Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

Abstract

Objective: To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

Design: Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

Setting: Secondary care.

Participants: Patients (≥18 years) undergoing major elective surgery (curative or palliative).

Interventions: Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

Outcomes and measures: Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

Review methods: Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

Results: 178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

Conclusions: Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

Prospero registration number: CRD42015019191.

Keywords: cardiology; gastroenterology; oncology; orthopaedic & trauma surgery; pain management; preventive medicine.

Figure 1

PRISMA flow diagram. ERAS, enhanced recovery after surgery; IMT, inspiratory muscle training; IS, incentive spirometry; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomised controlled trial.

Figure 2

Forest plot of prehabilitation for reducing all-cause perioperative mortality. All interventions were tested with usual care as control. IMT, inspiratory muscle training; ONS, oral nutritional supplements.

Figure 3

Forest plot of prehabilitation for reducing length of hospital stay. All interventions were tested with usual care as control. IMT, inspiratory muscle training; IS, incentive spirometry; MD, mean difference; ONS, oral nutritional supplements.

Figure 4

Forest plot of prehabilitation for reducing total postoperative complications. All interventions were tested with usual care as control.

Figure 5

Forest plot of prehabilitation for reducing postoperative pulmonary complications. All interventions were tested with usual care as control. IMT, inspiratory muscle training; IS, incentive spirometry.

Figure 6

Forest plot of pre-admission interventions for reducing pneumonia. All interventions were tested with usual care as control. IMT, inspiratory muscle training.