Vol 29, No 5 (2024)
Review paper
Published online: 2024-11-05

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Prehabilitation approaches for gastrointestinal cancer surgery: a narrative review

Sergii Girnyi1, Luigi Marano21, Jaroslaw Skokowski21, Piotr Mocarski1, Witold Kycler3, Gaetano Gallo4, Agnieszka Dyzmann-Sroka5, Karolina Kazmierczak-Siedlecka6, Leszek Kalinowski67, Tomasz Banasiewicz8, Karol Polom23
DOI: 10.5603/rpor.103136
Rep Pract Oncol Radiother 2024;29(5):614-626.

Abstract

Gastrointestinal (GI) cancer patients undergoing surgery are particularly vulnerable to malnutrition, which can significantly impact surgical outcomes. Prehabilitation interventions encompassing nutritional, physical, and psychosocial support have gained attention for their potential to mitigate these risks. However, the efficacy of multidisciplinary prehabilitation programs in this context remains underexplored. This narrative review synthesizes existing literature to evaluate the effectiveness of prehabilitation interventions in improving outcomes for GI cancer patients undergoing surgery. Drawing on a comprehensive analysis of available evidence, the review examines the integration of nutritional, physical, and psychosocial interventions and explores the implications for clinical practice and future research. The review highlights the importance of standardized protocols and interdisciplinary collaboration in optimizing prehabilitation programs for GI cancer patients. It identifies gaps in current research, particularly regarding the synergistic effects of integrating various intervention modalities and the role of innovative strategies such as immunonutrition. Moreover, the review underscores the need for larger studies to assess the effectiveness of multimodal prehabilitation approaches and establish standardized outcome measures.

In conclusion, despite advancements in understanding the importance of prehabilitation, significant gaps persist in the literature, warranting further research to refine prehabilitation protocols and improve perioperative outcomes for GI cancer patients. By addressing these research gaps and fostering interdisciplinary partnerships, future studies have the potential to enhance the effectiveness of prehabilitation interventions and optimize perioperative care in this population.

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References

  1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024; 74(3): 229–263.
  2. Arnold M, Abnet CC, Neale RE, et al. Global Burden of 5 Major Types of Gastrointestinal Cancer. Gastroenterology. 2020; 159(1): 335–349.e15.
  3. Cavaliere D, Parini D, Marano L, et al. SICO (Italian Society of Surgical Oncology). Surgical management of oncologic patient during and after the COVID-19 outbreak: practical recommendations from the Italian society of Surgical Oncology. Updates Surg. 2021; 73(1): 321–329.
  4. Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg. 2015; 2: 43.
  5. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997; 78(5): 606–617.
  6. Boccardi V, Marano L. The Geriatric Surgery: The Importance of Frailty Identification Beyond Chronological Age. Geriatrics (Basel). 2020; 5(1).
  7. Marano L, Carbone L, Poto GE, et al. Handgrip strength predicts length of hospital stay in an abdominal surgical setting: the role of frailty beyond age. Aging Clin Exp Res. 2022; 34(4): 811–817.
  8. Stiger RJ, Williams MA, Gustafson OD, et al. The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review. Disabil Rehabil. 2024 [Epub ahead of print]: 1–24.
  9. Erkul O, Cekic AB, Cansu A, et al. Effects of Sarcopenia on Postoperative Outcomes in Patients Who Underwent Gastrectomy for Gastric Cancer. J Surg Res. 2022; 274: 196–206.
  10. Jakobson T, Karjagin J, Vipp L, et al. Postoperative complications and mortality after major gastrointestinal surgery. Medicina (Kaunas). 2014; 50(2): 111–117.
  11. Downey CL, Bainbridge J, Jayne DG, et al. Impact of in-hospital postoperative complications on quality of life up to 12 months after major abdominal surgery. Br J Surg. 2023; 110(9): 1206–1212.
  12. Gemici K, Okuş A, Yıldız M, et al. A surgeon's nightmare: Complications. Ulus Cerrahi Derg. 2015; 31(2): 90–91.
  13. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016; 374(16): 1543–1551.
