Multimodal Prehabilitation Program Research Articles

Multimodal prehabilitation improves functional capacity in patients with advanced ovarian cancer undergoing cytoreductive surgery

ObjectivePrehabilitation, defined as the preparatory intervention to increase patient preparedness in the lead-up to surgery, has shown a decrease in post-operative complications in various types of surgery. However, there is...

Prehabilitation to Enhance Vascular Surgery Outcomes: A Narrative Review.

Prehabilitation, an emerging strategy, prepares patients for elective surgery by encouraging healthy behaviors, including physical exercise and healthy nutrition, while providing psychological support, to improve postoperative outcomes and foster healthier lifestyles. Despite growing interest, there is little research on prehabilitation. Specifically, studies involving prehabilitation in vascular surgery are heterogeneous with small sample sizes. This review aimed to investigate the reported positive impact of prehabilitation on vascular surgery patients, discuss prehabilitation models, highlight prehabilitation program-associated challenges, and suggest appropriate interventions. Prehabilitation improves physical fitness, reduces postoperative complications, and enhances overall recovery. Multimodal prehabilitation programs can positively impact vascular surgery patients, with benefits including improved cardiovascular fitness, reduced postoperative complications, shorter postoperative hospital stays, enhanced overall recovery, and improved quality of life. The currently reported prehabilitation programs are heterogeneous, with limitations regarding patient adherence and lack of long-term outcomes, posing challenges to their widespread adoption. Overall, prehabilitation shows promise for improving vascular surgery outcomes and fostering long-term healthy behaviors. The systematic implementation of prehabilitation in vascular surgery care pathways, overcoming reported limitations, and integrating multimodal prehabilitation into routine preoperative care holdpotential benefits. This review underscores the need for high-quality research to establish best practices in prehabilitation and integrate them into the standard of care for vascular surgery patients.

Current developments in prehabilitation in urologic oncology.

Prehabilitation describes interventions that are undertaken prior to a major surgical or medical intervention with the objective of improving functional capability with the goal of improving candidacy for therapy, bolstering one's ability to withstand treatment-associated toxicity, functional decline, and facilitating accelerated recovery. The objective of this review is to detail the key tenets of prehabilitation, synthesize contemporary advances in prehabilitation science within Urologic Oncology, and discuss key methodologic trial design considerations salient to future prehabilitation investigations. Contemporary prehabilitation clinical trials have primarily evaluated unimodal interventions aiming to improve functional capacity across the domains of physical exercise, nutrition, and cognition with heightened interest in evaluating multimodal interventions addressing two or more domains. Recent investigations have have demonstrated variable improvements in strength, balance, physical function, and quality of life with preoperative exercise. Although presurgical immunonutrition showed promise in other fields, initial results in uro-oncology have not demonstrated reductions in complications nor improvements in early survival. Emerging data supports the potential of multimodal prehabilitation programs to offer more comprehensive benefits, improving functional outcomes, reducing length of stay, and supporting improved recovery. To date, early prehabilitation studies in patients undergoing surgery for genitourinary malignancies have demonstrated variable ability to facilitate gains in functional capacity and perioperative outcomes. Key issues have arisen including the need to ensure that interventions are pragmatic, scalable, feasible, and acceptable in these populations that often also have a high prevalence of coincident multimorbidity, frailty, and mental health concerns that can increase risk of adverse outcomes after surgery. The integration of personalized prehabilitation strategies as extensions of perioperative enhanced recovery after surgery protocols, supportive care and survivorship paradigms offers of promise to further engage patients in their care, enhance patient resilience and outcomes, while reducing treatment burden in urologic oncology.

A randomized controlled clinical trial on multimodal prehabilitation in colorectal cancer patients to improve functional capacity: preliminary results.

