What is the recommended preoperative workup and prehabilitation for patients undergoing pleurectomy and lobectomy?

Preoperative Workup and Prehabilitation Before Pleurectomy and Lobectomy

All patients undergoing pleurectomy or lobectomy should receive preoperative nutritional screening, smoking cessation counseling, and chlorhexidine oropharyngeal decontamination, while high-risk patients (COPD GOLD 3, age >75 years) should undergo structured respiratory prehabilitation programs lasting 1-6 weeks to reduce postoperative complications and mortality. 1

Essential Preoperative Workup Components

Nutritional Assessment and Optimization

• Screen all patients for undernutrition using body mass index (BMI <18.5 kg/m²) and recent weight loss (>5% in 3 months), as these are independent risk factors for major complications (OR 3.8) and one-year mortality. 1

• Implement personalized nutritional strategies for malnourished patients, as impaired nutritional status correlates with higher postoperative complication rates, prolonged hospital stays, and shorter disease-free survival. 1

• Nutritional intervention should include whey protein supplementation when implementing multimodal prehabilitation programs. 2

Smoking Cessation

• Mandate preoperative smoking cessation regardless of the planned surgery date, using behavioral intervention combined with nicotine replacement therapy to reduce pulmonary complications. 1

• This recommendation carries GRADE 1+ evidence with strong agreement, making it one of the highest-quality recommendations available. 1

Oropharyngeal Decontamination

• Administer preoperative chlorhexidine oropharyngeal decontamination to reduce surgical site infections (1.3% vs 5.4%, p=0.042) and postoperative bacteremia (0.9% vs 6.2%, p=0.014). 1

• This intervention has GRADE 2+ evidence and represents a simple, low-cost intervention with demonstrated efficacy. 1

Risk Stratification for Prehabilitation Programs

High-Risk Patient Identification

Target prehabilitation specifically to patients at highest risk, including:

• COPD patients (especially GOLD 3 classification) 1
• Patients >75 years old 1
• Those with impaired cardiopulmonary reserve (VO₂max <12.9 ml/kg/min, FEV₁ <1.14 L) 3
• Patients with Charlson Comorbidity Index scores ≥2 4
• Those with Estimation of Physiologic Ability and Surgical Stress (E-PASS) scores >0.3 4

The evidence strongly supports that not all patients benefit equally from prehabilitation, and resources should be concentrated on these high-risk populations. 5

Structured Prehabilitation Protocol

Duration and Intensity

Implement short but intensive programs lasting 7 days to 6 weeks, as these have demonstrated significant reductions in postoperative complications and length of stay. 1

• A 2-week program is sufficient to produce clinically relevant improvements in perioperative functional capacity (60.9 m higher 6MWD, p<0.001). 2

• 4-6 week programs show the most robust evidence for patients with severe COPD, improving VO₂max from 12.9±1.8 to 19.2±2.1 ml/kg/min (p=0.00001) and FEV₁ from 1.14±0.7 to 1.65±0.8 L (p=0.02). 3

• High-intensity interval training (HIT) appears to be the optimal exercise modality, though heterogeneity exists in protocols. 5

Multimodal Components

Structure prehabilitation programs to include all of the following elements:

• Aerobic exercise: Progressive walking or cycling programs with documented distance/duration increases 2

• Resistance training: Elastic resistance band exercises targeting major muscle groups, performed at least 3 days per week 6, 2

• Respiratory training: Including breathing exercises, incentive spirometry (tri-ball pulmonary exerciser), and cough techniques 6, 4, 2

• Nutritional counseling with protein supplementation: Whey protein supplementation combined with dietary optimization 4, 2

• Psychological guidance: To address anxiety and improve coping mechanisms 2

Evidence for Effectiveness

The meta-analysis data demonstrates that prehabilitation reduces:

• Postoperative pulmonary complications (RR 0.33 [0.17-0.61]) 1
• Length of stay by 4.2 days (95% CI: -5.4 to -3 days) 1
• 30-day complication rates from 37% to 3% (p=0.037) in some studies 1
• Duration of chest drainage (8.8 vs 4.3 days, p=0.04) 1

A cost-effectiveness analysis showed savings of $41,085 during 15 months despite the additional cost of prehabilitation. 1

Critical Decision-Making Algorithm

When to Delay Surgery for Prehabilitation

A multidisciplinary team must assess the benefit-risk balance of postponing surgery by several days or weeks, particularly considering:

• Tumor stage and growth rate (early stage IB disease may tolerate 2-6 week delays) 3
• Severity of functional impairment (severe COPD with VO₂max <13 ml/kg/min benefits most) 3
• Patient motivation and ability to complete the program 5

Even 7-day intensive programs have shown benefit, making this a viable option when time is limited. 1

Patients Who May Not Require Prehabilitation

Patients with:

• Normal pulmonary function tests
• Good baseline exercise capacity
• No significant comorbidities
• Age <60 years with ASA class I

These patients may proceed directly to surgery with standard preoperative care. 5

Common Pitfalls to Avoid

• Do not implement prehabilitation programs uniformly across all patients—target high-risk populations where evidence of benefit is strongest. 1, 5

• Do not delay surgery excessively in patients with aggressive tumors for marginal functional gains—balance oncologic urgency with optimization. 1

• Do not rely on single-modality interventions (exercise alone, nutrition alone)—multimodal programs show superior outcomes. 4, 2

• Do not skip nutritional assessment—undernutrition is an independent predictor of mortality that is often overlooked. 1

• Do not forget chlorhexidine decontamination—this simple intervention significantly reduces infectious complications. 1

Specific Functional Improvements Expected

With appropriate prehabilitation, expect:

• Vital capacity improvement from 2.63±0.65 L to 2.75±0.63 L (p=0.0043) 4
• FEV₁ improvement from 1.73±0.46 L to 1.87±0.46 L (p=0.0012) 4
• PaO₂ improvement from 60±10 to 82±12 mmHg 3
• 6-minute walk distance increase of approximately 60 meters 2

These improvements translate directly to reduced postoperative morbidity, particularly in patients with baseline impairment. 3, 4, 2