“Everyone is pre-op in this room. You just don’t know when your procedure is,” said Thomas K. Varghese Jr., MD, MS, MBA, FACS, in Monday’s presentation on prehabilitation.
Attendees cracked smiles all over the room, but the kernel of most jokes is truth. The elderly are becoming a greater percentage of the population, and one consequence is an increase in the need for surgical care among patients with greater comorbidities, complexity, and frailty. In this environment, prehabilitation—a combination of physical therapy, psychosocial care, and lifestyle modifications meant to maximize surgical outcomes and recovery—is of growing importance.
Dr. Varghese, from The University of Utah in Salt Lake City, was one of four presenters at a Panel Session on the topic. He discussed the ACS Strong for Surgery program, then posed these questions: “Why are we waiting for patients to engage with us in the hospital? What if we shift the spotlight to engage with them when they show up in the clinic?”
He shared details from his own randomized clinical trial, which integrated physical therapy-centered prehab into a preoperative clinic for people undergoing lung cancer resection. The program found a baseline of low mobility in 49% of participants. After prehab personalized to each person’s changing level of function, researchers found fatigue scores had rebounded to baseline by 2 months post-surgery among patients in the active arm. Dr. Varghese said the research is ongoing, with a focus on a return to intended oncologic treatment.
Presenter Susan L. Gearhart, MD, FACS, a colorectal surgeon at Johns Hopkins University in Baltimore, Maryland, noted that prehab, while beneficial for patient engagement and preservation of overall functioning, is hard to standardize. Presenting findings from several studies, she described how limited standardization and patient adherence have somewhat hamstrung efforts to show prehab’s benefits. Nonetheless, she said existing studies have suggested prehabilitation need not be pre: use of prehab during chemotherapy, rather than before it, appears to help ensure patients avoid declines in overall functioning.
Benjamin D. Ferguson, MD, PhD, FACS, a hepato-pancreato-biliary surgeon at University of Michigan Health in Ann Arbor, echoed this point. He said that the advent of neoadjuvant chemotherapy for cancer has created a multi-month delay before surgery, creating an opening for the use of prehab.
However, Dr. Ferguson also pointed out imperfections in instruments used to determine frailty, including excessive complexity, subjectivity, and imprecision. He proposed alternatives, such as grip strength, sarcopenia, and nutrition, as proxies for frailty. He also emphasized that all prehab programs should be accessible, convenient, and focused on relevant health outcomes.
Liane S. Feldman, MD, FACS, who is chair of surgery at McGill University, in Montreal, Quebec, Canada, partly answered those concerns as she highlighted her own hospital’s program. It establishes patient status with a metric acronymized “FAME”: Function (baseline fitness), Aliments (nutrition), Mental Health (presence of anxiety and depression), and Evaluation (medical and surgical findings). Dr. Feldman said of her own department’s prehab, “Patients love it. It is the best thing we do in our hospital for our surgical patients.”