Major colorectal surgery is associated with 20 to 40% reduction in physiological and functional capacity and higher level of fatigue 6 to 8weeks after surgery. The primary aim of this study was to analyse the effects of a multimodal prehabilitation program in colorectal cancer patients to improve functional capacity. The secondary outcome was to evaluate postoperative complications and length of postoperative hospital stay as well as to determine the costs of implementation and indirect costs. A single centre, single-blind, randomized controlled trial was conducted. Patients of age > 18years undergoing elective colorectal resection for colonic cancer were eligible. Exclusion criteria were metastatic disease, severe walking impairments, renal failure stage > 2, ASA score > 3, preoperative chemo-radiation therapy. Patients have been randomized either to prehabilitation intervention groups, receiving 4-week trimodal prehabilitation (physical exercise and nutritional and psychological support) or to control receiving no prehabilitation. Both groups followed enhanced recovery programs and received rehabilitation accordingly. The primary outcome for functional capacity was measured by the 6-Minute Walking Test (6MWT) 4 and 8weeks after surgery; to evaluate post-operative complications the Clavien-Dindo classification was used. An interim analysis of 71 patients undergoing colorectal surgery was performed, with 35 assigned to interventional arm and 36 to control arm. Baseline characteristics were comparable in both groups. The prehabilitation group showed a significant increase in mean 6MWT distance pre-operatively compared to the control group, with an increase of 96m (523 ± 24.6 vs. 427 ± 25.3, p = 0.01). At 4 and 8weeks, the prehabilitation group maintained significant improvements, with an increase of 103m (514 ± 89 vs. 411 ± 115, p = 0.003) and 90m (531 ± 82 vs. 441 ± 107, p = 0.008), respectively. There were no statistical significant differences in post-operative complications and hospital length of stay between the two groups. The preliminary results of this study indicate that it is feasible to implement a prehabilitation protocol lasting approximately 4weeks. This protocol appears to yield a significant improvement in the physical performance of patients with colon cancer undergoing elective colorectal resection at 4 and 8weeks after surgery.

Differential response to preoperative exercise training in patients candidates to cardiac valve replacement

BackgroundThere is lack of evidence regarding safety, effectiveness and applicability of prehabilitation on cardiac surgery population, particularly in patients candidates to cardiac valve replacement. The aim of the study is to assess and compare the effect of a multimodal prehabilitation program on functional capacity in patients with severe aortic stenosis (AoS) and severe mitral regurgitation (MR) proposed for valve replacement surgery.MethodsSecondary analysis from a randomised controlled trial whose main objective was to analyze the efficacy of a 4–6 weeks multimodal prehabilitation program in cardiac surgery on reducing postoperative complications. For this secondary analysis, only candidates for valve replacement surgery were selected. The primary outcome was the change in endurance time (ET) from baseline to preoperative assessment measured by a cycling constant work-rate cardiopulmonary exercise test.Results68 patients were included in this secondary analysis, 34 (20 AoS and 14 MR) were allocated to the prehabilitation group and 34 (20 AoS and 14 MR) to control group. At baseline, patients with AoS had better left systolic ventricular function and lower prevalence of atrial fibrillation compared to MR (p = 0.022 and p = 0.035 respectively). After prehabilitation program, patients with MR showed greater improvement in ET than AoS patients (101% vs. 66% increase from baseline). No adverse events related to the prehabilitation program were observed.ConclusionsA 4–6 week exercise training program is safe and overall improves functional capacity in patients with severe AoS and MR. However, exercise response is different according to the cardiac valve type disfunction, and further studies are needed to know the factors that predispose some patients to have better training response.Trial registrationThe study has been registered on the Registry of National Institutes of Health ClinicalTrials.gov (NCT03466606) (05/03/2018).

Study protocol for a single-site feasibility study evaluating the adoption and fidelity of Prep-4-RT: prehabilitation for head and neck cancer patients undergoing radiotherapy

