Introduction A core screening, assessment and outcome set is needed in cancer prehabilitation to standardise what is measured in both research and services. Currently, there is significant variation in measures used, which limits comparability between studies and evidence synthesis. Standardising measures will improve the quality, comparability and impact of research by reducing heterogeneity between studies, minimising reporting bias, improving trial efficiency, enabling data synthesis into large datasets, supporting international collaboration and data sharing, and accelerating the implementation of best practices.Methods and analysis An international Delphi consensus process will be conducted involving patients, healthcare professionals and researchers to identify screening, assessment and outcomes and their corresponding measurement instruments, to be included in a core set. The study consists of three phases: (1) A scoping review to identify screening, assessment and outcomes and associated measurement instruments currently used in cancer prehabilitation. (2) At least two rounds of a modified Delphi survey to prioritise the identified screening, assessment and outcomes using a 1–9 Likert scale. Consensus will be defined across stakeholder groups using prespecified thresholds. A consensus meeting will be held if agreement is not reached. (3) Measurement instruments corresponding to each retained screening, assessment and outcome will be assessed for quality for measurement properties and feasibility. Further Delphi rounds will be conducted to reach consensus on the most appropriate measurement instrument for each core screening, assessment and outcome.Ethics and dissemination The study has ethical approval (Ref: 25/NW/0159). Findings will be disseminated through peer-reviewed publications, conference presentations, stakeholder networks and made publicly available via the Core Outcome Measures in Effectiveness Trials database.

BACKGROUND:Prehabilitation, a process of building physiological reserve before surgery to improve postoperative outcomes, is a complex, multimodal intervention that requires rigorous evaluation in clinical trials. Incomplete reporting by such trials obscures essential intervention components and delivery contexts, hindering comparability and interpretability. This, in turn, limits clinical implementation and the replication or refinement of interventions by researchers. The aim of this study was to develop a reporting checklist for RCTs of prehabilitation. METHODS:A modified two-round Delphi process using the EQUATOR framework with 53 international experts across exercise, nutrition, psychological, and perioperative care disciplines was conducted. An initial checklist of candidate items was adapted from existing reporting standards, contextualized for prehabilitation, and iteratively refined through expert voting. Items rated eight to nine on a nine-point scale by ≥70% of participants in round two were classified as 'essential' and those rated seven were considered 'important'. RESULTS:The final checklist comprised 40 items. Sixteen items were classified as 'essential' and 24 items were classified as 'important' for guiding comprehensive reporting of prehabilitation interventions. These items span key domains including intervention components, delivery methods, adherence, participant characteristics, and outcome measures. High agreement among experts underscores the checklist's relevance and usability. CONCLUSION:Adoption of Standards for reporting research methods, interventions, and Outcomes in Surgical Prehabilitation studies (SOS-Prehab), alongside methodological and outcome-reporting items of CONSORT could improve transparency, completeness, and interpretability of prehabilitation trials. This could enable better reproducibility, robust evidence synthesis, and accelerate translation into clinical practice and policy.

Background: Conventional pelvic exenteration (PE) comprises the removal of all or most central pelvic organs and is established in clinical practise. Previously, tumours involving bone or lateral sidewall structures were deemed inoperable due to associated morbidity, mortality, and poor oncological outcomes. Recently however high-complexity PE is increasingly described and is defined as encompassing conventional PE with the additional resection of bone or pelvic sidewall structures. This observational cohort study aimed to assess surgical outcomes, health-related quality of life (HrQoL), decision regret, and costs of high-complexity PE for more advanced tumours not treatable with conventional PE. Methods: High-complexity PE data were retrieved from a prospectively maintained quaternary database. The primary outcome was overall survival. Secondary outcomes were perioperative mortality, disease control, major morbidity, HrQoL, and health resource use. For cost–utility analysis, a no-PE group was extrapolated from the literature. Results: In total, 319 cases were included, with 64 conventional and 255 high-complexity PE, and the overall survival was equivalent, with medians of 10.5 and 9.8 years (p = 0.52), respectively. Local control (p = 0.30); 90-day mortality (0.0% vs. 1.2%, p = 1.00); R0-resection rate (87% vs. 83%, p = 0.08); 12-month HrQoL (p = 0.51); and decision regret (p = 0.90) were comparable. High-complexity PE significantly increased overall major morbidity (16% vs. 31%, p = 0.02); and perioperative costs (GBP 37,271 vs. GBP 45,733, p < 0.001). When modelled against no surgery, both groups appeared cost-effective with incremental cost-effectiveness ratios of GBP 2446 and GBP 5061. Conclusions: High-complexity PE is safe and feasible, offering comparable survival outcomes and HrQoL to conventional PE, but with greater morbidity and resource use. Despite this, it appears cost-effective when compared to no surgery and palliation.

