studies were all at increased risk of bias due to the inability to blind pa- tients and exercise providers. Some were single-blind (6 of 14), 1 was not blinded, and the others did not comment on whether or not the surgeons were blinded. For several studies, the description of the methods was not detailed enough to accurately assess the risk of bias in their methodology. The specialties of the manuscripts included 5 on general surgery, 3 colorectal, 3 urology, 2 hepatobiliary, and 1 surgical oncology. Articles were mostly from Canada and Europe. The studies included a total of 982 patients, with 502 undergoing a prehabili- tation program. The mean age range was 55 to 75 years of age, and the mean BMI range was overweight (BMI 25.0 to 29.9 kg/ m2 ), with only 2 studies exclusively including obese (BMI 30 kg/m2 ) patients.17,18 Most studies had an average BMI in the normal or low overweight range Abbreviations and Acronyms CASP ¼ Critical Appraisal Skills Programme ERAS ¼ enhanced recovery after surgery LOS ¼ length of stay PRISMA ¼ Preferred Reporting Items for Systematic Reviews and Meta-Analysis SSI ¼ surgical site infection 6MWT ¼ 6-minute walk test Vol. 231, No. 4, October 2020 Lyons et al Prehabilitation Before Surgery 481
- 3. (BMI 26 to 27 kg/m2 ). Study populations differed in some studies. For example, Dronkers and colleagues19 had significantly more diabetic patients in the interven- tion group (8 of 14, 57% vs 1 of 19, 5%) and Kim and associates20 had an average age difference of 10 years be- tween groups. Most studies did not list the ethnicities of the patient population, and Banerjee and coworkers21 had only Caucasian patients. There were insufficient numbers of patients to perform subgroup analyses to determine if obesity, diabetes, or age were effect modera- tors of the effectiveness of prehabilitation. Description of interventions The exercise programs differed greatly between studies. Two of these programs were supervised exercise programs vs 7 programs in which patients performed exercises on their own. The remaining 5 had a combination of super- vised and unsupervised sessions. Sessions were made up of different components such as physical therapy sessions, walking (most counted by pedometers), cycling, aerobics, resistance training, inspiratory muscle training, and weight training. For the supervised sessions, most included stretching or a warm-up, the exercise session, and a cool down. One study included pelvic floor exer- cises.22 Six studies included other interventions or compo- nents to their prehabilitation program.18,19,23-26 The most popular components included respiratory muscle training, or nutritional counseling/dieting instructions, supple- ments, and psychological counseling. The different prehabilitation programs ranged from durations of 2 weeks to 6 months. Patients were involved in sessions that ranged from 30 to 60 minutes, with a fre- quency of 5 to 6 sessions a week, on average. Most divided groups were based on those who were in the intervention group and were supposed to perform the prehabilitation program and those who were not. One study, by Carli and coauthors,27 had 2 different prehabilitation programs within the study, and patients were enrolled in different programs. There was 1 study with a unique program. Kim and colleagues20 used a 4-week exercise program customized to each patient, and based on their perceived exertion and heart rate reserve. For most studies, the control group was usual care; however, these studies did not define what that entailed. For 4 programs, patients in the control group were asked to do at home, self-regulated exercises compared with su- pervised exercises for the intervention group. Finally, Gil- lis and coauthors25 compared patients involved in a prehabilitation program with others involved in a rehabil- itation program after colorectal procedures. Three of the studies explicitly mentioned using an ERAS proto- col.25,26,29 Dunne and colleagues28 referenced ERAS; how- ever, it is unclear if they followed an ERAS protocol. Compliance and functional results Compliance ranged from 16% to 98% in the prehabilita- tion group. However, only 8 of the 14 studies mentioned Records identified through database searching (n=2,105) Additional records identified through other sources (n=2) Full-text articles excluded (n=14) Records excluded (n=207) Records after duplicates removed (n=396) Records screened (n=235) Full-text articles assessed for eligibility (n=28) Studies included in qualitative synthesis (n=14) n o i t a c i f i t n e d I g n i n e e r c S Eligibility Included Records excluded (n=161) Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis Flow Diagram. 482 Lyons et al Prehabilitation Before Surgery J Am Coll Surg
