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

Background: 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. Methods: 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. Results: 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. Conclusion: Patients with dyspnea have a potentially modifiable risk factor that may not be adequately addressed by prehabilitation interventions, contributing to higher readmission rates.