IntroductionPrep-4-RT is a co-designed stepped-care multimodal prehabilitation program for people scheduled to receive radiotherapy for head and neck cancer (HNC). Prehabilitation, which occurs between diagnosis and treatment commencement, aims to improve a patient’s health to reduce the incidence and severity of current and future impairments. HNC treatment can be distressing and has detrimental impacts on function and quality of life. HNC patients have increased social vulnerabilities including higher rates of socio-economic disadvantage and engagement in lifestyle habits which increase cancer risk. High levels of physical and psychological impacts of HNC treatment and increased social vulnerabilities of this population warrant investigation of optimal pathways of care, such as prehabilitation. This paper describes a research protocol to evaluate the feasibility of Prep-4-RT, which was designed to prepare HNC patients for the physical and psychological impacts of radiotherapy.Methods and analysisAt least sixty adult HNC patients, scheduled to receive radiotherapy (with or without chemotherapy), will be recruited over a five-month period. All participants will receive access to Prep-4-RT self-management resources. Participants identified through screening as high-risk will also be offered individualised interventions with relevant allied health professionals prior to the commencement of radiotherapy (psychologists, dietitians, speech pathologists and physiotherapists). Participants will complete evaluation surveys assessing their experiences with Prep-4-RT resources and interventions. Clinicians will also complete program evaluation surveys. Primary feasibility outcomes include adoption (uptake and intention to try) and fidelity (adherence to the specialist prehabilitation pathway). Secondary feasibility outcomes include acceptability (patient and clinician) of and satisfaction (patient) with Prep-4-RT as well as operational costs. Feasibility outcome data will be analysed using exact binomial and one-sample t tests, as appropriate.Ethics and disseminationEthics approval has been obtained at the Peter MacCallum Cancer Centre in Melbourne, Australia. Results will be presented at national conferences and published in peer-reviewed journal(s) so that it can be accessed by clinicians involved in the care of HNC patients receiving radiotherapy. If the model of care is found to be feasible and acceptable, the transferability and scalability to other cancer centres, or for other cancer types, may be investigated.Registration detailsANZCTA (Australian New Zealand Clinical Trials Registry) ACTRN12623000770662.

Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery-A Narrative Review.

Malnutrition plays a crucial role as a risk factor in patients undergoing major abdominal surgery. To mitigate the risk of complications, nutritional prehabilitation has been recommended for malnourished patients and those at severe metabolic risk. Various approaches have been devised, ranging from traditional short-term conditioning lasting 7-14 days to longer periods integrated into a comprehensive multimodal prehabilitation program. However, a significant challenge is the considerable heterogeneity of nutritional interventions, leading to a lack of clear, synthesizable evidence for specific dietary recommendations. This narrative review aims to outline the concept of nutritional prehabilitation, offers practical recommendations for clinical implementation, and also highlights the barriers and facilitators involved.

Detailed description of multidisciplinary prehabilitation in patients admitted to nerve sparring radical prostatectomy – A randomized feasibility study protocol

BackgroundLocalized prostate cancer treated with radical prostatectomy is highly effective, though severe side-effects are common after the surgery. Prehabilitation is an approach to optimize patient's physical and mental resources before surgery, to improve postoperative outcomes. The feasibility of a multi-modal home-based prehabilitation program, delivered using telehealth in patients awaiting radical prostatectomy is unknown. This paper describes the development of a prehabilitation program for patients awaiting radical prostatectomy. MethodA model by The Medical Research Council for developing and evaluating complex interventions (MRC Framework) was used in the development process. The Template for Intervention Description and Replication (TIDieR) checklist was applied for ensuring sufficient description of the interventions. A total of 40 patients will be randomized to either intervention or control group. Patients in the control group will follow standard care. The 4-week prehabilitation programme consists of exercise, pelvic floor exercise, sexual counseling, stress management and nutritional support. The interventions are home-based and delivered using telehealth. Feasibility outcomes will include recruitment, attrition rates, adherence, safety and suitability. ConclusionWe have developed a multimodal prehabilitation programme, which has the potential to bring tangible health benefits to men with prostate cancer awaiting radical prostatectomy. The results of the feasibility study will inform the design of a fully powered randomized controlled trial.

Prehabilitation in patients with cirrhosis awaiting liver transplantation: protocol of a feasibility study

IntroductionPatients with cirrhosis awaiting liver transplantation (LT) are often frail, and malnourished. The period of time on the waitlist provides an opportunity to improve their physical fitness. Prehabilitation appears to...

10 years of prehabilitation: From theory to clinical practice

In recent years, prehabilitation has generated high expectations as an innovative preoperative strategy to enhance clinical outcomes following surgery. Several studies have demonstrated that multimodal programs are effective in improving patients’ health status and cardiopulmonary reserve, allowing them to undergo surgery in better conditions and, consequently, reducing the incidence of postoperative complications.Most publications describe proof-of-concept studies, and literature about their implementation is more limited. The implementation of these programs requires new resources and significant organizational effort.In this paper, we share our experience implementing a multimodal prehabilitation program as a mainstream service at a tertiary hospital. Although there are still many unknowns regarding the optimal selection of patients, as well as the duration and components of the program, this article describes our journey in this field, aiming to provide insight for teams interested in developing a similar project.