- 4. compliance.19,20,22,25-27,30 Studies varied in how compliance was measured with the prehabilitation sessions and pro- gram. Some measured compliance by attendance at super- vised sessions. Others required patients to complete a diary or fill out questionnaires to track compliance. Most studies did not set weight loss or prehabilitation goals for the patients. The 6MWT was used in 7 of the 14 studies as a pri- mary outcome and was the main functional assessment. Five of these studies showed more improvement in the intervention group, 3 of which showed statistically signif- icant improvements. Most studies (13 of 14, 93%) found benefits from prehabilitation. In addition to improve- ments in the 6MWT, prehabilitation had positive effects on oxygenation, minute ventilation, and depression. A summary of the results is included in Table 2.17-30 Clinical outcomes Studies varied in their secondary outcomes and in their reporting of postoperative complications. Only 5 studies mentioned surgical site infections (SSI).18,25,26,28,29 Overall, there was no difference in the percentage of patients who experienced a postoperative SSI between the intervention and control groups (0 to 16% vs 0 to 13%). Thirteen of 14 studies reported overall complications, but their definitions were not standardized. Among these studies, 9 of 13 found no significant difference in postoper- ative complications (cumulative range 9% to 63% vs 13% to 80%). However, Soares and associates24 and Abdelaal and coworkers17 did find a significant reduction in pulmo- nary complications in the intervention group compared with the control group. Barberan-Garcia and colleagues29 and Liang and associates18 found a significant reduction in overall complications in the intervention group. Seven of the 14 studies reported complications using a standardized reporting system, specifically, the Clavien- Dindo classification, which are included in Table 2. Grade I complications require bedside or medication management; certain pharmacologic treatments, total parenteral nutrition, or blood transfusion is grade II; endoscopic, radiologic, or surgical intervention is needed for grade III; grade IV is life threatening and requires intensive care; and grade V is death.25,26 Among these 7 studies, none reported a statistically significant difference between the intervention and control groups. All but 1 of the studies reported LOS for the 2 groups. Nine of the 14 studies reported the same LOS for the prehabilitation and control groups. In the remaining 4 studies, the prehabili- tation group had a shorter LOS; however, this was not sta- tistically significant for 3 of the studies, and the fourth did not report a p value.17,19,23,29 DISCUSSION Abdominal and pelvic surgery represents a physiologic stress. Patients with comorbidities, including obesity and poor fitness levels, have a higher risk of complica- tions. Prehabilitation in surgical patients has gained popu- larity in recent years and has become increasingly investigated. If prehabilitation improves outcomes and re- duces complications, it would be important to implement these programs for patients undergoing surgery. Prehabi- litation requires time and effort on the part of the patient and healthcare system. In addition, these programs can delay the time to surgical intervention, so finding a clin- ical benefit to justify their implementation is important, which is why this systematic review was performed. Previ- ous systematic reviews on this subject have been pub- lished. However, these reviews have combined trials focusing on patients undergoing a broad spectrum of pro- cedures, from bariatric surgery patients to non-abdominal surgery, such as cardiac and thoracic surgery.31,32 Further- more, since the publication of the last systematic review on this subject by Hughes and colleagues,32 4 new ran- domized controlled trials have been