Background: Achieving evidence-based practice change in surgery has always been challenging, with many aspects of common clinical practice evolving through lower-level studies that are susceptible to bias and confounding rather than high-quality evidence. This challenge is even more pronounced in the setting of low-volume, high-complexity surgical oncology. Additionally, when the costs of interventions or technologies are high, designing and developing such studies within financially constrained national healthcare systems becomes even more complicated, potentially widening perceived healthcare inequalities between private and publicly funded systems. However, this is precisely the area where a lack of evidence can either hinder the development of significant new clinical advances or lead to the adoption of expensive and ineffective treatments. Here, we describe the novel approaches adopted in the design, development, and implementation of the ELECTRA trial, a randomised, controlled, double-blinded feasibility study with a planned extension to a late-phase trial. Methods: The Cancer Research UK ELECTRA (NCT05877352) trial is a three-armed randomised, controlled clinical trial designed to evaluate the incremental benefit of adding intraoperative electron beam radiotherapy (IOERT) to pelvic exenteration surgery for locally advanced and locally recurrent rectal cancer. ELECTRA is double-blinded, with patients, surgeons, and oncologists unaware of whether IOERT is administered or not. The primary feasibility outcome focuses on the ability to successfully recruit and randomise participants, while the subsequent primary outcome assesses IOERT field local control. Results: We describe the collaborative process involved in developing the trial, including national and international consultations to determine the best study design and the most optimal outcome measures to evaluate. We outline the extensive patient participation and input into the study design. Given the complexity and evolving nature of the field, with no clear international standardisations, we outline the processes used to address internationally agreed definitions, radiological standardisation, surgical learning curves, quality assurance, and pathological standardisation, as well as the broader impact and benefits of these activities. Finally, we describe the novel design utilised to facilitate the involvement of national and international units with varying levels of equipoise regarding IOERT. Conclusions: Historically, randomised clinical trials have not been the standard approach for evaluating surgical interventions due to their practical and methodological challenges, particularly in high-complexity, low-volume settings. Despite these difficulties, they remain the gold standard for evidence-based practice. The ELECTRA trial exemplifies a complex, innovative trial design that addresses an unmet need in a specialised area of high-complexity surgery. Using ELECTRA as an example, we highlight the genuine challenges in designing such complex trials and provide recommendations to facilitate the conduct of future well-designed surgical studies.

INTRODUCTION:Studies have demonstrated that prehabilitation in oesophagogastric cancer (OGC) improves body composition, physical fitness and quality of life, and can reduce surgical complications. However, it is not offered in all OGC centres. Furthermore, definitions, funding and access to services vary. We conducted a survey of prehabilitation in OGC centres in England and Wales. METHODS:OGC centres were identified through the National Oesophago-Gastric Cancer Audit (NOGCA). Survey questions were developed, piloted in two institutions and distributed via email in October 2022. Reminder emails were sent over two months until the survey closed in December 2022. RESULTS:Responses were received from 28 of 36 centres. There was near-universal agreement that prehabilitation should be considered standard of care for patients on curative pathways (27/28; 96%). Most centres (21/28; 75%) offered prehabilitation. The majority of respondents believed that prehabilitation should commence at diagnosis (27/28; 96%) and consist of at least aerobic training and dietitian input. Most (26/28; 93%) believed access to clinical psychologists should be included; however, only 12 (43%) had access to clinical psychologists. Respondents believed prehabilitation improves quality of life (26/28; 93%), fitness (26/28; 93%), smoking cessation (28/28; 100%), surgical complication rates (25/28; 89.3%), likelihood of proceeding to surgery (25/28; 89.3%) and overall survival (20/28; 71.4%). CONCLUSIONS:Despite barriers to funding and a lack of best practice guidelines, most units deliver prehabilitation. Units require higher quality evidence, consensus on the most important aspects of the intervention and core outcome sets to support the delivery of services and facilitate audit to assess the impact of their introduction.

