‘Prehab’ make patients fit for lifesaving surgery

Nurses in Bristol have found their ‘prehabilitation’ exercise plan helps patients improve their fitness so they can cope with cancer surgery 

Nurses in Bristol have found their ‘prehabilitation’ exercise plan helps patients improve their fitness so they can cope with cancer surgery 

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Patients with upper-gastrointestinal (GI) cancers are often quite unwell by the time they are diagnosed. This means they may not be fit enough to withstand surgery – making them ineligible for what can be a lifesaving intervention.

But a nurse-led initiative in Bristol is helping some patients improve their fitness enough to have the surgery.

Their ‘prehabilitation’ programme uses graduated exercise to build up cardiovascular fitness over several weeks, enabling patients to access what may be the only curative treatment for their condition.

Upper-GI specialist nurse Ruth Harding, who has worked on the prehabilitation project with fellow specialist nurses Carly Pillinger and Karen Clemett, says patients with hepatobiliary cancer can be divided into three roughly similar-sized groups.

Exercise at home

About a third of patients have potentially operable disease and are fit enough for surgery, and for another third surgery is not recommended because of the progression of the disease. The remaining third would be suitable for surgery but are too unfit at that point to go ahead.

In early 2017, a project at Bristol Royal Infirmary offered this third group a programme to improve their fitness and address nutrition. Many patients in this group suffer from jaundice – they often have a stent inserted – and weight loss. They are also predominately older people.

The upper-GI service in Bristol is a regional centre covering a wide area, so rather than asking patients to come to the hospital the focus has been on encouraging them to improve their fitness at home. GPs and dieticians have also been involved.

‘It has to be exercise that gets them out of breath, hot and perspiring’

Ruth Harding, specialist nurse

‘We’re keeping it quite simple in terms of the exercises they do,’ says Ms Harding. Rather than using a gym they are encouraged to take exercise that fits into their lifestyle and gradually build it up, with an emphasis on cardiovascular fitness.

The aim is for 30-45 minutes of worthwhile cardiovascular exercise five times a week, which is similar to the recommendation for the general population. ‘If they can get near to that, it’s really good,’ says Ms Harding. ‘Most people push themselves towards becoming medium risk for surgery rather than high risk.’

Reducing risk not only helps patients to withstand surgery but also reduces the chance of complications afterwards, and could reduce their length of stay in hospital post-surgery.

Structured phone call

The patients enrolled in the scheme are given a structured phone call each week from one of the team, checking what they have achieved over the previous week and setting goals for the coming week. ‘It’s important that we talk through with the patient what is being achieved and what is safe,’ says Ms Harding. ‘There’s a lot of discussion with the patients about where they are, and what we feel can and can’t be achieved, and what they want.

‘We say it has to be exercise that gets them out of breath, hot and perspiring. It can be walking, walking up hills, swimming or an exercise bike if they have one. It can be dog walking, borrowing the neighbour’s dog if necessary. People being able to do things in their own home or their own environment makes a difference. They are more likely to engage.’

Each week the patients are encouraged to add a little extra to their routine. It might be another five minutes of exercise or adding another lap or circuit to their walk.

‘We are finding that at least half of the patients are getting to surgery’

Ruth Harding

At the same time dieticians are working with the patients on areas such as calorie and nutrient intake, and helping them regain muscle mass. This can be challenging with this group of patients, whose conditions often mean they feel full quickly.

The response from patients has been very positive, Ms Harding says, which is perhaps not surprising as it offers a way to life-saving or life-extending surgery.

But it is a delicate balancing act. There is potential for cancers to progress if patients need months of prehabilitation to improve their fitness, and the exercise programme is limited to six weeks. ‘We are finding that at least half of them are getting to surgery,’ she says.

Team effort

In the first six months of the programme, three quarters of the 20 participants reached the point where they were offered surgery. Others had decided against surgery or were still high risk. For those not having surgery, improved fitness may still help them if they undergo palliative treatment.

One of the main challenges in setting up the scheme was finding a time when everyone in the team could attend a regular meeting. The team approach was vital, and the involvement of everyone from consultant surgeons and anaesthetists to cancer care and waiting list coordinators has been important in bringing people to surgery at the right point. Support for the project from the hepatobiliary surgeons has been particularly strong.

Ms Harding recommends nurses in other areas consider setting up similar schemes. ‘I would advise them to ensure they have everyone involved on board from the beginning, like we did,' she adds. 'Ensure you document each patient’s progress in a consistent manner, so you can build on their goals each time and pick up on any potential difficulties they are having early on to signpost them to additional support.’

Alison Moore is a freelance journalist


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