1.

Introduction to Enhanced
Recovery Programs: A Paradigm
Shift in Perioperative Care

Liane S. Feldman

What’s the Issue?

Despite improvements in surgical and anesthetic techniques, a
significant proportion of patients experience complications after major
gastrointestinal surgery [1], there is significant variability in care
processes and outcomes between practitioners [2–4], full patient
functional recovery requires weeks or months, even after ambulatory
surgery [5–7], and costs of care continue to rise without resulting in bet-
ter population health [8]. Achieving higher value care for patients,
defined as health outcomes that matter to patients achieved per dollar
spent, must become the goal [8].
Recovery after surgery is an outcome that matters to all stakeholders
involved in perioperative care [9]. Obstacles delaying recovery include
preoperative organ dysfunction, surgical stress and catabolism, pain, post-
operative nausea and vomiting, ileus, fluid excess, semistarvation, immo-
bilization, and surgical traditions or culture [10]. For many surgeons
training in the last 20 years, minimally invasive surgery was the answer to
improving recovery. However, even after low-impact procedures such as
laparoscopic cholecystectomy, full recovery of physical activities takes
longer than most surgeons think [5]. Outside of the traditional purview of
the surgeon, many other interventions have the potential to delay or accel-
erate recovery through their impact on the surgical stress response. These
include afferent neural blockade, pharmacologic interventions, fluid and
temperature management, nutrition, and exercise [11] (Fig. 1.1). There is
abundant evidence to guide best practices in perioperative care [12–14].

L.S. Feldman et al. (eds.), The SAGES / ERAS® 1

Society Manual of Enhanced Recovery Programs for
Gastrointestinal Surgery, DOI 10.1007/978-3-319-20364-5_1,
© Springer International Publishing Switzerland 2015
2 L.S. Feldman

Fig. 1.1. Approaches to reduce surgical stress and improve surgical recovery:
There are many developments in perioperative care that are outside the tradi-
tional purview of the surgeon that have significant potential to accelerate or
delay recovery after surgery (adapted from Kehlet H, Wilmore DW. Evidence-
based surgical care and the evolution of fast-track surgery. Ann Surg.
2008;248:189–98, with permission).

The issue is not lack of evidence or even lack of guidelines. The issue
rather is how can care be organized to make it easier to get this evidence
into practice and improve outcomes for our patients. To make progress,
we have to introduce new interventions that are proven beneficial, and,
perhaps as importantly, stop doing things that are not beneficial and may
even be harmful. But there is an estimated time lag of 17 years between
research and the time it takes to benefit society [15].

What Is an Enhanced Recovery Pathway?

An enhanced recovery pathway (ERP) is an evidence-based, multi-
modal, integrated consensus on perioperative care that reorganizes care
around surgery. The goal is to combine multiple evidence-based
interventions, each of which may have modest impact in isolation, into
 1. Introduction to Enhanced Recovery Programs… 3

Fig. 1.2. In the conventional approach (a), providers work in expertise silos and
the patient moves between these silos. ERPs instead look at the entire trajectory
of perioperative care to standardize processes and integrate interventions into a
cohesive package around the patient (b).

a coordinated, standardized package with synergistic beneficial effects

on reducing physiologic stress and supporting early return of function.
ERPs represent a paradigm shift from a clinician-focused system, where
each stakeholder functions in an expertise silo with significant variability
between providers, to a patient-centered system integrating each step
along the perioperative trajectory into a single pathway (Fig. 1.2). It is
4 L.S. Feldman

not simply a set of standard orders; in addition it should address patient

preparation, intraoperative management, and audit. This approach helps
introduce evidence into practice and results in less morbidity, less need
to remain in hospital, less variability between practitioners, and lower
resource use [16–19].
The ERP approach is a philosophical shift from traditional manage-
ment in several important ways. First, it provides a consistent approach to
perioperative care for all patients undergoing a particular procedure,
regardless of clinician. This standardizes processes and decreases
unwanted variability between practitioners, facilitating decision making
for nurses and for trainees. This requires that the team members arrive at
a consensus for “how we do it” during creation of the pathway. Routine
patients will progress along the predetermined trajectory without the need
for the team to write daily diet, pain, catheter, mobilization, fluid, and
monitoring orders. Patients who are informed of daily milestones begin-
ning in the preoperative period are more engaged and empowered in their
own care. Second, the pathway is geared towards accelerating recovery
for patients without complications, which is the majority of patients.
Rather than keeping all patients fasting because the minority of patients
will not tolerate early oral intake, it allows more patients to benefit from
early nutrition. Of course the team must continue to monitor and intervene
for patients who develop complications. Although surgeons are very tuned
to the “harms” sometimes resulting from surgery, pathways help us better
care for the majority of patients without complications, and in many cases
decrease the risk developing certain complication in the first place.
It is important for the program to address common contingencies or
complications that may occur. For example, absence of voiding after
removal of a urinary drain is best investigated and managed using a
bladder scan-based protocol, in order to avoid automatic reinsertion of
an indwelling catheter [20]. Similarly, intolerance of oral diet is rela-
tively frequent with early feeding after abdominal surgery, and occurs in
up to 35 % of patients to some degree [21]. However, NG tube insertion
is required in less than 10 % of patients, so a stepwise approach should
be outlined.
The ERP approach is applicable across a wide variety of procedures,
in both the inpatient and outpatient settings. It should include key inter-
ventions in the preoperative, intraoperative, and postoperative phases of
care (Table 1.1). Multiple elements of care are addressed in a procedure-
specific manner and follow evidence when available. The expression of
each element may differ between institutions depending on available
resources, experience, and skill, but a standard consensus should be
 1. Introduction to Enhanced Recovery Programs… 5

Table 1.1. Key elements to address and include in development of enhanced

recovery pathways. This approach is applicable across a variety of procedures,
but the expression of each element may differ between procedures and between
institutions.
Preoperative Preoperative risk assessment and optimization of organ
dysfunction
Patient education
Exercise/prehabilitation
Smoking abstinence
Examine use of routine bowel preparation
Modern fasting guidelines
Carbohydrate drinks (when evidence based)
Intraoperative Avoid fluid excess
Regional anesthesia (when evidence based)
Minimally invasive surgery
Short-acting opioids
Maintain normothermia
Glycemic control
Antiemetic prophylaxis (evidence based)
Postoperative Multimodal, opioid-sparing analgesia (evidence based and
procedure specific)
Anti-ileus prophylaxis
Examine use of drains, tubes, catheters, and monitoring (evidence
based)
Early nutrition
Early ambulation
Daily care maps, predefined discharge criteria
Postdischarge rehabilitation plan (evidence based)
From Kehlet H. Fast-track surgery-an update on physiological care principles to
enhance recovery. Langenbecks Arch Surg. 2011;396:585–90; with kind permission
of Springer Science + Business Media

reached within an institution. For example, there are multiple ways to

deliver opioid-sparing multimodal analgesia with one institution relying
on thoracic epidural, whereas others will integrate nerve blocks, while
still others might use intravenous lidocaine with patient-controlled anal-
gesia. The ERP team can also help change routine procedures for the
entire operating room, like introducing modern fasting guidelines, not
only for “pathway” patients.
It is not clear which elements of ERPs are most important, and many
different approaches, ranging from relatively simple to more complex,
can be successful [19]. Development and implementation of an ERP
approach is best accomplished by a multidisciplinary team including
surgeons, anesthesiologists, nurses involved in all phases of care, nutri-
6 L.S. Feldman

tionists, physiotherapists, pain service personnel, and administrators.

