Multi-Modal Prehabilitation in Thoracic Surgery: From Basic Concepts to Practical Modalities

Abstract

Over the last two decades, the invasiveness of thoracic surgery has decreased along with technological advances and better diagnostic tools, whereas the patient's comorbidities and frailty patterns have increased, as well as the number of early cancer stages that could benefit from curative resection. Poor aerobic fitness, nutritional defects, sarcopenia and "toxic" behaviors such as sedentary behavior, smoking and alcohol consumption are modifiable risk factors for major postoperative complications. The process of enhancing patients' physiological reserve in anticipation for surgery is referred to as prehabilitation. Components of prehabilitation programs include optimization of medical treatment, prescription of structured exercise program, correction of nutritional deficits and patient's education to adopt healthier behaviors. All patients may benefit from prehabilitation, which is part of the enhanced recovery after surgery (ERAS) programs. Faster functional recovery is expected in low-risk patients, whereas better clinical outcome and shorter hospital stay have been demonstrated in higher risk and physically unfit patients.

Keywords: aerobic capacity; exercise training; frailty; nutrition; patient empowerment; surgical stress.

Figure 1

Time course of neuroendocrine and inflammatory response to surgery. DC, dendritic cell; IL, interleukin; IFN-γ, interferon gamma; TGF-β, transforming growth factor-β. Th2 and Th1, T helper 1 and 2 cells; POD1,3, and x, postoperative day 1, 3 and undetermined.

Figure 2

Organization plan of peri-interventional processes. GP, general physician.

Figure 3

Time course of functional recovery depending on preoperative functional status assessed by MET (fit in blue, unfit in red) and on implementation of prehabilitation (solid lines, with prehabilitation; dashed line, without prehabilitation). MET, metabolic equivalent task.

Figure 4

Three pillars of prehabilitation.