PREHABILITATION BEFORE GASTROINTESTINAL CANCER SURGERY (PREHAB-GI): AN IMPLEMENTATION STUDY

BACKGROUND Surgery continues to be the primary treatment option for early-stage colorectal and upper gastrointestinal (UGI) cancers. However, up to 30-40% will experience a major complication. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and/or psychological interventions. We aimed to evaluate the implementation of a multimodal prehabilitation program in gastrointestinal cancer surgery patients. METHODS A single-arm implementation study using a pre-post design. Colorectal or UGI cancer patients scheduled for curative intent surgery at Concord Hospital with ≥14 days pre-surgery were recruited. The intervention was face-to-face or by telehealth (COVID adaptations): a 2-4-week program consisting of i) supervised exercise, ii) dietary education and protein supplements, iii) nursing support. The primary outcome was implementation using the RE-AIM (Reach/Effectiveness/Adoption/Implementation/Maintenance) framework. Secondary outcomes included functional, nutritional, and surgical outcomes. RESULTS Over 16 months, 181 were screened; 95 (52%) were eligible. Reach: 77/95 recruited (64 colorectal, 13 UGI). The median age was 70 years; 46 (60%) were males. Median intervention duration was 16 days. Effectiveness: Functional capacity using the 6-minute walk test and 2-minute step test improved from baseline to pre-surgery; 9.3m (p=0.038) and 6.5 steps (p=<0.001), respectively. Self-reported moderate, vigorous and resistance training statistically increased from baseline to pre-surgery. Hospital length of stay decreased by 1.9 days (p=0.010). There was no difference in total complications and readmissions. Adoption: 91% of referrals were directly from surgeons. Implementation: 72 completed the intervention; 5 withdrew after baseline assessment. 34% of assessments and intervention were delivered by telehealth. Adherence to the intervention was high; 94% exercise, 97% nutrition, 98% nursing. Overall, participant and clinician satisfaction was high. Maintenance: The program has been adopted as standard care with modifications post-study completion. CONCLUSIONS Our study shows that multimodal prehabilitation can be successfully implemented in a real-world setting, with a trend to improve functional and surgical outcomes.

Barriers and facilitators to the implementation of prehabilitation for elderly frail patients prior to elective surgery: a qualitative study with healthcare professionals

BackgroundPrehabilitation aims to enhance functional capacity before surgery, minimise complications and achieve a better postoperative outcome. This can be particularly useful for older, frail patients to better tolerate surgery. The aim of this study was to identify what barriers and facilitators healthcare professionals in Germany experienced in the implementation and delivery of the multimodal prehabilitation programme “PRAEP-GO” for (pre-)frail adults aged 70 years and older to inform the implementation of prehabilitation into standard care.MethodsA nested descriptive qualitative study was conducted using semi-structured face-to-face interviews with healthcare professionals involved in the PRAEP-GO trial from the Berlin and Brandenburg region in Germany. Transcripts were analysed using Kuckartz’ qualitative content analysis. Results were interpreted and synthesised using the Consolidated Framework for Implementation Research, a theoretical framework to allow their application to a more general context.ResultsA total of 14 interviews were conducted. Seven therapists (physio-, ergo-, sports therapy), five physicians and two employees from other professions with mainly administrative and organisational tasks in the project. All identified barriers and facilitating factors could be assigned to the themes of organisation, prehabilitation, cooperation and communication between healthcare professionals and with patients. Much optimisation potential was found regarding organisational aspects, e.g. addressing perceived staff shortages and optimising the patient pathway. Furthermore, it became apparent that communication and cooperation between professionals but also with patients need to be improved. More evidence regarding prehabilitation should be provided to convince professionals more. Prehabilitation should be multimodal and individualised, including the programme duration. Officially introducing prehabilitation into standard care would facilitate its delivery.DiscussionThese findings underscore the fact that successful implementation of prehabilitation programmes, such as PRAEP-GO, requires sufficient organisational infrastructure, human resources, access to knowledge, an adaptable and individualised programme design as well as good communication among professionals and with patients. The transferability of the findings is limited by the absence of nutritionists and resulting overrepresentation of other therapists in the sample. To further convince professionals and patients of the concept of prehabilitation, more research is needed to build a solid evidence base that will ensure greater awareness and, thus, more motivation and cooperation among professionals and patients.Trial registrationOpen Science Framework (osf.io/ksfgj).