BACKGROUND:Prehabilitation is safe, feasible and may improve a range of outcomes in patients with oesophago-gastric cancer (OGC). Recent studies have suggested the potential of prehabilitation to improve body composition, sarcopenia and physical fitness, reduce surgical complications and improve quality of life. Despite this, prehabilitation services are not offered throughout all OGC centres in the UK. Where prehabilitation is offered, delivery and definitions vary significantly, as do funding sources and access. METHODS:A professional association endorsed series of consensus meetings were conducted using a modified Delphi process developed by the Peri-Operative Quality Initiative (POQI) to identify and refine consensus statements relating to the development and delivery of prehabilitation services for OGC patients. Participants from a variety of disciplines were identified based on a track record of published studies in the field of prehabilitation and/or practice experience encompassing prehabilitation of OGC patients. Approval from the POQI board was obtained and independent supervision provided by POQI. RESULTS:A total of 20 statements were developed and agreed by 26 participants over a preliminary meeting and 2 semi-structured formal POQI meetings. Ten research themes were identified. In the case of one statement, consensus was not reached and the statement was recorded and developed into a research theme. A strong recommendation was made for the majority of the consensus statements (17 of 20). DISCUSSION:Consensus statements encompassing the interventions and outcomes of prehabilitation services in oesophago-gastric cancer surgery have been developed to inform the implementation of programmes.

Postoperative morbidity in patients undergoing curative colorectal cancer surgery is high. Prehabilitation has been suggested to reduce postoperative morbidity, however its effectiveness is still lacking. The aim of this study was to investigate the effectiveness of prehabilitation in reducing postoperative morbidity and length of hospital stay in patients undergoing colorectal cancer surgery. A comprehensive electronic search was conducted in the CINAHL, Cochrane Library, Medline, PsychINFO, AMED, and Embase databases from inception to April 2023. Randomised controlled trials testing the effectiveness of prehabilitation, including exercise, nutrition, and/or psychological interventions, compared with usual care in patients undergoing colorectal cancer surgery were included. Two independent review authors extracted relevant information and assessed the risk of bias. Random-effect meta-analyses were used to pool outcomes, and the quality of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. A total of 23 trials were identified (N = 2475 patients), including multimodal (3 trials), exercise (3 trials), nutrition (16 trials), and psychological (1 trial) prehabilitation. There was moderate-quality evidence that preoperative nutrition significantly reduced postoperative infectious complications (relative risk 0.65, 95 https://doi.org/10.17605/OSF.IO/VW72N ).

Exercise prehabilitation may improve the tolerance and effectiveness of anticancer treatments such as chemotherapy. This systematic review assesses the impact of exercise on chemotherapy outcomes and identifies research priorities. Nineteen studies (1418 patients) were reviewed, including 11 randomised controlled trials and eight observational studies. Exercise led to improvements in body composition, fitness, strength and quality of life (QoL) across studies. Exercise can be safely and effectively delivered during chemotherapy. Limited standardisation and small sample sizes highlight the need for larger, better-designed studies to optimise this low-cost intervention.

Study defined core standards and core outcomes for prehabilitation for all types of colorectal surgery.Co-produced by patients and healthcare professionals internationally.Consensus achieved on 33 core standards (what prehabilitation should include, who should be offered prehabilitation and who should be part of the prehabilitation team) and 21 core outcomes.The DiSCO core standards and core outcomes should be implemented into future colorectal prehabilitation research to achieve standardization, allow study comparison and expedite translation into patient care.

BackgroundAs the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.MethodsExpert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.ResultOlder adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.ConclusionsMIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

BackgroundLarge tissue defects following pelvic exenteration (PE) fill with fluid and small bowel, leading to the empty pelvis syndrome (EPS). EPS causes a constellation of complications including pelvic sepsis and reduced quality of life. EPS remains poorly defined and cannot be objectively measured. Pathophysiology of EPS is multifactorial, with increased pelvic dead space potentially important. This study aims to describe methodology to objectively measure volumetric changes relating to EPS.MethodsThe true pelvis is defined by the pelvic inlet and outlet. Within the true pelvis there is physiological pelvic dead space (PDS) between the peritoneal reflection and the inlet. This dead space is increased following PE and is defined as the exenteration pelvic dead space (EPD). EPD may be reduced with pelvic filling and the volume of filling is defined as the pelvic filling volume (PFV). PDS, EPD, and PFV were measured intraoperatively using a bladder syringe, and Archimedes' water displacement principle.ResultsA patient undergoing total infralevator PE had a PDS of 50 ml. A rectus flap rendered the pelvic outlet watertight. EPD was then measured as 540 ml. Therefore there was a 10.8-fold increase in true pelvis dead space. An omentoplasty was placed into the EPD, displacing 130 ml; therefore, PFV as a percentage of EPD was 24.1%.ConclusionsThis is the first reported quantitative assessment of pathophysiological volumetric changes of pelvic dead space; these measurements may correlate to severity of EPS. PDS, EPD, and PFV should be amendable to assessment based on perioperative cross-sectional imaging, allowing for potential prediction of EPS-related outcomes.