  14. Crevenna R, Palma S, Licht T. Cancer prehabilitation — a short review. Mag Eur Med Oncol. 2021; 14(1): 39–43.
  15. Yaceczko S, Baltz J. Evaluation of nutrition components within prehabilitation programs in gastrointestinal cancers: Is prehab worth the hype? Nutr Clin Pract. 2024; 39(1): 117–128.
  16. Piotrowski T, Ryczkowski A, Kalendralis P, et al. Forecasting model for qualitative prediction of the results of patient-specific quality assurance based on planning and complexity metrics and their interrelations. Pilot study. Rep Pract Oncol Radiother. 2024; 29(3): 318–328.
  17. Siriwardena AK. Centralisation of upper gastrointestinal cancer surgery. Ann R Coll Surg Engl. 2007; 89(4): 335–336.
  18. Perry R, Herbert G, Atkinson C, et al. Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open. 2021; 11(9): e050806.
  19. Bausys A, Mazeikaite M, Bickaite K, et al. The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review. Cancers (Basel). 2022; 14(9).
  20. O'Callaghan N, Douglas P, Keaver L. The persistence of nutrition impact symptoms in cancer survivors’ post-treatment. Proc Nutr Soc. 2022; 81(OCE4).
  21. Kichena S, Kamani A, Fricke B. Potential of prehabilitation in hepatocellular carcinoma: a narrative review of available evidence. Ann Palliat Med. 2024; 13(1): 101–111.
  22. Li C, Carli F, Lee L, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013; 27(4): 1072–1082.
  23. Moug SJ, Mutrie N, Barry SJE, et al. Prehabilitation is feasible in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy and may minimize physical deterioration: results from the REx trial. Colorectal Dis. 2019; 21(5): 548–562.
  24. Alejo LB, Pagola-Aldazabal I, Fiuza-Luces C, et al. Exercise prehabilitation program for patients under neoadjuvant treatment for rectal cancer: A pilot study. J Cancer Res Ther. 2019; 15(1): 20–25.
  25. Heldens AF, Bongers BC, de Vos-Geelen J, et al. Feasibility and preliminary effectiveness of a physical exercise training program during neoadjuvant chemoradiotherapy in individual patients with rectal cancer prior to major elective surgery. Eur J Surg Oncol. 2016; 42(9): 1322–1330.
  26. Loughney L, West MA, Dimitrov BD, et al. Physical activity levels in locally advanced rectal cancer patients following neoadjuvant chemoradiotherapy and an exercise training programme before surgery: a pilot study. Perioper Med (Lond). 2017; 6: 3.
  27. Durrand J, Singh SJ, Danjoux G. Prehabilitation. Clin Med (Lond). 2019; 19(6): 458–464.
  28. West MA, Lythgoe D, Barben CP, et al. Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth. 2014; 112(4): 665–671.
  29. Steffens D, Ismail H, Denehy L, et al. Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses. Ann Surg Oncol. 2021; 28(12): 7120–7146.
  30. Kasivisvanathan R, Abbassi-Ghadi N, McLeod ADM, et al. Cardiopulmonary exercise testing for predicting postoperative morbidity in patients undergoing hepatic resection surgery. HPB (Oxford). 2015; 17(7): 637–643.
  31. Stuart SR, Poço JG, Rodrigues MV, et al. Can we predict who will benefit from the deep inspiration breath hold (DIBH) technique for breast cancer irradiation? Rep Pract Oncol Radiother. 2023; 28(5): 582–591.
  32. Dunne DFJ, Jack S, Jones RP, et al. Randomized clinical trial of prehabilitation before planned liver resection. Br J Surg. 2016; 103(5): 504–512.
  33. Wang B, Shelat VG, Chow JJ, et al. Prehabilitation Program Improves Outcomes of Patients Undergoing Elective Liver Resection. J Surg Res. 2020; 251: 119–125.
  34. Patel AV, Friedenreich CM, Moore SC, et al. American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control. Med Sci Sports Exerc. 2019; 51(11): 2391–2402.