Prehabilitation in chronic inflammatory bowel disease: the Proactive care pathway

Inflammatory Bowel Diseases (IBD) cause diarrhea and abdominal pain that impair quality of life. Digestive damage frequently leads to undernutrition and sarcopenia, which worsen the prognosis of the disease. This led to the development of PROACTIVE, a multimodal prehabilitation program designed to improve the functional capacities, nutritional status and quality of life of IBD patients. 19patients have been included in our pilot program, with an initial personalized multimodal assessment, 10 group sessions with 4 patients, and a final multimodal assessment proposing personalized care for home. Initial data are positive, showing an improvement in patients' physical capacity and quality of life after 6 weeks.

The effect of prehabilitation on long-term survival and hospital admissions in older patients undergoing elective colorectal cancer surgery

IntroductionThere is a growing body of evidence for a beneficial effect of prehabilitation on short-term outcomes after colorectal cancer (CRC) surgery in older patients. However, long-term effects on survival or hospital admissions have not been investigated. This study reports these long-term outcomes from a previously published observational cohort study. MethodsWe compared patients ≥75 years who received elective CRC surgery in Reinier de Graaf Hospital before (2010–2013: standard care) and after implementation of a multimodal prehabilitation program (2014–2015; prehabilitation). With a six-year follow-up period, we analyzed survival using the Kaplan-Meier method and the occurrence of one or more hospital admissions using logistic regression analyses. ResultsOverall, 137 patients were included in the standard care group and 86 patients in the prehabilitation group. There were no differences in patients, tumor and treatment characteristics. After six years, 51.1% in the standard care group and 59.3% in the prehabilitation group (p = 0.167) were still alive. When corrected for confounders in the prehabilitation group less patients had one or more hospital admissions during follow-up (odds ratio (OR) 0.43 (95% CI 0.24–0.77). ConclusionsUnfortunately these limited historical cohorts did not allow for strong conclusions concerning long-time survival. However, after prehabilitation less patients had hospital admissions during follow up. Hopefully, this first study into the long-term effects of multimodal prehabilitation will trigger more future research.

Feasibility study of a multimodal prehabilitation programme in women receiving neoadjuvant therapy for breast cancer in a major cancer hospital: a protocol

IntroductionNeoadjuvant therapy has become a standard treatment for patients with stage II/III HER2 positive and triple negative breast cancer, and in well-selected patients with locally advanced and borderline resectable high...

Feasibility of Introducing a Prehabilitation Program into the Care of Gynecological Oncology Patients-A Single Institution Experience.

Prehabilitation is an upcoming strategy to optimize patient's functional capacity, nutritional status, and psychosocial well-being in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program into the standard care of gynecological oncology patients at an academic hospital in terms of recruitment, adherence, and safety, which were assessed by the number of patients eligible, recruitment rate, participation rate, and adherence to individual modalities. Data were derived from the F4S PREHAB trial, a single-center stepped-wedge trial implementing a multimodal prehabilitation program among various surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine, and vulvar cancer at the Radboudumc, an academic hospital in The Netherlands, between May 2022 and September 2023 were considered eligible for the F4S PREHAB trial and, consequently, were included in this cohort study. The multimodal prehabilitation program comprised a physical exercise intervention, nutritional intervention, psychological intervention, and an intoxication cessation program. A total of 152 patients were eligible and approached for participation of which 111 consented to participate, resulting in a recruitment rate of 73%. Participants attended an average of six exercise sessions and adhered to 85% of possible training sessions. Respectively, 93% and 98% of participants adhered to the prescribed daily protein and vitamin suppletion. Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, two managed to quit smoking. A total of 59% adhered to alcohol cessation advice. No adverse events were reported. This study demonstrates that introducing a multimodal prehabilitation program into the standard care of gynecological oncology patients is feasible in terms of recruitment and adherence, with no serious adverse events.

Multimodal prehabilitation in elective oncological colorectal surgery enhances preoperative physical fitness: a single center prospective real-world data analysis.

