Over 4 in 10 adults over the age of 60 will undergo abdominal surgery at some point in their life, 30% of which will experience post operative complications. Prehabilitation aims to reduce recovery time and can also improve eligibility for patients who would otherwise not qualify for surgery. This systematic review investigated the effect of prehabilitation on patients with sarcopenia or frailty undergoing elective upper abdominal surgery on post operative outcomes compared to those not undergoing prehabilitation.
Four databases (MEDLINE, Embase, CINAHL and Cochrane CENTRAL) were searched for randomised controlled trials from the year 2000 onwards with no language restriction. Eligible studies included adults with sarcopenia or frailty undergoing upper abdominal surgery; primary outcomes were postoperative pulmonary complications (PPCs) and all cause complications (measured by using log-odds ratios), secondary outcomes were functional capacity, length of hospital stay (LOS), intensive care unit (ICU) stay (measured by mean differences). Prehabilitation interventions were physical therapy, nutritional therapy, psychosocial, anaemia-related, respiratory therapy compared to no prehabilitation. Two raters independently extracted data and disagreements were resolved by consensus. The review was processed in accordance with PRISMA and AMSTAR-2 guidelines and the risk of bias of RCTs was assessed using the Joanna Briggs Institute (JBI) 13-point critical appraisal checklist. Meta-analysis was performed using random effect model, heterogeneity was performed using I2 and sensitivity analysis was also performed. Heterogeneity was evaluated using a random effects model I-square, and sensitivity analysis and meta-analysis were performed.
The review included 10 trials (1,503 participants). Studies were conducted in Spain (n=2), United Kingdom (n=2), Canada (n=2), Netherlands (n=1), Brazil (n=1), Australia and New Zealand (n=1) and Australia (n=1). Prehabilitation ranged between 8 days to 6 weeks, and modes of prehabilitation included exercise training only (n=4), combined exercise and inspiratory muscle training (n=3), combined exercise training and nutrition support (n=2) and anaemia treatment only (n=1). Study quality ranged between 8 and 13 on the JBI critical appraisal checklist.
Compared to no prehabilitation, prehabilitation reduced the odds of developing PPCs (OR -0.96, 95% CI -1.38 to -0.54, I2 = 0%)(5 trials, 674 participants) and reduced all cause complications (OR -0.21, 95% CI -0.475 to 0.055, I2 = 41.06%)(9 trials, 1336 participants). Prehabilitation overall did not reduce hospital LOS (SMD -0.48, 95% CI -1.34 to 0.38, I2 = 39.6%) (10 trials, 1503 participants) unless prehabilitation included exercise training, resulting in a small reduction in hospital LOS (SMD -0.91, 95% CI -1.67 to -0.14, I2 = 15.5%) (10 trials, 906 participants). Prehabilitation did not reduce ICU LOS (SMD -0.02, 95% CI -0.36 to 0.33, I2 = 31.68%)(5 trials, 1098 participants).
There are lower odds of developing PPC and all-cause complications when patients with sarcopenia or frailty undergo prehabilitation before upper abdominal surgery compared to no prehabilitation. There is a small reduction in hospital LOS (0.91 days) when prehabilitation includes exercise compared to no exercise intervention.
Amirkhosravi, F., Allenson, K.C., Moore, L.W. et al. Multimodal prehabilitation and postoperative outcomes in upper abdominal surgery: systematic review and meta-analysis. Sci Rep 14, 16012 (2024). https://doi.org/10.1038/s41598-024-66633-6
