Multimodal prehabilitation in gastrointestinal surgery: Key risk factors for patient outcomes.

Abstract

Surgical preconditioning initiatives, such as the Surgical Prehabilitation and Readiness program, have been shown to improve postoperative outcomes in older, high-risk patients. However, it remains unclear which patient subpopulations may experience reduced benefit with prehabilitation. Over 39 months, Surgical Prehabilitation and Readiness enrolled high-risk patients undergoing gastrointestinal surgery. The program addresses 4 domains: physical activity, pulmonary function, nutrition, and mindfulness. Multivariable analysis was used to identify independent predictors of nonideal outcome, defined as discharge to a facility, readmission within 30 days, or death within 30 days. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator was used to compare the observed-to-expected rates of 30-day mortality, 30-day readmission, and nonhome discharge to investigate drivers of nonideal outcome. Surgical Prehabilitation and Readiness enrolled 300 participants who underwent gastrointestinal surgery. Compared with expected outcomes, participants demonstrated lower rates of 30-day mortality (observed-to-expected rate: 0.32), 30-day readmission (observed-to-expected rate: 0.93), and nonhome discharge (observed-to-expected rate: 0.61). Despite these improvements, 60 patients (20%) experienced nonideal outcomes. These patients were significantly more likely to have baseline dyspnea (46.7% vs 28.3%), congestive heart failure (16.7% vs 7.9%), and open surgical approach (81.7% vs 62.1%). Multivariable analysis, adjusted for surgery type and approach, identified dyspnea (adjusted odds ratio: 2.48, P < .05) and disseminated cancer (odds ratio: 3.41, P < .05) as independent risk factors for nonideal outcomes. Patients with dyspnea had higher 30-day readmission rates (observed-to-expected rate: 1.16), primarily driving nonideal outcomes in this subgroup. Patients with dyspnea have a potentially modifiable risk factor that may not be adequately addressed by prehabilitation interventions, contributing to higher readmission rates.