IntroductionChronic cancer-related pain from locally recurrent infiltrative cancers within the bony confines of the pelvis is a devastating and hard to manage condition that can be refractory to many conventional pain management methods. Spinal cord stimulation (SCS) is an evolving and safe method of pain management and can be trialled in a quick and well-tolerated operation under local anaesthesia. To date, this has not been reported in the setting of locally recurrent inoperable pelvic cancers.Case descriptionIn the present study, we report two cases of patients with severe back and lower limb pain resulting from recurrent anal and rectal cancers involving the right lumbar and sacral nerve roots as well as the bony sacrum, which severely affected quality of life and daily functioning.DiscussionFollowing successful SCS, effective pain relief was observed.ConclusionSCS could represent an effective supplementary or alternative technique to conventional pain management in this challenging group of patients, especially if other available methods have been exhausted.

OBJECTIVES:Body composition assessment using CT images at the L3-level is increasingly applied in cancer research and has been shown to be strongly associated with long-term survival. Robust high-throughput automated segmentation is key to assess large patient cohorts and to support implementation of body composition analysis into routine clinical practice. We trained and externally validated a deep learning neural network (DLNN) to automatically segment L3-CT images. METHODS:Expert-drawn segmentations of visceral and subcutaneous adipose tissue (VAT/SAT) and skeletal muscle (SM) of L3-CT-images of 3187 patients undergoing abdominal surgery were used to train a DLNN. The external validation cohort was comprised of 2535 patients with abdominal cancer. DLNN performance was evaluated with (geometric) dice similarity (DS) and Lin's concordance correlation coefficient. RESULTS:There was a strong concordance between automatic and manual segmentations with median DS for SM, VAT, and SAT of 0.97 (IQR: 0.95-0.98), 0.98 (IQR: 0.95-0.98), and 0.95 (IQR: 0.92-0.97), respectively. Concordance correlations were excellent: SM 0.964 (0.959-0.968), VAT 0.998 (0.998-0.998), and SAT 0.992 (0.991-0.993). Bland-Altman metrics indicated only small and clinically insignificant systematic offsets; SM radiodensity: 0.23 Hounsfield units (0.5%), SM: 1.26 cm2.m-2 (2.8%), VAT: -1.02 cm2.m-2 (1.7%), and SAT: 3.24 cm2.m-2 (4.6%). CONCLUSION:A robustly-performing and independently externally validated DLNN for automated body composition analysis was developed. ADVANCES IN KNOWLEDGE:This DLNN was successfully trained and externally validated on several large patient cohorts. The trained algorithm could facilitate large-scale population studies and implementation of body composition analysis into clinical practice.

Cancer surgery is an essential treatment strategy but can disrupt patients’ physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, ‘surgery schools’, and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

ObjectiveThe empty pelvis syndrome (EPS) is common after pelvic exenteration (PE), causing fluid collections, bowel obstruction, perineal sinuses, and fistulas. The best approach to fill the pelvis to mitigate this remains controversial, and the impact of EPS on health-related quality of life (HrQoL) is unknown. This study is the first to begin to explore lived-experiences of EPS complications.MethodsUnstructured EPS virtual focus group meetings were conducted with a convenience sample of patients who underwent PE, as an extension of a modified-Delphi study. Interpretative phenomenological analysis was conducted on verbatim transcripts to generate group experiential themes.ResultsTwelve patients (eight UK, one Dutch, and three Belgian) participated in four focus groups. Eight EPS complications were reported, (two pelvic collections, five chronic perineal sinuses, and one bowel obstruction). Group experiential themes were 'Out of Options', depicting patients forced to accept complications or limited survival; 'The New Normal', with EPS potentially delaying adaptation to post-PE HrQoL; 'Information Influencing Adaptation,' emphasising the significance of patients understanding EPS to cope with its effects; and 'Symptoms,' reporting manifestations of EPS, the resultant physical limitations, and an intangible feeling that patients lost part of themselves.ConclusionsEPS may influence patient decision-making, regret, adaptation, and information-seeking. It can cause a variety of unpleasant symptoms and physical limitations, which may include phantom phenomenon. This work supports ongoing purposeful HrQoL research to better define these themes.