published. These pro- vide additional information which was included in this study. In this systematic review of randomized controlled tri- als, prehabilitation did not demonstrate a consistent, sig- nificant benefit in preventing postoperative complications, likely because of the heterogeneity of the studies. Also, a meta-analysis was unable to be performed because studies varied greatly in the populations included, prehabilitation program specifics, primary outcomes, and method of evaluating for their primary outcome. For this reason, further studies with more standardized programs and outcomes are needed before a clinical benefit can be determined. Of note, 5 of the 7 studies that used the 6MWT as a primary outcome showed improvement in the intervention group, suggesting prehabilitation im- proves functional status. Most studies failed to report intermediate outcomes such as fitness testing results, weight loss results, and long-term maintenance after surgery. These data are crit- ical to determine if the limitations of prehabilitation are due to poor compliance, poor effectiveness in achieving intermediate outcomes (eg fitness, weight loss, etc), or poor effectiveness in improving clinical outcomes (eg reducing postoperative complications). There was weak and low-quality evidence to support a decrease in complications among patients who completed prehabilitation before abdominal surgery. There were a number of potential reasons for this. First, study popula- tions were not always at the highest medical or surgical Vol. 231, No. 4, October 2020 Lyons et al Prehabilitation Before Surgery 483
- 5. risk. Most studies did not evaluate obese patients. Among those that did, they largely performed minimally invasive surgery, which mitigates the risks of obesity with surgery. Instead, focusing on obese patients undergoing high risk operations (open surgery or surgery with extraction site) may be more useful. Second, the proven interventions may not be feasible in surgery patients. For example, med- ical weight loss and exercise programs may last for several months. This is not practical for patients undergoing co- lon cancer surgery. Instead, interventions were often short in duration. Additionally, exercise programs may have intensive components unachievable for some patients, such as those with ventral hernias, where this may not be attainable or may even put patients at risk (increased risk of incarceration and strangulation). Third, the compliance and success of interventions were poorly documented. Among the articles reviewed, most programs did not report compliance. However, among those that did, there was generally poor patient compli- ance. Although it is known that diet and exercise are feasible among the general population, long-term compli- ance is poor. What is not able to be discerned from these trials is whether diet and exercise are achievable among the surgical population in the short term. Most studies did not report if patients actually performed the recom- mended activities and did not report outcomes of that program (such as weight loss or improved exercise toler- ance). Finally, most studies were small and heterogeneous. Despite limitations in the evidence base, healthcare providers, surgeons, and patients still believe that prehabi- litation has a role in healthcare because there is biologic plausibility, and diet and exercise have been shown to be effective in many other aspects of healthcare. It has been shown that prehabilitation is effective for patients Table 1. Study and Background Information Variable Kim20 Canada, 2009 Carli27 Canada, 2010 Dronkers19 Netherlands, 2010 Kaibori23 Japan, 2013 Soares24 Brazil, 2013 Gillis25 Canada, 2014 Participant, n Total 21 112 42 51 32 77 Intervention 14 58 22 26 16 26 Mean age, y All - 60 - - - 66 Intervention 55 - 71 68 59 - Control 65 - 69 71 55 - Male, % 62 58 74 71 53 62 BMI, kg/m2 All - - - - 24 - Intervention 27 28 27 - - 27 Control 25 27 26 - - 29 Specialty operation GS, bowel resection CR, resection or colonic reconstruction SO, elective colon HPB, hepatectomy GS, elective open upper abd CR, colorectal resection Intervention Cycling at home 20-30 min, 7 d/wk Stationary cycling 20-30min/d; weight training 3x/wk Supervised resistance and aerobic training 60 min 2x/wk; walking/cycling 30 min/d; breathing