Is cardio fitness linked to postoperative healing in patients undergoing major surgical procedures?

Cardiorespiratory Fitness is Strongly Linked to Postoperative Healing

Preoperative cardiorespiratory fitness is a powerful independent predictor of surgical outcomes, with higher fitness levels associated with reduced postoperative complications, shorter hospital stays, and lower mortality rates across major surgical procedures. 1

Evidence for the Fitness-Healing Link

Impact on Morbidity and Mortality

• Adequate preoperative physical activity level independently predicts short-term mortality (OR 5.5) and is more predictive than traditional risk factors like age or heart disease. 2
• Cardiorespiratory prehabilitation reduces postoperative pulmonary complications (OR 0.52), severe pneumonia (OR 0.40), and atelectasis (RR 0.53) in patients undergoing major surgery. 1
• In high-risk patients undergoing elective major abdominal surgery, prehabilitation significantly reduces postoperative complications from 62% to 31% (p = 0.001). 1
• Impaired cardiorespiratory fitness is an independent risk factor for both mortality and morbidity, with the perioperative period creating increased oxygen demand that unfit patients cannot meet, leading to organ failure. 3

Impact on Hospital Length of Stay

• Multimodal prehabilitation programs reduce hospital length of stay by 1 to 3.2 days across cardiac and colorectal surgery populations. 1
• Adequate preoperative activity level (HR 0.6) and inspiratory muscle strength (HR 0.6) independently predict shorter hospital stays. 2
• The combination of preoperative and postoperative rehabilitation (started within 2 weeks) is necessary to achieve reductions in complications and length of stay—postoperative rehabilitation alone does not demonstrate these benefits. 1

Impact on Quality of Life

• Prehabilitation improves preoperative physical conditions as measured by 6-minute walk tests and quality-of-life questionnaires. 1
• Physical activity improves insulin sensitivity, increases lean-to-fat mass ratio, and improves the transition from hospital to home. 1
• Four of five studies evaluating quality of life outcomes demonstrated significant improvements in one or more QOL measures following prehabilitation interventions. 1

Mechanisms Underlying the Fitness-Healing Connection

• The perioperative period creates increased oxygen demand; patients with impaired cardiorespiratory fitness cannot meet this demand, leading to oxygen deficit—the magnitude and duration of which dictates organ failure and death. 3
• Higher functional capability allows patients to better tolerate surgical intervention through improved cardiovascular reserve and metabolic conditioning. 4
• Modest improvements in fitness through exercise intervention are associated with considerable health outcome benefits, making fitness a strong and independent marker of risk. 4

Clinical Application: Prehabilitation Programs

Recommended Program Structure

Implement a multimodal cardiorespiratory and muscular prehabilitation program of at least 4 weeks preoperatively, combining aerobic exercise, resistance training, inspiratory muscle training, nutritional support, and psychological interventions. 1

Specific Components

• Inspiratory muscle training using a device with adjustable inspiratory pressure valve is most effective, requiring minimum 5 days (preferably 2 weeks) of twice-daily practice. 1
• Aerobic plus resistance exercise programs demonstrate therapeutic validity and improve cardiorespiratory fitness across multiple metrics. 1
• High-intensity interval training (HIIT) has been shown to be highly effective in improving preoperative fitness. 5
• For patients undergoing neoadjuvant therapy, exploit the 4-6 week period after cessation of therapy but prior to surgery to optimize patient fitness. 1

Evidence-Based Outcomes

• Inspiratory muscle training decreases postoperative pneumonia risk (RR 0.44-0.45) and atelectasis (RR 0.53-0.59). 1
• The largest study (276 patients) showed lung disease incidence decreased from 16% to 6.5% with prehabilitation. 1
• Trimodal prehabilitation attenuates postoperative loss of lean body mass compared to rehabilitation alone. 1

Critical Pitfalls to Avoid

• Do not rely on postoperative rehabilitation alone—only the combination of pre- and postoperative rehabilitation demonstrates benefits on complications and length of stay. 1
• Do not include only healthy, active patients without fitness deficiencies in prehabilitation programs—these populations are less likely to derive benefit; target patients with actual fitness-related deficiencies. 1
• Do not delay prehabilitation—commence immediately after diagnosis is made, as programs require minimum 4 weeks to achieve meaningful physiological adaptation. 1
• Recognize that up to 60% of patients undergoing preoperative cardiopulmonary exercise testing may have their fitness incorrectly stratified, potentially misinforming risk classification. 3

Postoperative Continuation

Combine prehabilitation with postoperative rehabilitation starting within the first 2 weeks after surgery (cardiovascular, respiratory, and mobilization physiotherapy) to maximize reduction in complications and length of stay. 1

• Early mobilization within 24 hours is critical and associated with reduced respiratory complications and shorter intensive care stays. 6
• Postoperative rehabilitation started within 8 weeks after cardiac surgery reduces medium- and long-term mortality at 1 year and 10 years. 1