BackgroundOutcomes after oesophagogastric cancer surgery remain poor. Cardiopulmonary exercise testing (CPET) used for risk stratification before oesophagogastric cancer surgery is based on conflicting evidence. This study explores the relationship between CPET and postoperative outcomes, specifically for patients undergoing neoadjuvant treatment.MethodsPatients undergoing oesophagogastric cancer resection and CPET (pre- or post-neoadjuvant treatment, or both) were retrospectively enrolled into a multicentre pooled cohort study. Oxygen uptake at peak exercise (VO2 peak) was compared with 1-yr postoperative survival. Secondary analyses explored relationships between patient characteristics, tumour pathology characteristics, CPET variables (absolute, relative to weight, ideal body weight, and body surface area), and postoperative outcomes (morbidity, 1-yr and 3-yr survival) were assessed using logistic regression analyses.ResultsSeven UK centres recruited 611 patients completing a 3-yr postoperative follow-up period. Oesophagectomy was undertaken in 475 patients (78%). Major complications occurred in 25%, with 18% 1-yr and 43% 3-yr mortality. No association between VO2 peak or other selected CPET variables and 1-yr survival was observed in the overall cohort. In the overall cohort, the anaerobic threshold relative to ideal body weight was associated with 3-yr survival (P=0.013). Tumour characteristics (ypT/ypN/tumour regression/lymphovascular invasion/resection margin; P<0.001) and Clavien–Dindo ≥3a (P<0.001) were associated with 1-yr and 3-yr survival. On subgroup analyses, pre-neoadjuvant treatment CPET; anaerobic threshold (absolute; P=0.024, relative to ideal body weight; P=0.001, body surface area; P=0.009) and VE/VCO2 at anaerobic threshold (P=0.026) were associated with 3-yr survival. No other CPET variables (pre- or post-neoadjuvant treatment) were associated with survival.ConclusionsVO2 peak was not associated with 1-yr survival after oesophagogastric cancer resection. Tumour characteristics and major complications were associated with survival; however, only some selected pre-neoadjuvant treatment CPET variables were associated with 3-yr survival. CPET in this cohort of patients demonstrates limited outcome predictive precision.Clinical trial registrationNCT03637647.

Background Malnutrition represents a key priority for global health policy, yet the impact of nutritional state on cancer surgery worldwide remains poorly described. We aimed to analyse the effect of malnutrition on early postoperative outcomes following elective surgery for colorectal or gastric cancer. Methods We did an international, multicentre, prospective cohort study of patients undergoing elective surgery for colorectal or gastric cancer between April 1, 2018, and Jan 31, 2019. Patients were excluded if the primary pathology was benign, they presented with cancer recurrence, or if they underwent emergency surgery (within 72 h of hospital admission). Malnutrition was defined with the Global Leadership Initiative on Malnutrition criteria. The primary outcome was death or a major complication within 30 days of surgery. Multilevel logistic regression and a three-way mediation analysis were done to establish the relationship between country income group, nutritional status, and 30-day postoperative outcomes. Findings This study included 5709 patients (4593 with colorectal cancer and 1116 with gastric cancer) from 381 hospitals in 75 countries. The mean age was 64middot8 years (SD 13middot5) and 2432 (42middot6%) patients were female . Severe malnutrition was present in 1899 (33middot3%) of 5709 patients, with a disproportionate burden in upper-middle-income countries (504 [44middot4%] of 1135) and low-income and lower-middle-income countries (601 [62middot5%] of 962). After adjustment for patient and hospital risk factors, severe malnutrition was associated with an increased risk of 30-day mortality across all country income groups (high income: adjusted odds ratio [aOR] 1middot96 [95% CI 1middot14-3middot37], p=0middot015; upper-middle income: 3middot05 [1middot45-6middot42], p=0middot003; low income and lower-middle income: 11middot57 [5middot87-22middot80], p < 0middot0001). Severe malnutrition mediated an estimated 32% of early deaths in low-income and lower-middle-income countries (aOR 1middot41 [95% CI 1middot22-1middot64]) and an estimated 40% of early deaths in upper-middle-income countries (1middot18 [1middot08-1middot30]). Interpretation Severe malnutrition is common in patients undergoing surgery for gastrointestinal cancers and is a risk factor for 30-day mortality following elective surgery for colorectal or gastric cancer. There is an urgent need to examine whether perioperative nutritional interventions can improve early outcomes following gastrointestinal cancer surgery worldwide.Copyright (c) 2023 The Author(s).

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.