Medical Optimization

Many patients going for major surgery have several comorbidities (chronic conditions), such as high blood pressure, diabetes, coronary artery disease, and arthritis. Some are smokers, others are obese, and many are frail, and therefore at risk of perioperative complications. Optimization of the medical status before surgery is thus needed by adjusting medication and monitoring vital signs.

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Physical Activity Program

The majority of patients that are referred to POP lead a sedentary life. The physical activity program aims to increase aerobic capacity, as well as muscle and core strength.

Recently published systematic reviews of preoperative physical exercise reported less postoperative complications and shorter length of stay in abdominal surgery patients, improvement of pre- and postoperative physical function. Although it is not clear what the role of exercise intensity is, it appears that moderate exercise, consisting of aerobic and resistance training components, is sufficient to provide adequate physiological reserve and energy, even in patients who receive chemotherapy.

The physiotherapist/kinesiologist will prescribe a moderately intense aerobic and resistance exercise program that can be performed three times per week for 4-5 weeks before surgery.

Each session is home-based and individualized, based upon the baseline fitness test (according to the American College of Sport Medicine, ACMS, standard) and includes:

• a 5-minute warm-up
• either 25 minutes of aerobic exercise, or 25 min of resistance training (5 exercises targeting major muscle groups performed at an intensity of 8-12 repetition maximum)
• a 5-minute cool-down

Training intensity progression will occur when the participant can complete aerobic exercise on mild exertion and/or when the participant can complete 15 repetitions of a given resistance exercise.

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Nutritional Plan

Cancer and organ dysfunction directly influence the nutritional status of patients (including their metabolism). Factors such as age, interventions such as chemo-therapy and radiation, and the stage of the disease also play a role. ÌýIn addition, a patient who is undernourished before surgery has greater risk of disease and mortality.

The primary goal of nutrition therapy during the perioperative period is thus to optimize nutrient stores pre-operatively and provide adequate nutrition to compensate for the muscular breakdown after surgery. This includes preventing the loss of lean body mass (the mass of the body minus the fat), which relates to the survival of critically ill patients.

The patients’ nutritional status and adequacy of dietary intake is assessed by a nutritionist using a three-day food record and the Subjective Global Assessment tool (a method of rating a patient’s nutritional status – typical factors assessed are weight changes, appetite, state of muscles and digestive system). Percentage of lean body mass and fat percentage is measured with a bioelectrical impedance machine. The nutritionist reviews the food diary, provides some counselling on how to optimize dietary intake, and suggests supplements if needed.

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Strategies to Allay Anxiety

The preoperative period is a difficult time period for patients as they have increased anxiety and express fear of possible post-operative outcomes. For many patients, the diagnosis of cancer thus comes as a profound change in their identity and their interaction socially.

Perceived stress and worry about the operation have both been associated with delayed recovery, postoperative complications, and impaired wound healing in elective surgery therefore, psychological preparation for surgery may improve outcomes.

Patients visit a trained psychologist who focuses on providing relaxation, breathing exercises and anxiety reduction techniques. These exercises are mirrored on a compact disc for home practice and use during hospital stay post-surgery.

Another goal of the psychological component is to enhance and reinforce patients' motivation to comply with the exercise and nutritional aspects of the intervention.