  35. Fan ST, Lau WY, Wong KK, et al. Pre-operative parenteral nutrition in patients with oesophageal cancer: a prospective, randomised clinical trial. Clin Nutr. 1989; 8(1): 23–27.
  36. Wijeysundera DN, Pearse RM, Shulman MA, et al. METS study investigators. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018; 391(10140): 2631–2640.
  37. van Kooten RT, Bahadoer RR, Peeters KC, et al. Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review. Eur J Surg Oncol. 2021; 47(12): 3049–3058.
  38. Bates A, West MA, Jack S, et al. Preparing for and Not Waiting for Surgery. Curr Oncol. 2024; 31(2): 629–648.
  39. Roland M, Guthrie B. Quality and Outcomes Framework: what have we learnt? BMJ. 2016; 354: i4060.
  40. Kyte D, Cockwell P, Lencioni M, et al. Reflections on the national patient-reported outcome measures (PROMs) programme: Where do we go from here? J R Soc Med. 2016; 109(12): 441–445.
  41. Levett DZH, Grimmett C. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions. Anaesthesia. 2019; 74 Suppl 1: 36–42.
  42. Argillander TE, Heil TC, Melis RJF, et al. Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery: A systematic review. Eur J Surg Oncol. 2022; 48(3): 570–581.
  43. Karlsson E, Egenvall M, Farahnak P, et al. Better preoperative physical performance reduces the odds of complication severity and discharge to care facility after abdominal cancer resection in people over the age of 70 - A prospective cohort study. Eur J Surg Oncol. 2018; 44(11): 1760–1767.
  44. Rodseth RN, Biccard BM, Le Manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014; 63(2): 170–180.
  45. Williams DGA, Molinger J, Wischmeyer PE. The malnourished surgery patient: a silent epidemic in perioperative outcomes? Curr Opin Anaesthesiol. 2019; 32(3): 405–411.
  46. Peixoto da Silva S, Santos JMO, Costa E Silva MP, et al. Cancer cachexia and its pathophysiology: links with sarcopenia, anorexia and asthenia. J Cachexia Sarcopenia Muscle. 2020; 11(3): 619–635.
  47. Boccardi V, Marano L. Improving geriatric outcomes through nutritional and immunonutritional strategies: Focus on surgical setting by a comprehensive evidence review. Ageing Res Rev. 2024; 96: 102272.
  48. Norman K, Haß U, Pirlich M. Malnutrition in Older Adults-Recent Advances and Remaining Challenges. Nutrients. 2021; 13(8).
  49. Jain R, Dotan E. Nutrition and Aging: a Practicing Oncologist's Perspective. Curr Oncol Rep. 2017; 19(11): 71.
  50. Figura N, Marano L, Moretti E, et al. Helicobacter pylori infection and gastric carcinoma: Not all the strains and patients are alike. World J Gastrointest Oncol. 2016; 8(1): 40–54.
  51. Marano L, Marmorino F, Desideri I, et al. NutriOnc Research Group. Clinical nutrition in surgical oncology: Young AIOM-AIRO-SICO multidisciplinary national survey on behalf of NutriOnc research group. Front Nutr. 2023; 10: 1045022.
  52. Muscaritoli M, Arends J, Bachmann P, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017; 36(1): 11–48.
  53. Thompson KL, Elliott L, Fuchs-Tarlovsky V, et al. Oncology Evidence-Based Nutrition Practice Guideline for Adults. J Acad Nutr Diet. 2017; 117(2): 297–310.e47.
  54. Evans DC, Corkins MR, Malone A, et al. ASPEN Malnutrition Committee. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021; 36(1): 22–28.
  55. Gillis C, Davies SJ, Carli F, et al. Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review. Front Nutr. 2021; 8: 644723.
  56. Deftereos I, Hitch D, Butzkueven S, et al. Implementation of a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: A multisite pilot study. J Hum Nutr Diet. 2023; 36(2): 479–492.
