Prehabilitation for major abdominal cancer surgery
Dietitians do prevention in every part of healthcare, even people facing major surgery for cancer, where effective interventions can prevent complications and improve recovery times. In this blog, dietitian Judith Ashcroft describes the multidisciplinary “prehabilitation” programme of which she is a part.
“Would you run a marathon without training for it?” This is the question we ask our patients and surgical teams at Aintree Hospital. Major abdominal surgery is an invasive treatment which causes a decline in physical fitness and often is associated with nutritional deterioration in the “peri-operative” phase (the time in the run up to and immediately after surgery), and therefore we believe it should be trained for.
Prehabilitation is an emerging concept aimed at improving patients’ fitness prior to surgery. Evidence is showing that pre-treatment exercise and nutrition counselling and psychological support speeds up surgical recovery, improves quality of life and improves fitness. The Enhanced Recovery After Surgery (ERAS) pathway has been successfully implemented to reduce surgical complications and length of stay at Aintree Hospital, which is a regional centre for liver and biliary surgery. To improve surgical outcomes even further, “Prehab” was the next step.
I approached my treatment in a better frame of mind” – Prehab Patient
A multidisciplinary team including a dietitian, physiotherapist and therapy assistant began trialling the Prehab programme for two days a week for twelve months from August 2017. A pathway was set up whereby patients being planned for elective surgery were referred by clinical nurse specialists.
For many people, a cancer diagnosis is a catalyst for evaluating lifestyle choices, including exercise levels and diet, and as a team we wanted to use this teachable moment to the greatest effect. Each patient was given a one-to-one appointment with the dietitian and physiotherapist where they were given personalised exercise and nutrition advice based on their current fitness levels and nutritional status as determined using validated questionnaires.
Every patient was also invited to attend group exercise classes which they could attend for one hour once to twice per week leading up to their surgery and during chemotherapy. Patients were also educated on what to expect from the ERAS pathway with regards to diet, nutritional supplements and mobilising on the ward. Six-week post-op appointments were conducted to assess fitness and nutritional status after surgery and to refer on to community gyms or dietetic services.
The service motivated me to keep active in preparation (and to recover after) surgery – Prehab Patient
Over 170 patients have been through the Prehab service so far. Patients feedback through surveys has been very positive, with patients feeling better prepared for surgery, more able to recover quickly, and well cared for and motivated to look after themselves.
The pre-appointment questionnaires were repeated six weeks post surgery and initial data analysis showed that 12% of patients actually had increased function and fitness on six-minute-walk-test, rather than decreased after surgery as would normally be expected. Patients felt 80% more likely to make long term health and lifestyle changes, and their friends/family are now 60% more likely to make similar changes. Mean weight loss was 2.2kg from pre-surgery to post-surgery, with a median of 1kg, indicating that most patients took on board the education provided.
I found it very good for improving my mood and outlook, and it made me feel more positive about myself. – Prehab Patient
So, where next? Evidence has shown there are other patient groups for whom Prehabilitation would be beneficial, such as vascular, lung, breast, and upper GI surgery. Our team is exploring how we can help these groups.
We have also involved patients in steering group meetings and events to promote the service, and their stories and experiences are very powerful evidence of the value of Prehab services. We believe that the results of the trial speak for themselves in demonstrating the necessity of Prehabilitation and the benefits that these services will have for the NHS.