exercises 60 min 3x/wk walking/ stretching; diet 50 min physical therapy sessions 2x/wk; stretching, relaxation, walking (10 min); walking 10 min 4x/wk; IMT 15 min/day 4x/wk Home-based aerobic and resistance exercise 50 min 3 d/wk; nutritional counseling; relaxation exercises Length of intervention, wk 4 4 2-4 4 2-3 4 Control Breathing/ circulatory exercises Walking/breathing regimen 30 min/d Home-based exercise advice Diet Standard care Rehabilitation CASP 12, mod 14, mod 16, high 16, high 15, high 19, high *Hiatal hernia (intervention[I]: 2, control[C]: 2), gastric sleeve (I: 4, C: 3), splenectomy (I: 2, C: 3), cholecystectomy (I: 18, C: 16). abd, abdominal; CASP, Critical Appraisal Skills Programme; CR, colorectal; GS, general surgery; HPB, hepatobiliary; IMT, inspiratory muscle training; lap, laparoscopic; SO, surgical oncology; U, urology; x, times. 484 Lyons et al Prehabilitation Before Surgery J Am Coll Surg
- 6. undergoing cardiothoracic or orthopaedic procedures, which is likely because these operations are closely linked to cardiopulmonary function and physical activity. Preha- bilitation is important for bariatric surgery, because those patients are undergoing surgery for weight loss, and exer- cise is crucial to achieve this. It is unclear why this review did not find a clear benefit for nonbariatric abdominal surgery. It could be a false negative and could require larger, less heterogenous studies to reach a true conclu- sion. Those interested in prehabilitation should come together to identify patient populations with the greatest potential benefit and provide standardized risk stratifica- tion for patients undergoing surgery. Interventions should be standardized and clearly reported. Finally, outcomes should not include only intermediate outcomes (eg compliance, weight loss, fitness, etc), but clinical out- comes using standardized definitions (eg NSQIP), severity grading (eg Clavien-Dindo complications), and long-term outcomes (eg fitness and weight loss). CONCLUSIONS Despite a strong theoretical basis supporting prehabilita- tion, it is not associated with a robust decrease in rate of complications among patients undergoing nonbariatric abdominal and pelvic surgery. While substantial interest exists in prehabilitation and its potential benefits, the value of these programs remains unclear. Future studies should use a standardized risk stratification for patient populations, interventions, and outcomes measurements. Ideally, pragmatic comparative effectiveness and random- ized trials should be performed to assess composite preha- bilitation regimens that include risk reduction strategies including smoking cessation and glycemic control. Jensen30 Denmark, 2015 Dunne28 UK, 2016 Abdelaal17 Egypt, 2017 Banerjee21 UK, 2018 Barberan- Garcia29 Spain, 2018 Bousquet- Dion26 Canada, 2018 Liang18 US, 2018 Santa Mina22 Canada, 2018 107 38 50 60 125 63 118 86 50 20 26 30 62 37 59 44 - 62 - - 71 - 50 - 69 - 56 72 - 74 - 61 71 - 52 73 - 71 - 62 74 68 44 88 75 73 30 100 26 - 30 27 - - 37 27 - 30 - - 21 28 - - - 29 - - 22 29 - - U, radical cystectomy HPB, liver resection GS, elective lap upper abd* U, radical cystectomy GS, elective major abd CR, non-metastatic colorectal cancer resection GS, ventral hernia repair U, radical prostatectomy Home-based endurance/ strength 2x/d (step training 15 min) 30 min cycling (12 total) Physical and respiratory therapy 40 min 2x/wk; respiratory therapy and walking 10 min 2x/d 4x/wk Cycle ergometer 60 min 2x/wk Cycle ergometer w50 min 1-3x/wk (12 total); walking/ home-based exercise Supervised exercise 30 min 1x/wk; aerobic activity/ resistance training 30 min 3-4x/wk; nutritional counseling; anxiety management Daily goal checklist including exercise, servings of fruits and vegetables; nutritional counseling Home-based moderate intensity exercise 60 min 3-4 d/wk; pelvic floor exercise 7 d/wk 2 4 4 3-6 6 4 4-24 - Standard care Standard care Standard care Standard care Standard care Standard care Standard counseling Pelvic floor exercise 17, high 20, high 18, high 16, high 18, high 17, high 19, high 19, high Table 1. Continued Vol. 231, No. 4, October 2020 Lyons et al Prehabilitation Before Surgery 485
