Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery

Abstract

Background: Surgery is a major physiologic stress comparable to intense exercise. Diminished cardiopulmonary reserve is a major predictor of poor outcomes. Current preoperative workup focuses mainly on identifying risk factors; however, little attention is devoted to improving cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a "surgical marathon" similar to the preparation of an athlete.

Study design: The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. We prospectively collected demographic, intraoperative (first hour), and postoperative data for patients enrolled in MSHOP undergoing major abdominal surgery. Statistical analysis was performed using 2:1 propensity score matching to compare the MSHOP group (n = 40) to emergency (n = 40) and elective, non-MSHOP (n = 76) patients.

Results: Overall, 70% of MSHOP patients complied with the program. Age, sex, American Society of Anesthesiologists (ASA) classification, and BMI did not differ significantly between groups. One hour intraoperatively, MSHOP patients showed improved systolic and diastolic blood pressures and lower heart rate (Figure). There was a significant reduction in Clavien-Dindo class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups (p = 0.05). This translated to total hospital charges averaging $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group (p < 0.001).

Conclusions: Patients undergoing prehabilitation before colectomy showed positive physiologic effects and experienced fewer complications. The average savings of $21,946 per patient represents a significant cost offset for a prehabilitation program, and should be considered for all patients undergoing surgery.

Figure 1.

(A) Change in systolic blood pressure (SBP) and (B) diastolic blood pressure (DBP) after the first hour of surgery. Patients who participated in the Michigan Surgical and Health Optimization Program (MSHOP) had significantly increased SBP and DBP 1 hour into surgery compared to both elective and emergency surgery patients.

Figure 2.

Comparison of postoperative complications between groups. MSHOP, Michigan Surgical and Health Optimization Program.

Figure 3.

Differences in total hospital charges between 3 groups. Total costs were significantly lower for the Michigan Surgical and Health Optimization Program (MSHOP) group compared to emergency surgery group, however this decreased cost was not significantly different compared to the elective surgery group.