Prehabilitation: A preemptive strike for faster recovery from surgery

It is especially important for weak patients to build up their reserve of strength and health before surgery as any operation stresses the body. — The Star

Prehabilitation or prehab is a term that most of us, including medical professionals, are not quite familiar with.

Unlike rehabilitation where a patient works towards regaining functionality after an injury, illness or surgery, prehab is where a patient’s wellness is optimised through physical, nutritional, occupational and psychological support, prior to surgery.

All this while, the focus has been on rehabilitation, but over the past few years, the talk has shifted to enhanced recovery after surgery (Eras).

This is a multimodel preoperative care pathway designed to reduce stress and achieve early recovery for patients undergoing major surgery – hence, the term prehab.

Studies show that prehab leads to fewer surgical complications, early recuperation, shorter hospital stays, a faster return to original health functions, decreased illness and death, and of course, less cost in the long run.

In the United Kingdom, the term has been formally used for the past two years, leading to increased awareness about what the programme entails.

“We’re noticing that prehab plays just as important a role as rehabilitation, if not more, but not all specialities have caught on to this term.

“Surgeons are more familiar with prehab because our (upper gastrointestinal) patients are usually thin and malnourished to begin with, due to poor nutrition.

“They are already weak and tend to lose muscle and function, so we have to put them through prehab before we can dispense treatment to ensure they can withstand the onslaught of surgery,” says Queen Elizabeth Hospital consultant upper gastrointestinal surgeon Dr Ooi Wei Keat in Kota Kinabalu.

The prehab team can be large, comprising a surgeon, dietitian, pharmacist, physiotherapist, occupational therapist, psychologist, and depending on the case, physicians.

Dr Ooi subspecialises in surgeries of the oesophagus (the foodpipe), as well as the stomach, but his core focus is on cancers of these two areas.

“Upper gastrointestinal cancers are on the rise and are a heavy burden for the people of Sabah.

“Due to the state’s logistical challenges and socioeconomic reasons, we see a lot of complications, even in the benign diseases.

“For example, it’s very common to see cases of perforated gastric ulcers [where the lining of the stomach splits open, causing food and digestive juices to leak out of the digestive tract].

“Cancers are also presented to us at a very late stage and there are complications such as bleeding and tumour perforations.

“Or patients are unable to eat because the tumour has completely blocked the stomach,” he says.

Providing the right support

Nutrition plays a big part in prehab.

A family member helps a patient who is unable to eat, with parenteral nutrition, or tube feeding, to optimise her nutrition before surgery. — Photos: Dr OOI WEI KEAT

For those unable to eat, specialised food is delivered intravenously into the bloodstream (i.e. parenteral nutrition), which requires the patient to be hospitalised.

Those able to eat and drink on their own can do so at home with guidance from the dietitian, as part of their surgical preparation.

“The next important component is the physical part – we want to see an increase in skeletal muscle mass,” says Dr Ooi.

“To work on leg muscles, they’re taught simple exercises in the ward or bed using resistance bands.

“Or we get our physiotherapists to group together older patients requiring assistance and walk them up the stairs or a fixed distance.

“When they walk together, they don’t feel alone and are motivated to go further.

“For patients with joint problems or knee pain or mobility issues, we get help from our sports medicine team, who will assess them and give special exercises.”

To strengthen respiratory muscles and enhance lung capacity, patients are asked to use an incentive spirometer.

When a patient has cancer, they may already be depressed, afraid or anxious about the disease.

Should this be the case, the ward nurses will try to assist to assuage their fears, but if extra intervention is needed, a psychologist – or if necessary, a psychiatrist – is called in.

Additionally, there are patients who are so weak that they cannot perform basic, daily tasks such as feeding or going to the toilet on their own.

“This is when we get the occupational therapist to design special apparatus to help such patients,” he says.

Balancing the timing

According to Aspen’s (American Society for Parenteral and Enteral Nutrition) clinical guidelines, which Malaysia follows, the healthcare team has up to two weeks to optimise nutritional prehabilitation in patients.