This team should meet routinely and have clear deliverables, following
a time line and general principles of project management. Creation and
implementation of a new ERP requires review of evidence or guidelines
for each step in the perioperative trajectory for a specific procedure;
reaching consensus between practitioners on how each care element will
be delivered within the local context; creating patient education materi-
als with daily milestones, standard order sets, nursing flow sheets, and
discharge criteria linked to milestones with a target discharge date; and
training of perioperative personnel. The team should audit selected pro-
cesses and outcomes and revise the program as needed as well as re-scan
the literature for new evidence every 2 years. Although there is nothing
particularly complex about elements of ERPs, it is a change in approach
and as with other quality improvement initiatives, enthusiastic surgical,
anesthesia, and nursing champions, as well as appropriate administrative
support, are critical to the success of the initiative.
Several specialty societies have developed an interest in educating
their members about enhanced recovery. The ERAS Society has devel-
oped an implementation program including an interactive audit that has
coached many centers through implementation. The American College of
Surgeon’s National Surgical Quality Improvement Program (NSQIP) has
an ongoing pilot project to help centers adopt an ERP for colon surgery,
including the ability to monitor care processes in addition to outcomes.
Enhanced recovery courses and workshops are available through SAGES,
the ACS, and others. We at McGill have an annual workshop addressing
ERPs, bringing together over 100 multidisciplinary professionals annu-
ally. Many centres involved in ERPs are happy to mentor colleagues
including through e-mail, phone calls, or site visits to facilitate
implementation.

Outcomes of the ERP Approach

In 2000, Kehlet published a seminal paper describing a multimodal
rehabilitation program for 60 patients (average age 74, 20 patients ASA
III–IV) undergoing elective open colon resection. The postoperative
care program included thoracic epidural, enforced early nutrition, and
mobilization, with a median 2-day hospital stay and 15 % readmissions
[22]. This was the beginning of the “fast track” concept, with significant
comparative research since then investigating the approach. A system-
 1. Introduction to Enhanced Recovery Programs… 7

atic review from 2014 identified 38 randomized trials in colorectal

(18 studies), genitourinary (5 studies), joint (5 studies), thoracic (3 studies),
and upper GI (6 studies) surgery. The review concluded that the use of
an ERP was associated with reduced hospital stay (standard mean differ-
ence 1.14 days) without an increase in readmissions. ERPs were also
associated with a 30 % reduction in complications at 30 days, with no
increased risk of major complications or death. The effect was similar
across different disciplines and for laparoscopic versus open colorectal
surgery [19]. A separate meta-analysis of 13 randomized trials in
colorectal surgery also found a shorter hospital stay by about 2 days,
without increased readmissions. This is related to better organization of
care [23], but also to fewer “general” complications and faster return of
bowel function (by about 1 day) [16]. A systematic review of economic
evaluations of colorectal ERPs found that eight of ten studies reported
lower costs with ERPs [24]. When taking the full care trajectory into
consideration, as well as implementation costs for the ERP, overall soci-
etal costs were lower when an ERP was used, with patients requiring
less time off work and had less care-giver burden [25].
At the McGill University Health Centre, we created a multidisci-
plinary team to create and implement ERP-prevalent procedures across
the department of surgery, building on previous institutional experience
with pathways for laparoscopic foregut surgery [26] and laparoscopic
colon surgery [27]. Working with clinical experts for each procedure, the
team, led by a full-time nurse coordinator, has introduced 11 clinical
pathways into practice, ranging from relatively simple ambulatory pro-
cedures to very complex in-patient procedures like esophagectomy. In
our institution, all patients start the pathway in the preoperative clinic
where standard educational information is reviewed by the preoperative
nurses. Outcomes have been consistent in terms of reductions in hospital
stay for prostatectomy [28], esophagectomy [29], colorectal surgery [25,
30] and lung resection [31], earlier time to achieve recovery milestones
[25, 31], reduced infections [31], and lower costs [25, 32].

Take-Home Messages
s ERPs facilitate introduction of evidence-based practice.
s ERPs foster interdisciplinary collaboration and culture.
s ERPs decrease unwanted variability between practitioners.
8 L.S. Feldman

s ERPs decrease hospital stay by improving care organization,

supporting function, and decreasing morbidity.
s ERPs reduce costs and improve the value of surgical care for
patients.

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accelerate recovery after colonic resection. Ann Surg. 2000;232(1):51–7.
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 Part I
The Science of Enhanced Recovery:
Building Blocks for Your Program
2. Preoperative Education

Deborah J. Watson and Elizabeth A. Davis

Preoperative patient education is an essential element in an enhanced

recovery program. It has been associated with lower levels of anxiety
[1], less postoperative pain, improved wound healing, and shorter hos-
pitalization [2]. Preoperative education provides patients with the tools
they need to manage the stress of their surgical experience and become
partners in their own recovery. Guidelines from the Enhanced Recovery
After Surgery (ERAS®) Society consistently recommend “routine, dedi-
cated preoperative counseling” [3, 4].
Since the enhanced recovery approach may be different from what
patients expect or have previously experienced, they need informa-
tion about how to participate. This should be provided using clear
written guidelines, including specific goals for each day of the peri-
operative period, the expected length of hospital stay, criteria for
hospital discharge [5], and how to continue their recovery following
discharge.
While print materials are frequently used to provide pre- and postop-
erative instructions, these materials are often written at a reading level
beyond the ability of most patients and contribute to confusion and poor
health outcomes for patients with low literacy skills [6]. Many people
are unable to understand and act upon available health information, due
to low health literacy [7].
In this chapter, we explore the concept of health literacy, discuss
ways to improve patient understanding, identify strategies to create
patient-friendly print materials, and describe the preoperative education
model supporting the enhanced recovery program at the McGill
University Health Centre (MUHC) in Montreal, Canada.

L.S. Feldman et al. (eds.), The SAGES / ERAS® 13

Society Manual of Enhanced Recovery Programs for
Gastrointestinal Surgery, DOI 10.1007/978-3-319-20364-5_2,
© Springer International Publishing Switzerland 2015
14 D.J. Watson and E.A. Davis

Health Literacy
Health literacy refers to a set of abilities that allow people to read
and evaluate information, fill out forms, understand and follow direc-
tions, navigate health care facilities, communicate with health profes-
sionals, and use information to make decisions about their health.
Low health literacy has been linked with poor health outcomes [8].
Ratzan and Parker describe health literacy as “the degree to which
individuals have the capacity to obtain, process and understand basic
health information and services needed to make appropriate health
decisions” [7]. The Canadian Expert Panel on Health Literacy defines
it as “the ability to access, understand, evaluate and communicate
information as a way to promote, maintain and improve health in a
variety of settings across the life-course.” The panel recognizes the
role of education, culture, language, the communication skills of pro-
fessionals, the nature of the materials and messages, and the settings
in which education is provided as important factors in the uptake of
health information [9].
In the USA it has been estimated that nearly 50 % of the adult popula-
tion, or 90 million people, have trouble reading and understanding
health information [10]. Six out of ten Canadians do not have the skills
to obtain, understand, and act upon health information and services, or
to make appropriate health decisions on their own [11]. Canada’s Expert
Panel on Health Literacy estimated that more than half of working-age
adults in Canada (55 % or 11.7 million) have inadequate health literacy
skills and seven out of eight adults over the age of 65 (88 % or 3.1 mil-
lion) are in the same situation [12]. In 2011, the European Health liter-
acy survey reported that among the eight participating European
countries, nearly one of two individuals had inadequate or low health
literacy [13]. Those most vulnerable are the elderly, minority groups,
immigrants whose first language is not the language of the majority, the
less educated, and the poor [7].
Health care professionals tend to underestimate the prevalence of low
health literacy because it is not possible to identify this patient popula-
tion by appearance. Most people with low literacy skills are of average
intelligence and able to compensate for their lack of reading ability.
People with low functional health literacy may have feelings of shame
and inadequacy, so may not admit their lack of understanding or ask for
help [14]. While it is not possible to predict low health literacy from a
person’s behavior, certain clues may point to it. Patients may fill out
 2. Preoperative Education 15

