Background: Prehabilitation shows efficacy to improve surgical outcomes, but scalability is limited by a marked efficacy-effectiveness gap. The intervention is a ‘teachable moment’ to encourage patients, particularly with chronic conditions, for positive lifestyles changes reducing disease burden. Objective: To assess health outcomes and cost of prehabilitation. Methods: Prospective cohort study in a real-life setting, with a control group built using propensity score matching, in candidates for major surgical procedures. Outcomes: comprehensive complication index, hospital and intensive care unit (ICU) stays and hospital costs per patient. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. Results: In the intention-to-treat analysis, no differences were found between study arms (n=328 each). The per-protocol analysis, including only patients completing the prehabilitation program (n=112, 34%), showed a reduction in mean hospital stay (9.9 (7.2) vs. 12.8 (12.4) days; p=0.035). Completers undergoing highly aggressive surgeries (n=60) additionally showed a reduction in ICU stay (2.3 (2.7) vs. 3.8 (4.2) days; p=0.021) and generated mean cost savings per patient of 3,092€ (32% cost reduction) (p=0.007). Five priority areas for action to enhance effectiveness of prehabilitation were identified. Conclusions: The study indicates low rate of completion and identifies priority areas for re-design of service delivery to enhance effectiveness of prehabilitation. Lessons learnt can be generalized to rehabilitation of chronic patients. Funding: ISCIII "FIS-Smart PITeS project (PI18/00841)", co-funded by FEDER/FSE “Una manera de hacer Europa”.

BACKGROUND:Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. METHODS:A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. RESULTS:We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4-30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% -878 - 2642; P=0.365). CONCLUSIONS:Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. CLINICAL TRIAL REGISTRATION:NCT02024776.

Introduction: Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. Objective: To characterize surgical population in a university hospital. Methods: All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. Results: One hundred and forty patients were included (60 +/- 15 yr-old, 56% male, 25% ASA in or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. Conclusions: The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome. (C) 2017 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

We read with interest the article ‘Fit for surgery? Perspectives on preoperative exercise testing and training’ published recently in the British Journal of Anaesthesia. Richardson and colleagues1Richardson K. Levett D.Z.H. Jack S. Grocott M.P.W. Fit for surgery? Perspectives on preoperative exercise testing and training.Br J Anaesth. 2017; 119: i34-43Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar provide profound insights on preoperative cardiopulmonary exercise testing and exercise training interventions (prehabilitation), and stress the fact that most publications on prehabilitation are feasibility or pilot studies, underpowered to assess clinical outcomes. However, this review fails to mention a recent randomised controlled trial published online ahead of print by our group.2Barberan-Garcia A. Ubré M. Roca J. et al.Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial.Ann Surg. 2018; 267: 50-56Crossref PubMed Scopus (390) Google Scholar We showed that a prehabilitation programme including both supervised high-intensity exercise training and promotion of physical activity reduced postoperative complications by 51% in high-risk patients undergoing elective major abdominal surgery. The methodological strengths of our clinical trial overcome limitations observed in previous publications as pointed out in the review by Richardson and colleagues,1Richardson K. Levett D.Z.H. Jack S. Grocott M.P.W. Fit for surgery? Perspectives on preoperative exercise testing and training.Br J Anaesth. 2017; 119: i34-43Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar as the sample size was powered for postoperative complications, using blinded evaluation and ensuring no contamination between study groups. Moreover, the robustness of our findings is supported by the consistency between intention-to-treat, per-protocol, and sensitivity analysis, providing strong evidence to support a relationship between enhanced aerobic capacity and improved postoperative clinical outcomes. In agreement with Richardson and colleagues,1Richardson K. Levett D.Z.H. Jack S. Grocott M.P.W. Fit for surgery? Perspectives on preoperative exercise testing and training.Br J Anaesth. 2017; 119: i34-43Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar multicentre studies assessing the impact of prehabilitation are required. However, it is important to highlight that our recently published clinical trial, not included in their review, provides valuable information supporting the effectiveness of prehabilitation to reduce postoperative complications in major abdominal surgery. We have no conflict of interest to declare.

Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes.To characterize surgical population in a university hospital.All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected.One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity.The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Presentamos el caso de una paciente con diagnósticos de bronquitis crónica, síndrome de apnea obstructiva del sueño y edemas laríngeos de gran tamaño que se intervino para resección mediante microcirugía transoral láser. En el postoperatorio inmediato desarrolló una insuficiencia respiratoria aguda por colapso faríngeo que requirió reintubación en condiciones de urgencia y traslado a UCI no prevista, en la que se mantuvo la ventilación mecánica durante 18h, procediendo a continuación a la extubación. La evolución posterior fue normal. Se describe la asociación de varios factores de riesgo para el tratamiento anestésico y la importancia de detectar en el preoperatorio la gravedad de cada una de las alteraciones, especialmente la severidad del síndrome de apnea obstructiva del sueño.

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for 18 h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome. (C) 2013 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.