Dr Ooi explains: “Part of the prehab function is also to optimise the patient’s underlying medical conditions, e.g. diabetes or hypertension.

“We need to balance between trying to bring the patient’s health to the maximum condition versus delaying the treatment, especially if it’s an aggressive form of cancer that is fast- spreading.

“For benign conditions, we have slightly more time, meaning we will sit down with the patient and gauge what their expectations are.

“If the patient wants treatment ASAP [as soon as possible] and we delay too long, they might get demotivated, so we discuss and come to a compromise.”

Recently, Dr Ooi had a patient who attempted suicide by drinking a corrosive substance, resulting in serious damage to his oesophagus and stomach.

He shares: “He was bleeding internally and we couldn’t wait for two weeks of prehab, so we had to perform emergency surgery to remove the stomach and oesophagus.

“He survived this initial ‘first aid’, but his condition was very bad and we needed to prehab him for one or two months before the definitive major surgery to correct the damages.

“During the emergency surgery, we were unable to reconnect back his food passage, so he was unable to eat.

“When he was almost ready for the major surgery, he went into renal [kidney] failure and required dialysis.

“He lost almost 70% of his admission weight and lay comatose in the intensive care unit for three weeks.”

A whole healthcare team was needed to manage this patient’s prehab.

Since the patient’s initial problem was psychological, a psychiatrist was called in to stabilise his mental health, a nutritionist worked on his weight gain, and a physiotherapist on his physical fitness.

“Together, we successfully reversed his kidney failure during prehab and he can walk now.

“In fact, we allowed him to go home for a short ‘holiday’ and for some normalcy; his mother told us he was climbing rambutan trees!

“After a week, he got readmitted to continue his prehab; we created an artificial stoma [a small opening in the abdomen that is used to remove faeces and urine into a collection bag] and inserted feeding tubes into his small bowel to deliver nutrition.

“Now, he is more positive and wants to live, so he’s improving in every way.

“He should be fit enough for surgery soon,” says Dr Ooi.

Generally, patients undergoing emergency surgery tend to fare slightly worse than those who are already prehabilitated.

Tracking progress

There are screening methods to assess prehab.

Building muscle mass, even slightly, is a component of prehab and leads to better post-surgery outcomes.

This includes bioelectrical impedance analysis (BIA), a non-invasive, painless method of measuring body composition such as muscle mass and body fat.

Dr Ooi says: “We don’t rely on body mass index [BMI] and weight alone, but also the functional status.

“For example, if patients are bedbound before prehab, but after two weeks, they can walk or use a wheelchair, that is an improvement.

“We also get our cardiology and respiratory colleagues to assess their heart and lung function, and tell us if they’re good enough to undergo anaesthesia and surgery.

“It really takes a whole team to bring a patient’s health to maximum, if not more.”

Time and cost aside, almost everyone can do prehab.

Otherwise healthy patients are not spared either and are pushed further as surgery is an assault or stress to the body.

“We want them to improve 110% as after surgery, there will be a dip for everyone, perhaps to 80%.

“If I can give you a headstart, you can still be 90% healthy post-surgery,” he says.

He adds: “How much prehab is needed depends on the health of the patient.

“Sometimes, patients only need advice on how to eat better, quit smoking or change their sedentary lifestyle habits one or two weeks prior to surgery.”

With obese patients, weight loss is not necessary before surgery.

If they have a malignant cancer, then surgeons will try to strike a balance between prehab and disease spread.

He says: “Time is of essence for obese patients so we don’t look for a drop in weight, but rather, their function and muscle mass.

“We put them through light exercises to increase muscle mass as even a slight drop in fat mass is good enough.

“Of course, we would prefer a 10% fat loss, but how they function is more important.”

At the end of the day, all surgeons want patients to return to normalcy as soon as possible, which is the point of prehabilitation.