forms incompletely or inappropriately. They may be unable to name

their medications or the indications for taking them. They may bring
someone with them to do the reading or they may avoid having to read
in front of others by saying, “I forgot my glasses” or “I’ll read this later”
[10]. Although low levels of literacy predispose people to low health
literacy, people who are good readers may also have low health literacy
skills. In the context of health care, they may not be able to translate
medical jargon and terminology into standard English that makes sense
to them [15].

Strategies to Improve Understanding

Communication between health care providers and patients can be
improved. Weiss suggests that clinicians slow down, use plain, non-
medical language, show or draw pictures, limit the amount of informa-
tion, use the teach-back or show-me technique, and create a shame-free
environment [6]. Other strategies include prioritizing clear communica-
tion within one’s organization and using a “universal precautions”
approach to communication.

Universal Precautions
Health literacy affects every patient interaction in every clinical situ-
ation. People of all ages, races, income levels, and educational back-
grounds are affected by inadequate health literacy and many are unlikely
to admit that they need clarification. If patients do not understand the
information provided by health care professionals, they are at risk for
poor health outcomes. The Canadian Council on Learning reported that
without adequate health literacy skill “ill-informed decisions may be
taken, health conditions may go unchecked or worsen, questions may go
unasked or remain unanswered, accidents may happen, and people may
get lost in the health-care system” [11]. Just as health care providers use
universal precautions to protect against the spread of infectious organ-
isms, we should use universal precautions to protect against inadequate
communication with patients and families [16]. Most people, regardless
of their reading or language skills, prefer medical information that is
easy to understand.
16 D.J. Watson and E.A. Davis

Teach-Back Method
One strategy to reinforce learning and optimize understanding is the
teach-back method. Having patients restate their understanding of key
points in their own words is linked with improved health outcomes [17].
Asking patients whether they understand the information will not con-
firm their understanding. Patients may answer affirmatively, even if they
do not understand, because of embarrassment or intimidation. Instead,
health care providers should say, “To be sure I have explained clearly,
please tell me in your own words what you understand.” Giving patients
sufficient time to explain their perceptions, and repeating or clarifying
information when needed, may optimize learning.

Internet Resources
Many patients are turning to the Internet for health information. Recent
statistics indicate that 2/3 of Internet users seek health information online.
It is considered the third most common Internet activity [18]. Not all web-
sites are reliable. Some sites may be misleading and confusing for the
average health care consumer. There is a plethora of website evaluation
tools available and health care providers should become comfortable
assessing health information websites in order to recommend reliable ones
to their patients. At our institution, patients seeking more information
about their surgical procedure, anaesthesia, becoming fit, or smoking ces-
sation are referred to appropriate websites in our printed material.

Patient-Friendly Print Materials

Patient-friendly print materials are essential tools in the preoperative
education toolkit. A procedure-specific patient guide increases consis-
tency for the messages received throughout the perioperative period. It
reinforces the verbal messages patients receive from members of the
health care team. Lists of daily goals create realistic expectations about
such things as postoperative nutrition, mobilization, and length of hos-
pital stay. Two elements of information identified by patients as particu-
larly valued are explicit plans for the day and knowing their recovery
goals [19]. These messages reduce anxiety and allow patients to play an
active role in their own recovery. The use of images helps patients to
visualize their progress (Fig. 2.1).
 DAY of DAY AFTER DAYS AFTER DAYS AFTER DAYS AFTER
SURGERY 1 SURGERY 2 SURGERY 3 SURGERY 4 SURGERY
Path to Home Guide:
Liver Surgery

Breathing
Exercises
x3 x3

Activities
Epidural Epidural Epidural Pills
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Pills

pain should be pain should be pain should be

kept below 4 kept below 4 kept below 4
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

pain should be pain should be

Pain Control
kept below 4 kept below 4
Gum, protein drinks, Gum, protein drinks, Gum, protein drinks, Gum, protein drinks,
Gum, clear liquids.
food as tolerated. food as tolerated. food as tolerated. food as tolerated.

GUM GUM GUM GUM

GUM GUM GUM GUM

Nutrition
GUM

GUM

This material is also available through the

MUHC Patient Education Office website
(www.muhcpatienteducation.ca)

© copyright 13 May 2014, McGill University Health Centre.

Reproduction in whole or in part without express written permission of

Tubes & Drains

[email protected] is prohibited.

Fig. 2.1. Example of patient-friendly information illustrating daily goals for nutrition, pain management, drains, and exercise after liver
surgery. This was created by the McGill Surgical Recovery Group and the McGill University Health Centre (MUHC) Patient Education
2. Preoperative Education

Office. It is given to patients as part of the information package discussed in the preoperative clinic and is available on the surgical wards
as large posters. For each pathway, the same template is used to create patient-friendly materials aligned with procedure-specific daily
17

goals (courtesy of the McGill University Health Centre Patient Education Office).
18 D.J. Watson and E.A. Davis

Plain Language
The use of plain language, instead of technical language or medical
jargon, will improve the clarity of communication. Plain language is a
way of organizing and presenting information so that it makes sense and
is easy for everyone to understand [20]. It uses logical organization,
simple words, short sentences, active voice, and friendly tone, to make
written material easier to read. An essential feature of writing in plain
language is testing the material with the target audience to determine
whether the audience understands the intended message.
Plain language is a patient-centered approach to writing. It uses
familiar words and a conversational style to convey information clearly
so that it can be understood by as many people as possible. For exam-
ple, instead of saying, “Participants should register prior to the start of
the program,” it is clearer to say, “Please sign up before the program
begins.” Writers of plain language materials must make choices about
what to include in each document to keep them from being too long. It
is best to identify one primary message and support it with a limited
number of key points. A strategy for selecting these points is to consider
what the reader should know, do, and feel as a result of reading the
material [21].
A difference of opinion exists about what grade level should be the
target for writing in plain language. Grade level is an estimate of read-
ability as it relates to years of schooling. The higher the grade level, the
more difficult it is to understand the text. The Canadian Public Health
Association recommends, when writing for the general public, that
material should be written between grade levels 6 and 8 so that it has a
better chance of being understood by all readers [22]. Researchers have
established that the literacy demands of most health materials exceed
the reading abilities of the average adult [23]. Regardless of grade level,
the main focus should be on whether materials can be understood by the
target audience. Evaluation by the target audience is an essential part of
development.
Writing in plain language is a skill that requires time and effort to
master. It involves a thorough understanding of the readers’ needs, and the
ability to explain complex medical information in a clear, meaningful way.
Many health care professionals have become accustomed to writing for
their colleagues using complex vocabulary and a more formal style. This
 2. Preoperative Education 19

“professional” style of writing is actually a barrier to communication

with patients [10].
Critics of plain language suggest that it may offend people who have
strong reading skills. However, research shows that people actually pre-
fer materials that are easy to read [6]. Plain language accurately explains
concepts and information in a way that eliminates barriers to under-
standing and demonstrates respect for the audience [10].

