Reducing post-operative complications and length of hospital stay
A number of moderate quality randomised control trials providing data on post-operative complications were identified (1,3-4, 9, 11). There was one good quality meta-analysis that provided a quantitative synthesis on seven trials (2). It demonstrated a significant reduction in overall post-operative complications in the prehabilitation group compared with the control group (OR 0.52; 95% CI 0.30 to 0.88; p = 0.01; I2 = 15%). Further to this, the study went on to analyse overall pulmonary complications rates and demonstrated a significantly lower complication rates in the prehabilitation group (OR 0.37; 95% CI 0.20 to 0.67; p = 0.001; I2 = 0%). Length of stay was also analysed as part of a meta-analysis and did not show any significant difference between the two groups (MD − 0.58; 95% CI − 1.28 to 0.13; p = 0.11; I2 = 56%) (2).
Quality of Evidence
Grade A. High quality systematic review and meta-analysis of randomised controlled trials.
Strength of recommendation
Grade 1. Strong recommendation.
Pre-operative exercise, which may or may not include nutritional and psychological intervention, within the pre-operative period, improves overall post-operative complications, as well as pulmonary specific post-operative complications. The length of hospital stay after surgery was equivocal between patients who received pre-operative exercises and control groups
1. Dunne DF, Jack S, Jones RP, et al. Randomized clinical trial of prehabilitation before planned liver resection. The British journal of surgery 2016;103(5):504-12. doi: 10.1002/bjs.10096
2. Heger P, Probst P, Wiskemann J, et al. A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366). Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2020;24(6):1375-85. doi: 10.1007/s11605-019-04287-w
3. Yamana I, Takeno S, Hashimoto T, et al. Randomized Controlled Study to Evaluate the Efficacy of a Preoperative Respiratory Rehabilitation Program to Prevent Postoperative Pulmonary Complications after Esophagectomy. Digestive surgery 2015;32(5):331-7. doi: 10.1159/000434758 [published Online First: 2015/07/18]
4. Gillis C, Li C, Lee L, et al. Prehabilitation versus REHABILITATIONA randomized control trial in patients undergoing colorectal resection for cancer. The Journal of the American Society of Anesthesiologists 2014;121(5):937-47.
5. KIm DJ MN, Carli F, Montgomery DL, Zavorsky GS. Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery. Tohoku J Exp Med 2009;217(2):109-15.
6. Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018;44(7):919-26. doi: 10.1016/j.ejso.2018.04.016
7. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. International journal of surgery (London, England) 2017;39:156-62. doi: 10.1016/j.ijsu.2017.01.111
8. Chen BP, Awasthi R, Sweet SN, et al. Four-week prehabilitation program is sufficient to modify exercise behaviors and improve preoperative functional walking capacity in patients with colorectal cancer. Support Care Cancer 2017;25(1):33-40. doi: 10.1007/s00520-016-3379-8
9. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. The British journal of surgery 2010;97(8):1187-97. doi: 10.1002/bjs.7102
10. Bruns ER, van den Heuvel B, Buskens CJ, et al. The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2016;18(8):O267-77. doi: 10.1111/codi.13429
11. Bousquet-Dion G, Awasthi R, Loiselle SE, et al. Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial. Acta Oncol 2018;57(6):849-59. doi: 10.1080/0284186X.2017.1423180
Reduction in Post-Operative Complications and Hospital Length of Stay
Cardiopulmonary exercise testing is used to assist with risk-stratification for patients undergoing thoracic surgery (1).
Cohort studies have identified a reduction in morbidity (31.6% vs 83.3%) and mortality (4.3% vs 33.3%) in patients undergoing lung cancer resection in those deemed high or acceptable risk of perioperative complications based on cardiopulmonary exercise testing, with maximal oxygen uptake of <15ml/kg/minute the threshold for high risk (2). A systematic review by Crandall et al relating to exercise interventions for surgically managed non-small cell lung cancer patients identified a reduction in post-operative complications and hospital length of stay (3).
A review of 11 studies by Garcia et al concluded that there was a reduction in length of hospital stay and post-operative pulmonary complications in patients undergoing exercise training before lung resection (4).
A Cochrane review of eight randomised control trials identified a reduced incidence in post-operative atelectasis and pneumonia in patients undergoing physical therapy before cardiac surgery (inspiratory muscle training in 5 studies, and aerobic or breathing exercises in 3), along with a reduction in hospital length of stay, but no evidence to suggest an impact on all-cause mortality, pneumothorax or prolonged mechanical ventilation (5).