Surgery can lead to curation in colorectal cancer (CRC) but is associated with significant morbidity. Prehabilitation plays an important role in increasing preoperative physical fitness to reduce morbidity risk; however, data from real-world practice is scarce. This study aimed to evaluate the change in preoperative physical fitness and to evaluate which patients benefit most from prehabilitation. In this single-arm prospective cohort study, consecutive patients undergoing elective colorectal oncological surgery were offered a 3- to 4-week multimodal prehabilitation program (supervised physical exercise training, dietary consultation, protein and vitamin supplementation, smoking cessation, and psychological support). The primary outcome was the change in preoperative aerobic fitness (steep ramp test (SRT)). Secondary outcomes were the change in functional walking capacity (6-minute walk test (6MWT)), and muscle strength (one-repetition maximum (1RM) for various muscle groups). To evaluate who benefit most from prehabilitation, participants were divided in quartiles (Q1, Q2, Q3, and Q4) based on baseline performance. In total, 101 patients participated (51.4% male, aged 69.7 ± 12.7 years). The preoperative change in SRT was +28.3 W, +0.36 W/kg, +16.7% (P<0.001). Patients in all quartiles improved at the group level; however, the relative improvement decreased from Q1-Q2, Q2-Q3, and Q3-Q4 (P=0.049). Change in 6MWT was +37.5 m, +7.7% (P<0.001) and 1RM improved with 5.6-33.2 kg, 16.1-32.5% for the various muscle groups (P<0.001). Prehabilitation in elective oncological colorectal surgery is associated with enhanced preoperative physical fitness regardless of baseline performance. Improvements were relatively larger in less fit patients.

Multimodal prehabilitation program in patients with resectable perihilar cholangiocarcinoma: keypoints for an implementation protocol and literature review.

Postoperative complications after perihilar cholangiocarcinoma surgical procedure are still very high. The implementation of a multimodal prehabilitation program could improve these outcomes. Based on our experience and that of the literature in hepatobiliary and pancreatic surgery, we propose a protocol to promote its implementation. First, we performed a retrospective analysis of the implementation feasibility of a multimodal prehabilitation program in patients' candidates for elective perihilar cholangiocarcinoma surgery in our center. Second, we conducted a literature search of publications in PubMed until December 2022. Relevant data about hepato-pancreato-biliary surgery and prehabilitation programs in features and postoperative outcomes was analyzed. Since October 2020, 11 patients were evaluated for prehabilitation in our hospital. Two of them could not be resected intraoperatively due to disease extension. The median hospital stay was 10days (iqr, 7-11). There were no major complications and 1 patient died. Of a total of 17 articles related to prehabilitation in hepato-biliary-pancreatic surgery, no reports focusing exclusively on perihilar cholangiocarcinoma were found. Six of the studies had nutritional therapies in addition to physical interventions, and 12 studies used home-based exercise therapy. Based on our experience and the data obtained from other studies, a prehabilitation program could be useful to improve perioperative physical and mental fitness in patients' candidates for elective perihilar cholangiocarcinoma surgery. However, more well-designed studies are needed to allow us to obtain more evidence.

EFFECTS OF NUTRITION STATUS AND PERIOPERATIVE NUTRITION SUPPLEMENT COMPLETION ON POSTOPERATIVE OUTCOMES IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE UNDERGOING SURGERY

