It is encouraging to read the realistic and balanced view of the role of prehabilitation in preparing patients for major surgery presented by Winter-Blyth and Moorthy (BMJ 2017;358:j3702). The case for preoperative optimisation of the patient as a route to improved postoperative outcomes is, as described, now gaining more widespread acceptance. We agree that the prescription of exercise within the healthcare setting is complex, ultimately requiring buy-in from the myriad of professionals involved in a patient’s journey to surgery: the GP, specialist nurse, surgeon, anaesthetist and oncologist to name but a few. This alone represents a significant but achievable challenge requiring education and clear communication within the multidisciplinary team1.
Change in attitude and indeed change in policy is required on a nationwide level2,3. Within the current politically-driven time to treatment framework, there is limited opportunity for vital risk-reduction strategies such as prehabilitation. Public perception focuses on undergoing surgery as soon as possible with limited understanding of the effect this can have on outcome4. This is particularly pertinent in cancer surgery, where an arbitrary 31 days is allocated from time of diagnosis to date of surgery. High risk patients comprise approximately 12% of the population undergoing major surgical procedures, but account for 80% of all mortality5. Adequately preparing such patients for the marathon of surgery within this time frame is optimistic at best.
As prehabilitation makes the deserved transition from research modality to key clinical process, we must continue to gather evidence for its benefit and use this to lobby those in power to acknowledge that time to treatment is a poor indicator of the quality of our surgical services. The impact of postoperative complications on quality of life is well documented6,7, with a subsequent domino effect of decreased long-term survival8. Concentrating investment in preoperative strategies to improve patients’ ability to cope with the stress of surgery rather than publicising artificial performance indicators represents far better use of tax-payers money, and a much safer method of marathon-proofing our patients.
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2. Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncol. 2017 Feb;56(2):128-133.
3. Grocott MPW, Plumb JOM, Edwards M, Fecher-Jones I, Levett DZH. Re-designing the pathway to surgery: better care and added value. Perioper Med (Lond). 2017 Jun 20;6:9.
4. Alexander D, Allardice GM, Moug SJ, Morrison DS. A retrospective cohort study of the influence of lifestyle factors on the survival of patients undergoing surgery for colorectal cancer. Colorectal Dis. 2017 Jun;19(6):544-550.
5. Pearse RM, Harrison DA, James P et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006, 10(3):R81.
6. Brown SR, Mathew R, Keding A et al. The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery. Ann Surg. 2014;259(5):916-923.
7. Derogar M, Orsini N, Sadr-Azodi O, Lagergren P. Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal cancer surgery. J Clin Oncol. 2012 May 10;30(14):1615-9.
8. Straatman J, Cuesta MA, de Lange-de Klerk ES, van der Peet DL. Long-Term Survival After Complications Following Major Abdominal Surgery. J Gastrointest Surg. 2016 May;20(5):1034-41.
Competing interests: No competing interests