By Bernhard Riedel, FANZCA, MBA, PhD,
Anaesthetists are increasingly embracing the field of perioperative medicine. As such, the preoperative workup of patients prior to major surgery is expanding beyond risk stratification and optimization (e.g. lowering cardiac risk) to now include active ‘prehabilitation’ of patients—getting them ‘strong for surgery’. This is especially important given that impaired preoperative functional capacity associates with increasing postoperative morbidity and mortality. Prehabilitation commonly includes exercise therapy in patients that are deconditioned but importantly also includes components such as haematinic optimization, nutritional optimization and psychological therapy.
To improve functional capacity surgery may however have to be delayed for up to 4 weeks. The question then begs: Do all deconditioned patients respond to exercise therapy and warrant such postponement of surgery?
In a retrospective review of twenty-six patients who underwent active prehabilitation with an exercise program prior to major cancer surgery it was found that only 50% of patients responded to their exercise therapy; however, the response seen, when assessed objectively with cardiopulmonary exercise testing (CPET), was significant. Responders had a median increase in anaerobic threshold and peak VO2 of >20%, with an absolute increase in peak VO2 of 3.8 mL.kg−1.min−1 (IQR 2.0 – 5.7; p<0.001).
Responders were more likely those with a lower baseline AT (9.1 mL.kg−1.min−1; p=0.002) and, importantly, associated with a tendency for fewer major postoperative complications. Such, objective identification of responders (cf. non responders) would allow targeted exercise therapy to ensure benefit from postponement of surgery. Further research, however, is required to understand why non-responders failed to respond e.g. require more structured supervision in hospital- or community-based settings rather than home-based exercise programs. Furthermore, a prospective RCT should also explore outcome benefits, including health economic analysis, of prehabilitation.