Clear Design
Clear design refers to the layout of a document. For educational
materials, design features should be chosen to make the information
look attractive and easy to read. Design should be simple, well orga-
nized, and consistent throughout the document. It should guide readers
through the material and help them find and remember information [10].
Elements to be considered are font, type size, line length, white space,
bullets, and images.
A font size of at least 12 points is recommended for patient education
material [24]. The use of upper and lower case letters improves read-
ability since it is more difficult to read words that are written in all capi-
tal letters. Using plenty of white space makes the text more inviting and
allows the reader to see how the material is organized. Dense, crowded
text can be intimidating to readers [25]. The use of boxes will draw
attention to materials that should be emphasized. Vertical lists of words
or statements, using bullets, are easier to read and remember than lists
written in paragraph form. However, lists should be limited to no more
than seven items or the reader will be overwhelmed [24].

Images
Images should facilitate learning [26]. Pictures should illustrate and
reinforce the text, be simple and realistic, include captions, and be cul-
turally appropriate. When body parts are pictured, they should be shown
in the context of the whole body [10, 21].
20 D.J. Watson and E.A. Davis

Preoperative Education Model

A shift in organizational culture to one that values preoperative edu-
cation is fundamental. Making patient education an organizational prior-
ity and creating a shame-free environment that encourages patients to
speak up and ask questions should be the first step when setting up an
enhanced recovery program. All health care providers must be sensitized
to the concept of health literacy and understand its impact on health
outcomes. In many cases, nurses’ knowledge of health literacy is limited
and organizations do not prioritize it [27].
In our organization, the orientation program for preoperative nurses
includes information about health literacy. Nurses who work in the pre-
operative clinic are selected not only for their critical thinking ability,
but also for their educational skills. We use a multidisciplinary approach
to developing patient education materials, so that information is less
fragmented. A preoperative visit is scheduled at least 2 weeks before the
date of surgery, and a nurse, physician, and nutritionist meet each patient
individually. For colorectal surgery, the enteral stoma nurse is also part
of the team, meeting with future stoma patients preoperatively for their
first education session. We prefer a unique preoperative clinic visit sepa-
rate from when the patient was given initial information about their
diagnosis, and recommend the presence of a caregiver during the educa-
tion session if possible.
All patients receive a procedure-specific booklet to guide them
through their perioperative journey. These materials are created along-
side the creation of each new pathway in our department. We do not
introduce a new pathway into clinical practice without having the
patient materials. The preoperative clinic nurse reviews the booklet
with the patient and asks them to bring it with them to the hospital when
they come for surgery. A poster with the key daily milestones is
included and also printed in poster size for the surgical wards.
Evaluation of patient booklets is done on an ongoing basis and materi-
als are modified based on patient and staff feedback and new evidence.
Patients respond positively to the booklets, using them as a resource
before, during, and after their surgery. Enhanced recovery patient mate-
rials are also available on the Internet for patients who prefer to access
them on a computer, tablet, or phone. The booklets and poster inserts
are all available for download in pdf format by the MUHC Patient
 2. Preoperative Education 21

Education Office (www.muhcpatienteducation.ca/surgery-guides/

surgery-patient-guides.html?sectionID=31).
Patients who are expected to have an ostomy are given the link to an
online learning module to help them prepare for surgery, manage their
stoma, and reinforce the verbal information they receive (information
available at http://www.muhcpatienteducation.ca/surgery-guides/
ostomy.html?sectionID=132).

Conclusion
In order for an enhanced recovery program to be successful, it is
necessary to include patients as informed participants in the process.
Preoperative education should be provided by an interprofessional team,
using clear communication and patient-friendly teaching materials. This
has been shown to reduce anxiety and improve surgical outcomes.

Take-Home Messages
• Preoperative education is an essential component of an enhanced
recovery program.
• Health care providers should understand the prevalence of low
health literacy and its impact on patient outcomes.
• Printed materials using plain language and clear design may
improve patient understanding of health information.
• Pictures linked to written or spoken text may increase patient
attention, understanding, recall, and adherence to instructions.

References
1. Alanazi AA. Reducing anxiety in preoperative patients: a systematic review. Br J
Nurs. 2014;23(7):387–93.
2. Keicolt-Glaser JK, Page GG, Marucha PT, et al. Psychological influences on surgical
recovery. Am Psychol. 1998;53:1209–18.
3. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elec-
tive colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommen-
dations. World J Surg. 2012;37:259–84. doi:10.1007/s00268-012-1772-0.
22 D.J. Watson and E.A. Davis

4. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/
pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommenda-
tions. World J Surg. 2012;37:285–305. doi:10.1007/s00268-012-1787-6.
5. Feldman LS, Baldini G, Lee L, et al. Enhanced recovery pathways: organization of
evidence-based, fast-track perioperative care. In: Fink MP, editor. ACS surgery: prin-
ciples and practice. New York: WebMD; 2013.
6. Weiss B. Health literacy: a manual for clinicians. Chicago, IL: American Medical
Association and American Medical Association Foundation; 2003.
7. Nielsen-Bohlman L, Panzer A, Kindig D, editors. Health literacy: a prescription to end
confusion. Washington, DC: The National Academies Press; 2004.
8. Bass L. Health literacy: implications for teaching the adult patient. J Infus Nurs.
2005;28:15–22.
9. Rootman I, Gordon-El-Bihbety D. A vision for a health literate Canada: report of the
expert panel on health literacy. Ottawa, ON: Canadian Public Health Association;
2008. http://www.cpha.ca/en/portals/h-l/panel.aspx. Accessed 11 June 2009.
10. Wizowski L, Harper T, Hutchings T. Writing health information for patients and fami-
lies: a guide to creating patient education materials that are easy to read, understand
and use. 3rd ed. Hamilton: Hamilton Health Sciences; 2008.
11. Canadian Council on Learning. Health literacy in Canada: a healthy understanding.
Ottawa, ON: Canadian Council on Learning; 2008. http://www.ccl-cca.ca/CCL/
Reports/HealthLiteracy?Language=EN. Accessed 11 June 2009.
12. National Assessment of Adult Literacy. National Center for Education Statistics.
USA: Department of Education; 2003.
13. Doyle G, Cafferkey K, Fullam J. The European Health Literacy Survey: results from
Ireland. In: EU Health Literacy Survey. MSD/NALA Health Literacy Initiative. 2012.
Available via healthliteracy.ie. http://www.healthliteracy.ie/wp-content/
uploads/2010/11/EU-Health-Literacy-Survey-Full-Report.pdf. Accessed 28 Aug 2014.
14. Parikh N, Parker R, Nurss J, et al. Shame and health literacy: the unspoken connec-
tion. Patient Educ Couns. 1996;27:33–9.
15. Mayer G, Villaire M. Health literacy in primary care: a clinician’s guide. New York:
Springer; 2007.
16. Brown D, Ludwig R, Buck G, et al. Health literacy: universal precautions needed.
J Allied Health. 2004;33:150–5.
17. Tamura-Lis W. Teach-back for quality education and patient safety. Urol Nurs.
2013;33(6):267–71. doi:10.7257/1053-816X.2013.33.6.267.
18. Zickuhr K. Generations online in 2010. Available from: http://pewinternet.org/
Reports/2010/Generations-2010/Overview.aspx. Cited Nov 2010.
19. Caligtan CA, Carroll DL, Hurley AC, et al. Bedside information technology to support
patient-centered care. Int J Med Inform. 2012;81:442–51.
20. Cornett S. The Ohio State University Health Literacy Distance Education. Module #7:
guidelines for selecting and writing easy to read health materials. 2011. www.health-
literacy.osu.edu. Accessed 30 Nov 2011.
21. Osborne H. Health literacy from A to Z: practical ways to communicate your health
message. Sudbury, MA: Jones and Bartlett; 2005.
 2. Preoperative Education 23

