We get in shape for fun runs and even beach holidays, yet the idea of getting fit for an operation is not something most people would consider.
But this simple omission is having a big impact on the success of procedures and pushing up complication rates, according to Ravi Mahajan, a professor of anaesthesia and intensive care at Nottingham University Hospital NHS Trust and president of the Royal College of Anaesthetists.
‘An operation can put the body under enormous stress by disrupting hormone levels, triggering the immune system and the sympathetic nervous system all at the same time,’ he says.
‘Large numbers of patients have had surgery that has resulted in complications, leading to longer hospital stays or re-admission for further treatment, because they were unfit, overweight or smoked.
‘Physical and mental preparation in the run-up to an operation can ensure the body is better equipped to cope with these upheavals and hasten recovery.’
The Royal College of Anaesthetists is calling for prehabilitation (or ‘prehab’), a combination of exercise, education and psychological support in the months before an operation, to become routine in NHS hospitals.
It has launched a toolkit called Fitter Better Sooner to guide patients on how to prepare for an operation and hospital stay.
There are around 250,000 high-risk operations a year in England and Wales and there is about a 20 per cent risk of complications such as respiratory failure (where problems with breathing result in a lack of oxygen and an excess of carbon dioxide) or pneumonia.
‘Patients should be encouraged to boost their fitness and mental wellbeing before a procedure to make it more likely that it will go well and they’ll recover faster,’ says Professor Mahajan.
Currently, prehab is only offered in a handful of hospitals because it is a relatively new concept — but those hospitals have already reaped the benefits. For the past two years, patients booked in for operations for abdominal cancer at Manchester University NHS Trust have been receiving prehab before their operations.
The 12-week programme includes breathing exercises and physiotherapy, as well as coaching on nutrition and help to quit smoking.
Patients also have a 20-minute fitness test and attend ‘Surgery School’, where they learn more about their operation and meet the doctors and nurses who will be looking after them.
Data published last year in the journal Anaesthesia showed that patients taking part in the scheme had a 50 per cent reduction in such complications as pneumonia and the length of their hospital stay was cut by three days.
Patients are encouraged to keep building their strength at home, too. ‘We give lots of tips on what to do and what to avoid,’ says Nikki McGill, a physiotherapist at the trust. For example, patients are taught simple arm exercises and lunges and have to repeatedly stand up from a seated position.
Walking, cycling, gardening and dancing can also be beneficial to boost fitness before an operation.
Dr John Moore, a consultant in critical care and anaesthesia, who is leading the Manchester study, says: ‘Our patients are essentially training for a “big event” (i.e. an operation) and should try muscle- strengthening exercises, such as lifting weights for 20 minutes a day, and cardiovascular exercise, such as walking or cycling for an hour at least three times a week.’
Meanwhile, in another study, at the Royal Bournemouth Hospital, patients who were offered sessions with a psychologist to discuss their concerns before an orthopaedic operation experienced less pain after the procedure.
‘More than 150 patients receiving hip and knee surgery have taken advantage of the therapy sessions and, on average, are discharged two days earlier than those who don’t see a psychologist,’ says Professor Mahajan. ‘Discussing anxieties before an operation can aid patients’ recovery.’
Anyone can benefit from prehab, even if they only have a few days’ notice before a procedure, says Dr Andrew Klein, a consultant anaesthetist at Royal Papworth Hospital in Cambridge.
‘If you have months or weeks, you can work on fitness and weight loss, but even in two or three days, you can make a difference to the outcome by ensuring optimum nutrition, stopping smoking and treating problems such as anaemia by giving iron supplements.’
Those who do make the effort to train for their upcoming surgery may even find they can avoid it altogether. ‘Take the case of knee replacement operations,’ says Dr Klein. ‘Some patients who lose weight and gain muscle strength in their legs may not need to have one at all. Prehab makes sense.’
For prehab advice, visit rcoa.ac.uk