Surgical prehabilitation is possible and feasible in a multitude of settings, is associated with a high degree of patient engagement, and may result in improved post-operative outcomes for patients who are at high risk of developing postoperative complications. The multi-modality and -delivery model pioneered at UHN can be translated to other settings, particularly those with existing rehabilitation infrastructure. Although prehab interventions increase costs up-front, downstream savings may accrue if complications are decreased. Key challenges for implementation elsewhere include integration within existing pre-operative care pathways, timely referral to prehab (exercise interventions likely take 3-4 weeks to demonstrate improvements), patient screening and selection, and types of interventions offered. Prehab remains a promising area of research and clinical optimization, but there are still many questions surrounding interventions, delivery, and outcomes.

Surgical prehabilitation (“prehab”) is an intervention undertaken in the preoperative period to improve postoperative outcomes. This implementation study was designed to assess the feasibility and effectiveness of a multimodal prehab intervention for patients with frailty who were scheduled to undergo high-risk surgeries. Many prior prehab trials have been conducted but very few have documented how to build a program. Interventions undertaken for this study included prescription of aerobic and resistance exercise training, dietary consultation and supplementation, stress management offered by a psychologist, smoking cessation programming and optimization of medical problems, as needed.

Surgeons and their teams referred patients based on clinical frailty, which strongly correlates with adverse surgical outcomes. Participants chose which modalities they wished to join, with nearly all participating in exercise and fewer in nutrition or stress management. Participants were also allowed to choose between in-person, virtual, or hybrid models of delivery. 94% of participants completed the program. Clinically important differences were found in physical performance and psychosocial wellbeing after participation, and all patients returned to their postoperative baseline within 90 days of surgery. Although the study was not designed to compare hard outcomes, compared with controls, participants had 22% fewer major complications and a 3-day shorter length of stay in hospital. Patient satisfaction ratings were very high.

Prehab at UHN has now transitioned to a clinical program and is now one of the largest of its kind in North America. It is supported by COVID recovery funding and has experienced 400% growth in patient volume from Sept 2021 until July 2023. The model of care innovated at UHN is feasible at other centres in the province and represents a patient-centred, health behaviour-focused approach to improving outcomes in the highest-risk surgical patients.

• Sibley, D., Chen, M., West, M.,Matthew, A., Santa Mina, D., & Randall, I. 2023. Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review. Applied Physiology, Nutrition, and Metabolism. 10.1139/apnm-2022-0272
• Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, et al. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol. 2020 Sep 25;10:571091. doi: 10.3389/fonc.2020.571091.
• Santa Mina, D, van Rooijen, SJ, Minnella, E, Alibhai, SMH, Brahmbhatt, P, Gillis, C, Grocott, MPW, et al. Multiphasic prehabilitation across the Cancer Continuum: A narrative review and conceptual framework. Front Oncol. 2021 Jan 11;10:598425.
• Santa Mina D, Sellers D, Au D, Alibhai SMH, Clarke H, Cuthbertson BH, et al. A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations. Front Oncol. 2021 Mar 10;11:629207. doi: 10.3389/fonc.2021.629207.