22. Canadian Public Health Association. Plain Language Service. 2008. http://www.cpha.
ca/en/pls/FAQ.aspx. Accessed 26 July 2009.
23. Rudd R. Literacy implications for health communications and for health. 2001. http://
www.hsph.harvard.edu/healthliteracy/talk_rudd.html. Accessed 11 June 2009.
24. Doak C, Doak L, Root J. Teaching patients with low literacy skills. Philadelphia, PA:
Lippincott; 1996.
25. Smith S, Trevena L, Nutbeam D, et al. Information needs and preferences of low and
high literacy consumers for decisions about colorectal cancer screening: utilizing a
linguistic model. Health Expect. 2008;11:123–36.
26. Macabasco-O'Connell A, Fry-Bowers EK. Knowledge and perceptions of health lit-
eracy among nursing professionals. J Health Commun. 2011;16 Suppl 3:295–307. doi
:10.1080/10810730.2011.604389.
27. Houts PS, Doak CC, Doak LG, et al. The role of pictures in improving health
communication: a review of research on attention, comprehension, recall, and adher-
ence. Patient Educ Couns. 2006;61:173–90.

Key References
Weiss B. Health literacy: a manual for clinicians. Chicago, IL: American Medical
Association and American Medical Association Foundation; 2003.
Wizowski L, Harper T, Hutchings T. Writing health information for patients and families:
a guide to creating patient education materials that are easy to read, understand and
use. 3rd ed. Hamilton: Hamilton Health Sciences; 2008.
Osborne H. Health literacy from A to Z: practical ways to communicate your health mes-
sage. Sudbury, MA: Jones and Bartlett; 2005.
Houts PS, Doak CC, Doak LG, et al. The role of pictures in improving health communica-
tion: a review of research on attention, comprehension, recall, and adherence. Patient
Educ Couns. 2006;61:173–90.
3. Medical Optimization
and Prehabilitation

Thomas N. Robinson, Francesco Carli,

and Celena Scheede-Bergdahl

Medical Optimization
Preoperative medical optimization goes beyond simple preoperative
risk assessment and aims to improve surgical outcomes. A concept criti-
cal to successful preoperative medical optimization is to target patients
with preexisting physiologic compromise in whom physiologic reserves
can be improved to better withstand the planned surgical intervention. In
contrast, a healthy non-compromised patient has relatively less to gain
from preoperative medical optimization efforts. This chapter provides
specific, practical recommendations to optimize postoperative out-
comes by focusing on the optimizing pulmonary status, cardiac disease,
medication management, glucose control, frailty, and prehabilitation
(Table 3.1).

Pulmonary Interventions
Inspiratory Pulmonary Training
Inspiratory muscle training using incentive spirometry breathing
exercises preoperatively reduces postoperative pulmonary complica-
tions. An example of a preoperative inspiratory muscle training regimen
is training patients to perform 20 min daily of incentive spirometry
breathing exercises for at least 2 weeks prior to an operation. Following
cardiac operations, this protocol can reduce both serious pulmonary
complications and pneumonia by 50 %.

L.S. Feldman et al. (eds.), The SAGES / ERAS® 25

Society Manual of Enhanced Recovery Programs for
Gastrointestinal Surgery, DOI 10.1007/978-3-319-20364-5_3,
© Springer International Publishing Switzerland 2015
26 T.N. Robinson et al.

Table 3.1. Preoperative medical optimization

and prehabilitation—overview.
Pulmonary
• Inspiratory pulmonary training
• Smoking cessation
Medication management
• Anticoagulation
Cardiac
• Beta-blockers
Diabetes
• Glucose management
Geriatric assessment
• Assess frailty
Prehabilitation

Smoking Cessation
Stopping smoking can reduce postoperative complications. Numerous
studies have found that smoking cessation can reduce postoperative
complications, and particularly pulmonary complications, by more than
40 %. Evidence suggests that at least 4 weeks of no smoking is required
to allow the postoperative benefits of smoking cessation; this fact may
require delay in elective scheduling of an operation.

Cardiac Interventions
The literature regarding beta-blockade for reduction of postoperative
myocardial ischemia is mixed and sometimes contradictory. The poten-
tial benefit of perioperative beta-blockade when used in high-risk
patients is a reduction of postoperative ischemia, myocardial infarction,
and cardiovascular death in high-risk patients. However, perioperative
beta-blockade has been found in some studies to increase the risk of
stroke and even death, particularly in beta-blocker naïve patients.
Strong evidence exists both to continue beta-blockers in the periopera-
tive period in patients who are chronically on beta-blockers and to
prescribe beta-blockers for high-risk patients with coronary artery dis-
ease who are undergoing high-risk operations (e.g., major vascular
operations).
 3. Medical Optimization and Prehabilitation 27

Medication Management
Anticoagulation Management
Managing anticoagulants in the perioperative setting is becoming
increasingly commonplace. The decision regarding anticoagulation
around an elective operation balances the risk of thromboembolism
against the risk of bleeding. In patients with a high risk of thromboem-
bolism (e.g., mechanical heart valve, venous thromboembolism within 3
months, high-risk atrial fibrillation), bridging of oral warfarin antico-
agulation with shorter lasting low-molecular-weight heparin injections
is recommended. An evidence-based regimen for bridging therapy is
described in Table 3.2. In patients with low risk of thromboembolism
(e.g., bileaflet valve without risk factors, venous thromboembolism
more than 12 months previously, low-risk atrial fibrillation), no bridging
with low-molecular-weight heparin is recommended. In these low-risk
cases, warfarin should be stopped 5 days prior to the planned operation
and started 12–24 h postoperatively.
Target specific oral anticoagulants are a new class of oral anticoagu-
lants. These medications are cleared by the kidneys. With normal renal
function, the medications rivaroxaban and dabigatran should be stopped
24 h prior to a standard bleeding risk operation and 48–72 h prior to a
high-risk bleeding operation.
Antiplatelet drugs represent a common dilemma in perioperative
care. In general for low-bleeding-risk operations, antiplatelet therapy
with aspirin and clopidogrel can be continued throughout the periopera-

Table 3.2. Bridging warfarin anticoagulation with low-molecular-weight

heparin—an evidence-based approach.
Preoperative
5 days pre-op Stop warfarin 5 days
3 days pre-op Begin subcutaneous low-molecular-weight heparin
(enoxaparin 1 mg/kg Q12 h or dalteparin 200 IU/kg Q24 h)
24 h pre-op Discontinue LMWH injections
Administer approximately ½ total daily dose for the last dose
Postoperative
Post-op LMWH Low-risk bleeding—24 h post-op
resumption High-risk bleeding—48–72 h post-op
12–24 h post-op Resume warfarin
Lab testing Check INR at 5–7 days
Acronyms: LMWH low-molecular-weight heparin
28 T.N. Robinson et al.

tive setting. For high-risk bleeding operations, aspirin should be stopped

5 days prior to the procedure for low-cardiovascular-risk patient and are
recommended to be continued throughout the perioperative period in
patients with high risk of an adverse cardiovascular event. And finally,
clopidogrel should be stopped 5 days prior to major operations. If
patient are at high risk of an adverse cardiovascular event, bridging
therapy with short-acting GPIIb/IIIa antagonists may be considered.

