Presurgery planning may boost postop outcomes

At Internal Medicine Meeting 2024's Perioperative Medicine precourse, Margaret M. Beliveau, MD, FACP, asked attendees for the definition of surgical success.

"Is it actually to make it through the surgery or the anesthesia and come out the other end into the [postanesthesia care unit]? Is that sort of success? Or is it more about returning to your previous level of activity and function?" said Dr. Beliveau, who is the associate program director for the Southwest Indiana Internal Medicine Residency Program at Indiana University in Evansville.

Patients are more interested in the latter, Dr. Beliveau said. "It's not just like, 'Did I get through the surgery?', it's 'Have I returned to at least my baseline physical functioning and my baseline psychological functioning?'" she said. "If you look at patients, particularly those who started out with a little bit of disability, after major elective abdominal surgery, 50% … still have some degree of disability that they didn't have before the surgery. So this is an important issue, and it's certainly important to our patients."

Deconditioning after surgery can happen very quickly, within 24 to 48 hours, Dr. Beliveau reminded her audience. "It doesn't take six weeks. It's a short process," she said. This is where prehabilitation comes in, by targeting modifiable factors to help patients optimize fitness before surgery and improve their recovery afterward.

"The more fit you are, the less likely you are [to have complications]. That's why younger patients do so well," Dr. Beliveau said. In addition, patients who are in better physical shape also have shorter hospital stays postsurgery, she noted.

Dr. Beliveau reviewed the components of prehabilitation, which include exercise and respiratory training, nutrition support, psychological support, and smoking and alcohol cessation. Physical activity doesn't necessarily need to be supervised, and some patients' insurance won't cover that anyway, Dr. Beliveau said. "But check-ins or logging can be helpful, encouraging the patient to continue to try to improve their fitness."

In addition, Dr. Beliveau stressed that promoting physical activity before surgery should go beyond simply referring patients to physical therapy. "The evidence actually supports inspiratory muscle training, aerobic training, and resistance training in these patients," she said. "And when we do this, the reason why it helps so much in postoperative pulmonary complications is it improves our inspiratory muscle strength, it improves our aerobic function."

Respiratory training can include incentive spirometry practice, she noted. "Particularly if we're operating in the upper abdomen or in the chest, [patients] need to know how to use the incentive spirometer," she said. "They should be doing it and practicing it before surgery so it is not a mystery to them as they're post-op and they're getting narcotics." Endurance-based inspiratory muscle training improves prolonged inspiration at 30% maximal inspiratory pressure, while high-intensity inspiratory muscle training boosts peak respiration, "another very useful technique," Dr. Beliveau noted.

Nutrition support, meanwhile, can involve advice on how to improve diet, as well as protein supplementation, particularly after high-intensity training and before sleep. In addition, multivitamins, and vitamin D in particular, can be helpful, Dr. Beliveau said.

Physicians can screen patients before surgery to identify frailty, malnutrition, micronutrient deficiencies, and anemia, Dr. Beliveau noted. "About 50% of our elderly surgical patients are malnourished to some degree," she said. Low serum albumin levels can be a marker of compromised nutritional status, while patients who have had bariatric surgery, especially Roux-en-Y gastric bypass, are at higher risk for micronutrient deficiency, she said.

Once physicians know what patients are dealing with, they can intervene by providing individualized dietary counseling. Evidence support for oral nutrition supplements "is not great and rigorous data, but it makes sense that trying to supplement the nutrition early should work," Dr. Beliveau said.

Supplements should be given for seven days at a minimum, she advised. She noted that many enhanced recovery after surgery (ERAS) protocols recommend high-protein drinks and high-carbohydrate drinks for at least seven days before surgery in patients with diabetes as well as those without. "I often see the patients after they've seen the surgeon and they've got their little bag of protein drinks with them that they can take home," she said. Carbohydrate loading can also be useful, but there are less robust data showing that immunonutrition products are being used in ERAS protocols, Dr. Beliveau noted.

To provide good psychological support, make sure patients are well educated and understand what is going to happen to them during preop, in the operating room, and during postop. "We forget about that," Dr. Beliveau said. "I see a lot of patients that are asking me questions that I can't answer because I think the surgeon needs to answer them, or they might ask about what's the type of anesthesia. … They need to be educated about what's going to happen to empower them."

Breathing and relaxation techniques can also help patients' state of mind, she noted. "And of course, patients should participate in shared decision making. It really enhances their confidence in the whole process," Dr. Beliveau said.

Finally, regarding alcohol and smoking cessation, "I don't think I need to say anything more," she said. "We know that stopping smoking and stopping alcohol improves outcomes in our surgical patients."

Dr. Beliveau next reviewed which patients are more likely to benefit from prehabilitation. In 2019, the ERAS Society published guidelines for perioperative care in cardiac surgery in JAMA Surgery that included a class IIa recommendation for prehabilitation. "Obviously, this is for elective cardiac surgery, not emergency cardiac surgery," she said.

Frail patients and those undergoing vascular surgery, major abdominal surgery, thoracic surgery, and cancer surgery, especially those who have received neoadjuvant chemotherapy, are also good candidates for prehabilitation, Dr. Beliveau noted.

Regarding harms, "essentially, so far, in a lot of these programs, we don't really see a lot of medical complications," Dr. Beliveau said. It's possible that prehabilitation can delay surgery, particularly if a patient is especially frail or malnourished, but prehabilitation for one or two weeks is associated with improved outcomes in most cases, she noted. "If we do longer-term studies, patients don't adhere to it, patients sometimes get a little more anxious and stressed," she said.

Limitations involved with prehabilitation include the potential for differences between exercise-only and multimodal programs. In addition, "we don't have any good data yet in orthopedic surgery, which is probably the most common surgery that we do in most of our hospitals, and there hasn't been a lot of data in urology surgery," Dr. Beliveau said.

The main limitation, though, is that prehabilitation involves a large set of complicated interventions. "You have to have a big program going, and the reimbursement structure, unfortunately, is challenging for this," Dr. Beliveau noted. "The studies are typically small and the outcomes are not consistent, so we don't really know how much of an impact this is going to have. We don't know whether it improves mortality."

Even given that caveat, Dr. Beliveau made the case that prehabilitation in surgical patients is worth doing. "It seems to make sense that if we can improve outcomes that are important to their lives, like their level of physical functioning, we may be able to really improve overall function and outcomes," she said.