Abstract BACKGROUND Malnutrition is common in inflammatory bowel disease, (IBD) and is associated with poor disease activity, greater hospital length of stay (LOS), higher 30-day readmission rates, and increased risk of postoperative complications. Structured, multimodal prehabilitation including nutrition counseling improves various outcomes after elective cancer and orthopedic surgeries. We examined the effects of malnutrition and perioperative nutrition supplementation on surgical outcomes in IBD patients participating in a multimodal prehabilitation program. METHODS This was a retrospective study of patients aged 18-80 enrolled in a 10-week prehabilitation program undergoing surgery for IBD. Beginning 4 weeks prior to surgery, patients met with a multidisciplinary team including a nurse practitioner, physical therapist and registered dietitian. Patients were provided 3 preoperative carbohydrate loading oral nutrition supplements (ONS) 48 hours prior to surgery, and 20 perioperative immunonutrition ONS. Malnutrition was defined using the Global Leadership in Malnutrition criteria as moderate or severe. We used Fisher’s exact test to determine associations between malnutrition, ONS use, and postoperative complications (defined by the comprehensive complication index (CCI, with CCI scores &amp;gt;20 classified as severe)), and 30-day readmission. Logistic and linear regression were used to analyze length of stay (LOS), opioid use (defined as morphine milligram equivalents, MME), nutrition status, and ONS completion. RESULTS 25 patients (48% female, mean age 44, 18 (72%) with Crohn’s disease) completed the prehabilitation program between 05/2022 and 10/2023. 10 patients (40%) met criteria for malnutrition (of these, 50% were moderate and 50% severe). Malnutrition was not significantly associated with CCI severity (p=0.07), LOS (p =0.07), opioid use (p=0.07) or 30 day readmission rates (0.06). Higher ONS use for carbohydrate loading and immunonutrition were more likely to have a LOS&amp;lt;5 days (p=0.05 and p=0.03 respectively). CONCLUSION ONS for preoperative carbohydrate loading and perioperative immunonutrition may shorten LOS after surgery among patients with IBD. In our study, higher amounts of ONS consumption led to a shorter LOS. Larger, controlled studies will help to further clarify the effects of malnutrition, carbohydrate loading, and immunonutrition among patients with IBD preparing for surgery.

MULTIMODAL PREHABILITATION MAY IMPROVE SURGICAL OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Surgery is associated with loss of lean body mass and physical deconditioning, which can delay healing and lead to complications. Multimodal prehabilitation (PH) with nutrition optimization and physical therapy improves outcomes after cancer surgery. However, the effects of prehabilitation for inflammatory bowel disease (IBD) surgery are not established. We aimed to assess surgical outcomes among IBD patients exposed to prehabilitation relative to no prehabilitation. METHODS We conducted a case-controlled study of the impact of prehabilitation in patients with IBD who underwent major abdominal surgery for Crohn’s disease (CD) or ulcerative colitis (UC) between May 1st, 2022 and June 6th, 2023 at a tertiary care center. Cases were defined as those who participated in a multimodal PH program that included nutrition counseling (weight optimization, preoperative carbohydrate loading and perioperative immunonutrition), medication management, physical therapy, and psychosocial evaluation beginning 4 weeks prior to surgery; controls received standard of care (SOC) written preoperative surgical instructions without PH. We assessed postoperative complications (defined by the comprehensive complications index (CCI)), severe complications (CCI&amp;gt;20), reoperation rate, 30-day readmission, post operative length of stay (LOS) and post-operative opioid use (defined by daily morphine milligram equivalents (MME)). Statistical tests included linear and logistic regression, Mann-Whitney U test, Chi-Square test, and Fisher’s exact test, as appropriate. RESULTS A total of 68 patients were identified, including 20 PH (cases) and 48 SOC (controls). Among PH, 75% had CD with the remainder UC; surgeries included ileocecal resection (45%), colectomy with ileostomy (25%), ileal pouch-anal anastomosis (25%), and small bowel resection (5%). Among SOC, 31% had CD with the remainder UC, and surgeries included colectomy with ileostomy (60%), stage 2 IPAA (29%), and small bowel (6%) or ileal (4%) resections. Age, sex, race, and ethnicity was similar between groups. Overall and severe complication rates were similar between PH and SOC (mean CCI scores 13.42 PH vs 11.25 SOC (p = 0.58), and CCI &amp;gt; 20 in 40% PH patients vs 29% SOC (p = 0.56)). Median post-operative LOS was shorter among PH vs SOC (3.0 vs 3.5d, p=0.02), and median post-operative opioid use was lower among PH vs SOC (19.5 vs 20.8 MME, p = 0.04). Readmission within 30 days occurred in 30% of PH and 17% of SOC (p = 0.22). Reoperation within 30 days occurred in 5% of PH and 17% of SOC (p = 0.37). CONCLUSION: Multimodal prehabilitation may improve select surgical outcomes in IBD, including length of stay and opioid use after surgery. Larger, prospective, controlled studies may help to further clarify the impact of PH on surgical outcomes for IBD, including complications, readmissions, and functional status. Table 1. Patient Characteristics and Outcomes by Prehabilitation Exposure Status