Glucose Management
Patients with diabetes are at higher risk for postoperative morbidity
and mortality. For diabetics, operations should be scheduled early in the
morning to avoid prolonged periods of starvation. Additionally, patients
with poorly controlled glucose or end-organ dysfunction related to dia-
betes should be recognized as high risk and optimal glucose control
should be achieved preoperatively. While hyperglycemia is associated
with development of complications, it is not yet clear which level of
glycemia should be targeted to improve postoperative outcomes.

Frailty Evaluation
Older adults have increased surgical risk due to globally reduced
physiologic reserves, a phenomenon termed frailty. Frailty by definition
confers increased risk of adverse healthcare events including disability.
The presence of frailty independently predicts adverse surgical out-
comes including complications, need for discharge institutionalization,
and mortality.
The measurement of frailty is completed by simple clinical tests that
quantify the various domains, or characteristics, which make up the frail
older adult. Frailty characteristics include impaired cognition, functional
dependence, poor mobility, undernutrition, high comorbidity burden,
and geriatric syndromes. A person is determined to be frail by summing
the number of abnormal frailty characteristics present preoperatively.
Frail older adults will have an accumulation of a higher number of
abnormal frailty characteristics than the non-frail older adult. Clinical
characteristics of frailty and simple clinical tools to measure these char-
acteristics can be found in Table 3.3. Finding frailty in an older adult
prior to an operation may be an indication for interventions such as
prehabilitation.
 3. Medical Optimization and Prehabilitation 29

Table 3.3. Characteristics of the frail older adult.

Frailty Clinical measurement tool (abnormal score)
characteristic
Impaired cognition Mini-Cog Test (≤3)
Mini-Mental Status Exam (≤24)
Functional Katz Activity of Daily Living Test (one or more
dependence dependent ADLs)
Instrumental Activity of Daily Living Test (one or more
dependent iADLs)
Poor mobility Time Up-and-Go Test (≥15 s)
5 m walking speed (≥6 s)
Undernutrition ≥10 lb weight loss in past year
Hypoalbuminemia (<3.4 g/dL)
High comorbidity Charlson Index (≥3)
burden Cumulative Illness Rating Score (≥3)
Geriatric syndromes Unintentional fall in past 6-months (≥1 fall)
Presence of a pressure ulcer

Prehabilitation
Impact of Surgery on Physical and Emotional
Functions
Despite advances in surgical techniques, anesthetic pharmacology,
and perioperative care, which have made even major operations safe and
accessible to a variety of patients potentially at risk, there remains a
group of patients who have suboptimal recovery. Almost 30 % of patients
undergoing major abdominal surgery have postoperative complications,
and, even in the absence of morbid events, major surgery is associated
with 40 % reduction in functional capacity. Patients experience physical
fatigue, disturbed sleep, and a decreased capacity to mentally concentrate
for up to 9 weeks once they return home from surgery. Long periods of
physical inactivity induce loss of muscle mass, deconditioning, pulmo-
nary complications, and decubitus. Preoperative health status, functional
capacity and muscle strength, and anxiety and depression correlate with
postoperative fatigue, medical complications, and postoperative cogni-
tive disturbances, and this is particularly true in the elderly, persons with
cancer, and persons with limited physiological and mental reserve who
are the most susceptible to the negative effects of surgery.
30 T.N. Robinson et al.

Traditionally efforts have been made to improve the recovery process

by intervening in the postoperative period. However, the postoperative
period may not be the most opportune time as any of these surgical
patients are tired, depressed, and anxious. These patients may be await-
ing extra treatment for the tumor and are therefore unwilling to be
engaged in any rehabilitative process. Instead, the preoperative period
may be a more appropriate time to engage the patients in building up
physical reserve, and with the understanding that these activities would
help them to overcome the stress of surgery.

What Is Surgical Prehabilitation?

The process of enhancing functional capacity of the individual to
enable him or her to withstand an incoming stressor has been termed
prehabilitation. Conventionally, patients are prepared for the stresses of
surgery through education and positive reinforcement; however, the use
of an exercise program prior to surgery is not routinely practiced.
The benefits of exercise have been demonstrated for the prevention/
management of many chronic conditions, and in medicine, regular
exercise has been shown to decrease the incidence of ischemic heart
disease, hypertension, diabetes, stroke, and fractures in the elderly,
related to improved balance and strength. With regular physical activity,
there is increase in aerobic capacity, a decrease in sympathetic over-
reactivity, an improvement of insulin sensitivity, and increased ratio of
lean body mass to body fat. Exercise training, particularly in sports
medicine, has been used as a method of preventing a specific injury or
facilitating recuperation. Evidence seems to suggest that, by increasing
the aerobic and muscle strength capacity of the patient by means of
increased physical activity prior to surgery, physiological reserve
increases and postoperative recuperation is facilitated.
The first published systematic review included 12 studies and con-
cluded that preoperative exercise therapy was effective for reducing
postoperative complication rates and accelerating the hospital discharge
of patients undergoing cardiac and abdominal surgery. All four studies on
cardiac and abdominal surgery reported the beneficial effect of inspira-
tory muscle training as a primary intervention. The risk of developing
postoperative pulmonary complications was significantly higher in the
group that did not receive training. Unfortunately, little information
regarding the type of exercise, frequency, duration, and intensity was
provided. Conversely, the outcome after joint arthroplasty was not
 3. Medical Optimization and Prehabilitation 31

significantly affected by preoperative exercise therapy. In the orthopedic

groups, the prehabilitation program lasted for up to 6 weeks, while in the
cardiac and abdominal group the average was 3–4 weeks. Whether these
inconsistencies were due to variations in the physical status of the
patients or the different muscle groups targeted was not established.
More recently, another systematic review of eight studies demonstrated
that exercise confers some physiologic improvement, however with lim-
ited clinical benefit not always translated into better clinical outcome.
An initial randomized trial conducted by our group in patients
undergoing colorectal surgery comparing a 4-week home-based
intense (aerobic and resistance) exercise program with a “sham” inter-
vention consisting of a daily walk and breathing exercises before sur-
gery showed a deterioration in postoperative functional capacity in the
intense exercise group. Full adherence with the exercise program was
very low. Predictors of poor surgical outcome included functional
deterioration while waiting for surgery, age over 75 years, high anxi-
ety, and lack of social support. These results suggest that an interven-
tion based on intense exercise alone was not sufficient to enhance
functional capacity if factors such as nutrition, anxiety, and other
perioperative care elements (e.g., smoking and alcohol cessation, gly-
cemic control, standardized intraoperative and early postoperative
surgical and anesthetic care) were not taken into consideration during
the program. This highlights the point that while physical activity
undoubtedly has several benefits in restoring physiological reserve in
preparation for abdominal surgery, one cannot exclude the important
role played by other modalities such as pharmacological optimization,
nutritional supplementation, cognitive enhancement, psychosocial
support, and caregiver involvement.
Based on these findings, we designed a multimodal prehabilitation
program consisting of moderate-intensity physical exercise, comple-
mented by nutritional counseling/supplementation and anxiety reduction
strategies. The benefits of this approach were supported by a recent pilot
study, followed by a subsequent RCT comparing initiation of the pro-
gram prior to colorectal cancer surgery or afterwards. In the prehabilita-
tion program, over 80 % of patients recovered to their baseline functional
walking capacity by 8 weeks, compared to only 40 % of patients in the
control group (Fig. 3.1).
32 T.N. Robinson et al.