- 8. Table 2. Continued Variable Kim 20 Carli 27 Dronkers 19 Kaibori 23 Soares 24 Gillis 25 Jensen 30 Dunne 28 Abdelaal 17 Banerjee 21 Barberan- Garcia 29 Bousquet- Dion 26 Liang 18 Santa Mina 22 5 I - - - - - - 6 (3) - - - - - - - C - - - - - - 7 (4) - - - - - - - Finding Peak power output increased by 26%, p 0.05; HR and submaximal oxygen uptake responded to training, p 0.05; 6MWT: I þ31 m, C þ27 m 6MWT: I -11 m, C þ9 m; proportion showing an improvement in walking capacity was greater in the control than in the intervention group preop (47 vs 22%; p ¼ 0.051) and postop (41 vs 11%; p ¼ 0.019); depression improved for I group preop; anxiety did not improve for either group preop but decreased postop Respiratory muscle endurance increased preop in I compared to C, p 0.01; no significant difference between I and C for timed up-and-go, chair rise, physical work capacity and QOL; no significant difference in postop complications Whole body mass and fat mass in I significantly decreased 6 mos postop; no significant difference in operating time, blood loss, postoperative complication, and hospital death rate 6MWT: I 369, C 223, p 0.05; maximal inspiratory pressure increased for 12 patients in I group (p ¼ 0.028) compared with baseline; preoperative period: 13/16 patients in I increased walking distance from baseline; C group 13/16 decreased walking distance over the same period, p ¼ 0.009 6MWT increased by 20 m in 53% of I compared to 15% of C group p ¼ 0.006; 84% of I recovered to at least baseline exercise capacity at 8 wks postop compared with 62% of C group, p ¼ 0.049; no significant difference in anxiety or depression between groups Ability to perform PADL improved by 1 day, p 0.05; no significant difference in incidence (p ¼ 0.47) or severity (p ¼ 0.64) of complications or 30-day readmission (p ¼ 0.49); mortality: I 6% C 7% Preop oxygen uptake at anaerobic threshold and peak exercise improved; overall SF-36 increased by 11, p ¼ 0.037 Significant difference between groups on SVC, IC, MIP, MEP, and 6MWT both pre and postop (p 0.001) Improvements in peak values of oxygen pulse (p ¼ 0.001), minute ventilation (p ¼ 0.002) and power output (p 0.001); median HDU stay 1 d p ¼ 0.938; fewer patients in intervention group needed inotropic support (2 vs 7 patients; p ¼ 0.078) Baseline to preop: 6MWT (p ¼ 0.953), psychological status (p ¼ 0.937), SF-36 did not improve; ET (p 0.001), physical activity (p 0.001) improved 6MWT: I þ21 m, C þ10m; 54% intervention increased walking distance by more than 20 m, as compared with 38% of control (p ¼ 0.261) VHR on 44 prehab and 34 standard counseling; more patients in prehab met preop weight loss goal (27% vs 18%); higher dropout and need for emergent repair in preop group; fewer wound complication in prehab patient (6.8% vs 17.6%, p ¼ 0.167) 6MWT improved more for I than C, (p ¼ 0.006) 4 weeks postop; grip strength was greater for I than C 26 weeks postop, p ¼ 0.022; I group had less anxietyc, p ¼ 0.025 *1. 6MWT, 6 minute walk test; CPET, cardiopulmonary exercise testing; ET, endurance time; HDU, high dependency unit; HR, heart rate; IC, inspiratory capacity; intraop, intraoperative; LOS, length of stay; m, meters; MEP, maximum expiratory pressure; MIP, maximum inspiratory pressure; PADL, personal activities of daily living; postop, postoperative; QOL, quality of life; SF-36, short form (36) health survey; SSI, surgical site infection; SVC, slow vital capacity; VHR, ventral hernia repair. Vol. 231, No. 4, October 2020 Lyons et al Prehabilitation Before Surgery 487
- 9. Studies should also focus on finding effective exercise reg- imens that are easy for patients to maintain and adhere to. Author Contributions Study conception and design: Lyons, Bernardi, Olavarria, Dhanani, Ko, Kao, Liang Acquisition of data: Lyons, Bernardi, Olavarria, Dhanani, Liang Analysis and interpretation of data: Lyons, Bernardi, Shah, Holihan, Ko, Kao, Liang Drafting of manuscript: Lyons, Bernardi, Olavarria, Dhanani, Shah, Holihan, Ko, Kao, Liang Critical revision: Lyons, Bernardi, Olavarria, Dhanani, Shah, Holihan, Ko, Kao, Liang REFERENCES 1. Nunoo-Mensah JW, Rosen M, Chan LS, et al. Prevalence of intra-abdominal surgery: what is an individual’s lifetime risk? South Med J 2009;102:25e29. 2. Longo WE, Virgo KS, Johnson FE, et al. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum 2000;43:83e91. 3. Mayo NE, Feldman L, Scott S, et al. 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