A similar review of by Gomes Neto et al identified a reduction in post-operative respiratory complications in patients receiving pre-operative inspiratory muscle training, and other studies have shown reduced post-operative pulmonary complications in patients undergoing pre-operative inspiratory muscle training (6) (7). A meta-analysis by Kendall et al, covering 12 RCTs, identified a reduction in post-operative pulmonary complications and hospital length of stay in patients undergoing inspiratory muscle training prior to and post- cardiac, thoracic and abdominal surgery (8).
Boujibar et al demonstrated a reduction in post-operative complication rate in patients undergoing lobectomy who had undergone pre-habilitation (exercise re-training, strengthening and smoking cessation) compared to a cohort who did not receive prehabilitation (9).
Quality of Evidence
Grade A – there does remain heterogeneity amongst studies undertaken relating to intervention type (e.g. aerobic training, inspiratory muscle training), length of pre-habilitation and cohort of patients.
Strength of Recommendation
1 – Strong recommendation
There is evidence of reduced hospital length of stay and pulmonary complications in patients who receive pre-operative respiratory and aerobic exercises. Exercises focused on inspiratory muscle training appear to be most efficacious.
1. Sanchez-Lorente D, Navarro-Ripoll R, Guzman R, Moises J, Gimeno E, Boada M, et al. Prehabilitation in thoracic surgery. J Thorac Dis [Internet]. 2018 Aug;10(Suppl 22):S2593–600. Available from: https://pubmed.ncbi.nlm.nih.gov/30345096
2. Stanzani F, Paisani D de M, Oliveira A de, Souza RC de, Perfeito JAJ, Faresin SM. Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients. J Bras Pneumol [Internet]. 2014;40(1):21–9. Available from: https://pubmed.ncbi.nlm.nih.gov/24626266
3. Crandall K, Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): A systematic review. Surg Oncol [Internet]. 2014;23(1):17–30. Available from: http://www.sciencedirect.com/science/article/pii/S0960740414000024
4. Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg [Internet]. 2016 Sep 1;23(3):486–97. Available from: https://doi.org/10.1093/icvts/ivw152
5. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012;
6. Gomes Neto M, Martinez BP, Reis HFC, Carvalho VO. Pre- and postoperative inspiratory muscle training in patients undergoing cardiac surgery: systematic review and meta-analysis. Clin Rehabil [Internet]. 2016 May 6;31(4):454–64. Available from: https://doi.org/10.1177/0269215516648754
7. Chen X, Hou L, Zhang Y, Liu X, Shao B, Yuan B, et al. The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial. Clin Rehabil [Internet]. 2019 Feb 6;33(5):913–22. Available from: https://doi.org/10.1177/0269215519828212
8. Kendall F, Oliveira J, Peleteiro B, Pinho P, Bastos PT. Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: a systematic review and meta-analysis. Disabil Rehabil [Internet]. 2018 Apr 10;40(8):864–82. Available from: https://doi.org/10.1080/09638288.2016.1277396
9. Boujibar F, Bonnevie T, Debeaumont D, Bubenheim M, Cuvellier A, Peillon C, et al. Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study. J Thorac Dis [Internet]. 2018 Apr;10(4):2240–8. Available from: https://pubmed.ncbi.nlm.nih.gov/29850128
10. Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvão DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane database Syst Rev [Internet]. 2019 Feb 11;2(2):CD012685–CD012685. Available from: https://pubmed.ncbi.nlm.nih.gov/30741408
11. Rosero ID, Ramírez-Vélez R, Lucia A, Martínez-Velilla N, Santos-Lozano A, Valenzuela PL, et al. Systematic Review and Meta-Analysis of Randomized, Controlled Trials on Preoperative Physical Exercise Interventions in Patients with Non-Small-Cell Lung Cancer. Cancers (Basel) [Internet]. 2019 Jul 5;11(7):944. Available from: https://pubmed.ncbi.nlm.nih.gov/31284372
12. Jones LW, Peddle CJ, Eves ND, Haykowsky MJ, Courneya KS, Mackey JR, et al. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer [Internet]. 2007 Aug 1;110(3):590–8. Available from: https://doi.org/10.1002/cncr.22830
13. Licker M, Karenovics W, Diaper J, Frésard I, Triponez F, Ellenberger C, et al. Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial. J Thorac Oncol [Internet]. 2017 Feb 1;12(2):323–33. Available from: https://doi.org/10.1016/j.jtho.2016.09.125
Improved Post-Operative Outcomes and Hospital Length of Stay
There is evidence available highlighting the importance of cardiorespiratory fitness in relation to post-operative and quality of life outcomes [1-3] [5-7].