Minimum
level of
functional
ability

Prehabilitation Surgical Rehabilitation Post-rehabilitation

phase procedure phase phase

Minimum level
of functioning
Prehab-patient

Non-prehab patient

Fig. 3.1. Trajectory of functional capacity throughout the surgical process.

Representation of trajectory of functional capacity demonstrates an abrupt
decline postoperatively, followed by a slow return (“recovery”) to baseline. A
prehabilitation intervention, by increasing functional reserve preoperatively,
results in less of a drop in capacity and faster return to baseline levels (from
Carli F, Zavorsky GS. Optimizing functional exercise capacity in an elderly
surgical population. Curr Opin Nutr Metab Care 2005;8:23–32, with permission).

Physical Activity as an Essential Component

of Prehabilitation
Both strength and aerobic training increase endurance capacity, play
an important role in weight management, improve muscle strength,
reduce the risk of fall, and increase the range of motion in a number of
joints, particularly in the elderly.
Current recommendations for aerobic exercise for the elderly popula-
tion include a combination of moderate-to-vigorous intensities, if
deemed appropriate for the individual. These intensities, on a scale of
1–10 representing a rating of perceived exertion (RPE), should be
approximately 5–6 for moderate and 7–8 for vigorous exercises
(Fig. 3.2). In the case of this population, the exercise intensity should
start conservatively at first, and progress depending on the physical
 3. Medical Optimization and Prehabilitation 33

Fig. 3.2. Sample of the Rate of Perceived Exertion Scale (RPE, Borg). A scale
such as this may be transferred onto a large poster board and mounted within
view of the exercising patient. Often the RPE is color coded (from green or blue
at rest to red at maximal efforts) or has cartoons representing effort. Key words
represent exercise intensity (from Carli F, Scheede-Bergdahl C. Prehabilitation
to enhance perioperative care. Anesthesiol Clin 2015;33:17–33, with permission).

status, abilities, and concurrent medical conditions of each individual.

The intensity of exercise included in prehabilitation programs should
introduce the activity at an intensity that is more than what the individ-
ual already partakes in, so that the body experiences the “stress” of
additional work. It is, however, important to avoid prescribing exercise
that is too intense, which may result in fatigue, injury, or—as in our
previous experience—poor adherence. The modality of training may
include activities such as walking, swimming, cycling, or other similar
34 T.N. Robinson et al.

Table 3.4. Key guidelines for older adults (2008 physical activity guidelines for
Americans).
The following guidelines are the same for adults and older adults:
• All older adults should avoid inactivity. Some physical activity is better than
none, and older adults who participate in any amount of physical activity gain
some health benefits.
• For substantial health benefits, older adults should do at least 150 min (2 h
and 30 min) a week of moderate-intensity or 75 min (1 h and 15 min) a week
of vigorous-intensity aerobic physical activity, or an equivalent combination
of moderate- and vigorous-intensity aerobic activity. Aerobic activity should
be performed in episodes of at least 10 min, and preferably, it should be
spread throughout the week.
• For additional and more extensive health benefits, older adults should
increase their aerobic physical activity to 300 min (5 h) a week of moderate-
intensity or 150 min a week of vigorous-intensity aerobic physical activity, or
an equivalent combination of moderate- and vigorous-intensity activity.
Additional health benefits are gained by engaging in physical activity beyond
this amount.
• Older adults should also do muscle-strengthening activities that are of
moderate or high intensity and involve all major muscle groups on 2 or more
days a week, as these activities provide additional health benefits.
The following guidelines are just for older adults:
• When older adults cannot do 150 min of moderate-intensity aerobic activity a
week because of chronic conditions, they should be as physically active as
their abilities and conditions allow.
• Older adults should do exercises that maintain or improve balance if they are
at risk of falling.
• Older adults should determine their level of effort for physical activity
relative to their level of fitness.
• Older adults with chronic conditions should understand whether and how
their conditions affect their ability to do regular physical activity safely.
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activity. Most importantly is that the patient enjoys the activity and is
able to maintain the activity for at least 10 min per session. Physical
activity guidelines for older adults are presented in Table 3.4.
As there is a decrease in skeletal muscle mass and muscle strength as
a result of age and disease, the implementation of resistance training,
which has been shown to reduce this rate of decline, is extremely
important for prehabilitation. Such training has positive effects on
functionality, health, and quality of life. Again, in order to achieve
strength gains in untrained individuals, the patient should be able to
perform 8–12 repetitions of each exercise, with the final one or two
 3. Medical Optimization and Prehabilitation 35

becoming “difficult to perform.” These exercises should be progressed

as the patient finds it “relatively easy” to perform the 12 repetitions.
Resistance training exercises should be performed approximately 2–3
times a week on non-consecutive days, allowing for adequate recovery
between sessions. Progressive prehabilitation strength-program guide-
lines for resistance training are recommended for elderly and frail people.
A minimum of 8–10 different exercises involving the major, multi-jointed
muscle groups (arms, shoulders, chest, abdomen, back, hips, and legs)
are recommended. A sample training program has been included in
Table 3.5.

Complementing Physical Activity with Nutrition

The nutritional status of patients scheduled for abdominal surgery is
directly influenced by the presence of cancer or chronic disease which
impacts on all aspects of intermediary (protein, carbohydrate, lipid, trace
element, vitamin) metabolism. Thus, the primary goal of nutrition ther-
apy during the prehabilitation period is to optimize nutrient stores pre-
operatively and provide adequate nutrition to compensate for the
catabolic response of surgery postoperatively.
The benefits of integrating nutrition and physical exercise have been
studied in elderly patients whereby it has been shown that a minimum of
140 g of carbohydrate taken 3 h before exercise increases liver and
muscle glycogen and facilitates the completion of the exercise session.
Also the time of ingesting a protein meal is of importance; elderly indi-
viduals who consume 10 g proteins immediately after weight training
have their mean quadriceps fibre area increased by 24 % as well as their
dynamic muscular strength.
With regard to the type of nutrients, a synergistic effect has been
shown between arginine and fish oils with positive impact on postopera-
tive morbidity. Whey protein is another nutritional component that has
attracted the interest of exercise physiologists as it is a protein which is
highly bioavailable, is rapidly digested, and contains all the indispens-
able amino acids. Whey protein is also associated with an increase in
protein synthesis, and is found to score highest on the quality assess-
ments used to assess protein quality, such as net protein utilization,
biological value, and the protein digestibility. Finally, whey protein
plays a role in oxidative stress defense, by increasing the content of
intracellular stores of the antioxidant glutathione (GSH). GSH is a major
intracellular antioxidant that neutralizes reactive oxygen species (ROS)
36 T.N. Robinson et al.