  57. Kasvis P, Vigano A, Bui T, et al. Impact of Dietary Counseling on Health-Related Quality of Life in Patients with Cancer Awaiting Hepato-Pancreato-Biliary Surgery. Nutr Cancer. 2023; 75(4): 1151–1164.
  58. Le Cornu KA, McKiernan FJ, Kapadia SA, et al. A prospective randomized study of preoperative nutritional supplementation in patients awaiting elective orthotopic liver transplantation. Transplantation. 2000; 69(7): 1364–1369.
  59. De Felice F, Cattaneo CG, Poto GE, et al. Mapping the landscape of immunonutrition and cancer research: a comprehensive bibliometric analysis on behalf of NutriOnc Research Group. Int J Surg. 2024; 110(1): 395–405.
  60. Marano L, Porfidia R, Pezzella M, et al. Clinical and immunological impact of early postoperative enteral immunonutrition after total gastrectomy in gastric cancer patients: a prospective randomized study. Ann Surg Oncol. 2013; 20(12): 3912–3918.
  61. Braga M, Gianotti L, Vignali A, et al. Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet. Crit Care Med. 1998; 26(1): 24–30.
  62. Heslin MJ, Latkany L, Leung D, et al. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg. 1997; 226(4): 567–77; discussion 577.
  63. Senkal M, Zumtobel V, Bauer KH, et al. Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study. Arch Surg. 1999; 134(12): 1309–1316.
  64. Senkal M, Mumme A, Eickhoff U, et al. Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients. Crit Care Med. 1997; 25(9): 1489–1496.
  65. Braga M, Gianotti L, Radaelli G, et al. Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Arch Surg. 1999; 134(4): 428–433.
  66. Gennari R, Alexander JW. Arginine, glutamine, and dehydroepiandrosterone reverse the immunosuppressive effect of prednisone during gut-derived sepsis. Crit Care Med. 1997; 25(7): 1207–1214.
  67. Ashida R, Okamura Y, Wakabayashi-Nakao K, et al. The Impact of Preoperative Enteral Nutrition Enriched with Eicosapentaenoic Acid on Postoperative Hypercytokinemia after Pancreatoduodenectomy: The Results of a Double-Blinded Randomized Controlled Trial. Dig Surg. 2019; 36(4): 348–356.
  68. Uno H, Furukawa K, Suzuki D, et al. Immunonutrition suppresses acute inflammatory responses through modulation of resolvin E1 in patients undergoing major hepatobiliary resection. Surgery. 2016; 160(1): 228–236.
  69. Okamoto Y, Okano K, Izuishi K, et al. Attenuation of the systemic inflammatory response and infectious complications after gastrectomy with preoperative oral arginine and omega-3 fatty acids supplemented immunonutrition. World J Surg. 2009; 33(9): 1815–1821.
  70. Aida T, Furukawa K, Suzuki D, et al. Preoperative immunonutrition decreases postoperative complications by modulating prostaglandin E2 production and T-cell differentiation in patients undergoing pancreatoduodenectomy. Surgery. 2014; 155(1): 124–133.
  71. Russell K, Zhang HG, Gillanders LK, et al. Preoperative immunonutrition in patients undergoing liver resection: A prospective randomized trial. World J Hepatol. 2019; 11(3): 305–317.
  72. Gillis C, Buhler K, Bresee L, et al. Effects of Nutritional Prehabilitation, With and Without Exercise, on Outcomes of Patients Who Undergo Colorectal Surgery: A Systematic Review and Meta-analysis. Gastroenterology. 2018; 155(2): 391–410.e4.
  73. Kenny E, Samavat H, Touger-Decker R, et al. Adverse perioperative outcomes among patients undergoing gastrointestinal cancer surgery: Quantifying attributable risk from malnutrition. JPEN J Parenter Enteral Nutr. 2022; 46(3): 517–525.
  74. Mehnert A, Hartung TJ, Friedrich M, et al. Death-Related Anxiety in Patients With Advanced Cancer: Validation of the German Version of the Death and Dying Distress Scale. J Pain Symptom Manage. 2016; 52(4): 582–587.