A study by Prentis et al, indicated that Cardiopulmonary Exercise Testing (CPET) results were a good predictor for morbidity and length of hospital stay following Abdominal Aortic Aneurysm (AAA) Repair (Endovascular Aneurysm repair- EVAR, and Open surgery) . This study took place over a 3-year period and involved a cohort of 185 AAA repairs patients. 84 underwent open surgery and 101 EVAR. Outcomes measured included postoperative morbidity and Length of hospital stay.
Unfit, open surgery patients were shown to have worse post-operative outcomes. These patients spent longer in critical care and in hospital in general compared to open surgery patients who were more fit. Unfit individuals spent an average of 6.4 days in critical care compared to 2.4 days in the more fit group (P value= 0.002) . Moreover, unfit open surgery patients spent longer in hospital (mean stay 23.1 days) when compared to fit open surgery patients (mean stay 11 days) (P value= <0.0001). This therefore emphasises the importance of optimising fitness before open AAA surgery.
A systematic review by Pouwels et al also suggests there is some benefit to patients if cardiorespiratory fitness (CRF) is optimised before surgery . Barakat et al, conducted one of the studies mentioned in this review which involved AAA repair patients . The patients took part in pre-operative exercise therapy (PET) organised 3 times per week for 6 six weeks. Results showed peak VO2 increased from 18.2mL O2/kg/min to 19.9mL O2/kg/min. As well as demonstrating improvement to CRF, these results also give some indication to the frequency of sessions future PET programmes should incorporate in order to improve CRF.
A systematic review by O’Doherty et al also highlights the benefits to health-related quality of life (HRQL) . For example, Carli & colleagues’ results showed improved Hospital Anxiety and Depression Scale (HADS) scores in those who underwent pre-operative exercise programmes . This suggests that there may be psychological benefits to be gained from such intervention. Furthermore, Arthur & colleagues were able to demonstrate an improved Medical Outcome Study 36-item Short Form Survey (SF-36) score in those that did pre-operative exercise compared to the control group (P value= 0.04) . An improved score in this survey demonstrated by the intervention group once again portrays the potential HRQL benefits in patients who participate in pre-operative exercise programmes.
Quality: B- these studies are consistent with the premise that exercise before surgery improves fitness and mental health outcomes in certain surgical patients. However, there is inconsistency regarding the degree in which post-operative outcomes are improved by such exercise programmes.
Strength: 2- due to the specific type of surgical patients analysed in this summary, one cannot extrapolate the data to cover all surgical patients.
Conclusion: Pre-operative exercise has the ability to improve CRF. This has been shown to derive better post-operative outcomes within certain groups of surgical patients based on length of hospital stay and time in critical care. Some indication has also been given into the exercise programme specifications regarding frequency of sessions. Creating a clear and robust programme will aid health professionals in clinical settings when prescribing pre-operative exercise to surgical patients. However, for this to be achievable, more insight is needed into the other FITT-VP (Frequency, Intensity, Time, Type, Volume, and Progression) principles. Finally, the ability to enhance the mental health of surgical patients is another reason why health professionals should recommend pre-operative exercise programmes.
- Prentis JM, Trenell MI, Jones DJ, Lees T, Clarke M, Snowden CP. Submaximal exercise testing predicts perioperative hospitalization after aortic aneurysm repair. Journal of vascular surgery. 2012 Dec 1;56(6):1564-70.
- Pouwels S, Willigendael EM, Van Sambeek MR, Nienhuijs SW, Cuypers PW, Teijink JA. Beneficial effects of pre-operative exercise therapy in patients with an abdominal aortic aneurysm: a systematic review. European Journal of Vascular and Endovascular Surgery. 2015 Jan 1;49(1):66-76.
- Barakat HM, Shahin Y, Barnes R, Gohil R, Souroullas P, Khan J, McCollum PT, Chetter IC. Supervised exercise program improves aerobic fitness in patients awaiting abdominal aortic aneurysm repair. Annals of Vascular Surgery. 2014 Jan 1;28(1):74-9.
- American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins; 2013 Mar 4.
- 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 May 1;110(5):679-89.
- Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. Randomized clinical trial of prehabilitation in colorectal surgery. British Journal of Surgery. 2010 Aug;97(8):1187-97.
- Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery: a randomized, controlled trial. Annals of internal medicine. 2000 Aug 15;133(4):253-62.