Table 3.5. Example of 4-week prehabilitation program including physical

activity, nutrition, and relaxation exercises.
Aerobic exercise
• Start a slow walk in order to adequately warm up
• 30-min minimum of aerobic activity (walking/biking) three times per week at
moderate intensity (4–6 on the Borg Scale). If the participant finds the
activity to be easier (2–3 on the Borg Scale) then the walking pace or
duration should be gradually increased. It is recommended not to surpass 7–8
on the Borg Scale. Example: Walk at a normal pace for 5 min and then walk
at a quicker pace for 2 min and repeat for the duration of time
Resistance exercise
• All exercises are to be done starting with one set of about 10–12 repetitions.
Number of sets and repetitions gradually increase to two sets, and 12–15
repetitions
– Use of a Theraband/handheld weights and some body weight exercises
– Body weight exercise involve the following:
– Push-ups (wall, modified, or full)
– Squats with the use of a chair
– Hamstring curls
– Calf raises
– Abdominal crunches (chair or floor)
– Theraband/handheld weight exercises involve the following:
– Chest exercise
– Deltoid lifts
– Bicep curls
– Triceps extension
Flexibility
• Flexibility exercises are given for the following muscles (each exercise
should be performed twice and held for a minimum of 20 s):
– Chest
– Biceps
– Triceps
– Quadriceps
– Hamstring
– Calf
Breathing relaxation exercise
• Abdominal breathing (15 min twice daily)
• Use of relaxation CD (nature sounds and breathing instructions)
It is instructed to take protein within 30 min upon completion of the exercise
regimen
 3. Medical Optimization and Prehabilitation 37

by donating its sulfhydryl proton. Nutritional assessment and sufficient

provision of proteins (1.5–2.0 g protein per kilogram body weight) are
needed in patients with a history of weight loss, cancer, or chronic
inflammatory diseases. In a recent prehabilitation nutrition RCT (no
physical exercise) patients scheduled for colorectal resection for cancer
received daily 2 g/kg body weight of protein for 4 weeks before surgery
and their functional walking capacity (a measure of recovery, assessed
by the 6-min walk test) increased by over 20 m in more than 50 % of the
subjects. This was in contrast to patients who received 0.8 g/kg of pro-
teins for 4 weeks as recommended, and their functional capacity
decreased during the preoperative period.

Strategies to Attenuate the State of Anxiety

and Depression Encountered Before Surgery
The physical burden of surgery is closely linked to the emotional one.
Elevated levels of psychosocial distress seen in patients undergoing
abdominal surgery are related to the diagnosis (cancer for example), the
treatment (chemotherapy), and most often disability (stoma siting).
Several studies have identified that anxiety and depression can impact
on postoperative outcome; for example those who were more stressed on
the third day after surgery stayed longer in hospital and those who were
more optimistic were not often hospitalized. Depression was associated
with more infection-related complication and poor wound healing.
In a recent prehabilitation study in patients who underwent colorectal
resections, those who improved in functional capacity showed also posi-
tive changes in mental health and some aspects of the SF-36 subscale
vitality. Anxiety at baseline was also associated with poorer recovery. The
belief that fitness aided recovery was a strong predictor of improvement.
These observations indicate the need to incorporate mental strategies
to interact with physical activity and enhance the effect of prehabilita-
tion. Interventional studies that improve healing outcomes by reducing
psychological stress provide further evidence of the impact of psycho-
logical and behavioral factors in wound repair, length of stay, less
demand for analgesia postoperatively, and increased patient satisfaction.
The use of information booklets and tailored messages on how to pro-
mote personal health help to empower patients in controlling their own
health and becoming more involved in the healing process.
38 T.N. Robinson et al.

Who Would Benefit from Prehabilitation?

As people are living well in their late 70s, they are more likely to
undergo surgery. Morbidity and mortality associated with surgery
increase with advancing age once above 75 years of age. There is a large
heterogeneity in this population with frail and cognitively impaired on
one side and highly functional and robust from the other side. There has
also been a shift in the comorbidity of this population with an increase
in cancer, obesity, diabetes, cognitive impairment, and osteoarthritis.
Comprehensive preoperative assessments which take into consideration
functionality, comorbidity, cognition, social support, nutrition, and
medical assessment could help at identifying those who are at risk of
adverse events and formulating a treatment plan before surgery.
While there has been several studies emphasizing the benefit of long-
term endurance training in patients with chronic heart failure and the posi-
tive effect of rehabilitation physical exercise after reconstructive surgery,
few studies have focused on surgical prehabilitation in the elderly and
patients with cancer with the intent to increase physiological reserve and
enhance functional capacity in preparation of surgery. It is assumed that
elderly, frail patients with medical comorbidities, with poor functional and
social status, or at risk of malnutrition would need some attention.
The appropriate time for the development of a prehabilitation pro-
gram would be during the preoperative assessment period for elective
operations. At this time, the multidisciplinary team, which should
include internal medicine, geriatrics, anesthesia, surgery, nutrition, kine-
siologist/physiotherapist, and nursing, would devise a risk stratification
model and identify the type and duration of prehabilitation needed in
order to balance the potential benefit of such intervention versus the
potential harms of delaying surgery.

Conclusions
Surgical prehabilitation is an emerging concept which derives from
the realization that despite innovations in perisurgical care and technol-
ogy some aspects of postoperative outcome have not significantly
changed. This is probably due to other factors such as patients’ health
and functional status, which are modifiable. As the population gets
older and surgical mortality decreases, patients are increasingly con-
cerned with quality of life, community reintegration, and cognitive
well-being. Innovative comprehensive preoperative risk evaluation and
 3. Medical Optimization and Prehabilitation 39

implementation of multidisciplinary prehabilitation programs need to

be further developed and tested, particularly directed to patients at risk.
The integrated role of physical exercise, adequate nutrition, and
psychosocial balance, together with medical and pharmacological opti-
mization, deserves to receive more attention.

Take-Home Messages
• Target preoperative medical optimization efforts on patients
who have reduced physiologic reserves, not healthy
individuals.
• Inspiratory muscle training with incentive spirometry and
smoking cessation can reduce pulmonary complications.
• Measuring frailty in older adults includes quantification of char-
acteristics including impaired cognition, functional dependence,
poor mobility, undernutrition, high comorbidity burden, and the
presence of a geriatric syndrome.
• Prehabilitation is a comprehensive preoperative program which
aims to better prepare the patient to withstand the stress of sur-
gery and promote faster recovery. This is critical for the most
efficient implementation of subsequent treatment protocols.
• The program includes physical activity, adequate energy and
protein intake, mental strategies to reduce psychological stress,
and pharmacological optimization.

Suggested Reading
1. 2009 ACCF/AHA focused update on perioperative beta blockade—2009 writing group
to review new evidence and update the 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery. Circulation. 2009;120: 2123–51.
2. Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict post-
operative discharge institutionalization in the geriatric patient. J Am Coll Surg. 2011;
213:37–42.
3. Carli F, Zavorsky G. Optimizing functional exercise capacity in the elderly surgical
population. Curr Opin Clin Nutr Metab Care. 2005;8:23–32.
4. Silver JK, Baima J. Cancer prehabilitation. Am J Phys Med Rehabil. 2013;92:715–27.
5. Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B,
Charlebois P, Feldman L, Carli F. Prehabilitation vs rehabilitation, a randomized control
trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014;
121(5):937–47.