  75. Roche KN, Cooper D, Armstrong TS, et al. The link between psychological distress and survival in solid tumor patients: A systematic review. Cancer Med. 2023; 12(3): 3343–3364.
  76. Foster C, Haviland J, Winter J, et al. Members of the Study Advisory Committee. Pre-Surgery Depression and Confidence to Manage Problems Predict Recovery Trajectories of Health and Wellbeing in the First Two Years following Colorectal Cancer: Results from the CREW Cohort Study. PLoS One. 2016; 11(5): e0155434.
  77. Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical outcomes: an evidence-based literature review. J Am Acad Orthop Surg. 2006; 14(7): 397–405.
  78. Kiecolt-Glaser JK, Robles TF, Heffner KL, et al. Psycho-oncology and cancer: psychoneuroimmunology and cancer. Ann Oncol. 2002; 13 Suppl 4: 165–169.
  79. Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biol Psychiatry. 2003; 54(3): 269–282.
  80. Grant BF, Hasin DS, Chou SP, et al. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry. 2004; 61(11): 1107–1115.
  81. Burrows T, Kay-Lambkin F, Pursey K, et al. Food addiction and associations with mental health symptoms: a systematic review with meta-analysis. J Hum Nutr Diet. 2018; 31(4): 544–572.
  82. Bultz BD, Carlson LE. Emotional distress: the sixth vital sign--future directions in cancer care. Psychooncology. 2006; 15(2): 93–95.
  83. Cordova MJ, Riba MB, Spiegel D. Post-traumatic stress disorder and cancer. Lancet Psychiatry. 2017; 4(4): 330–338.
  84. Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006; 166(10): 1092–1097.
  85. Kroenke K, Spitzer R. The PHQ-9: A New Depression Diagnostic and Severity Measure. Psych Ann. 2002; 32(9): 509–515.
  86. Butow P, Price MA, Shaw JM, et al. Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines. Psychooncology. 2015; 24(9): 987–1001.
  87. Hutchison SD, Steginga SK, Dunn J. The tiered model of psychosocial intervention in cancer: a community based approach. Psychooncology. 2006; 15(6): 541–546.
  88. Mavros MN, Athanasiou S, Gkegkes ID, et al. Do psychological variables affect early surgical recovery? PLoS One. 2011; 6(5): e20306.
  89. Tsimopoulou I, Pasquali S, Howard R, et al. Psychological Prehabilitation Before Cancer Surgery: A Systematic Review. Ann Surg Oncol. 2015; 22(13): 4117–4123.
  90. Marinelli V, Danzi OP, Mazzi MA, et al. PREPARE: PreoPerative Anxiety REduction. One-Year Feasibility RCT on a Brief Psychological Intervention for Pancreatic Cancer Patients Prior to Major Surgery. Front Psychol. 2020; 11: 362.
  91. Han B, Li Q, Chen Xi. Effects of the frailty phenotype on post-operative complications in older surgical patients: a systematic review and meta-analysis. BMC Geriatr. 2019; 19(1): 141.
  92. Fried LP, Tangen CM, Walston J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56(3): M146–M156.
  93. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017; 9(9): CD006211.
  94. Harari D, Hopper A, Dhesi J, et al. Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing. 2007; 36(2): 190–196.
  95. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023; 71(7): 2052–2081.
  96. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017; 152(3): 292–298.
  97. Clegg A, Rogers L, Young J. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. Age Ageing. 2015; 44(1): 148–152.
  98. Hall DE, Arya S, Schmid KK, et al. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2017; 152(2): 175–182.
  99. Lee K, Zhou J, Norris MK, et al. Prehabilitative Exercise for the Enhancement of Physical, Psychosocial, and Biological Outcomes Among Patients Diagnosed with Cancer. Curr Oncol Rep. 2020; 22(7): 71.
  100. Shen J, Dai S, Li Z, et al. Effect of Enteral Immunonutrition in Patients Undergoing Surgery for Gastrointestinal Cancer: An Updated Systematic Review and Meta-Analysis. Front Nutr. 2022; 9: 941975.