Reviewed by Dr Reza Lankarani, General Surgeon

Founder | Surgical Pioneering Newsletter and Podcast Series

Editorial Board Member | Genesis Journal of Surgery and Medicine

1. Arrange and Summarize

Publication Details:

This meta-analysis by Qi Li et al. was published online in BJS Open on September 8, 2025, with the DOI: https://doi.org/10.1093/bjsopen/zraf091(https://doi.org/10.1093/bjsopen/zraf091).

Overview:

The study aimed to evaluate the impact of prehabilitation (PR)—a preoperative program involving exercise, and sometimes nutrition and psychological support—on postoperative outcomes in patients with upper gastrointestinal tract cancer (UGIC), including esophageal, gastric, and gastroesophageal junction cancers.

Methods:

The authors conducted a systematic review and meta-analysis of 16 studies (8 randomized controlled trials and 8 cohort studies) involving 2,085 patients, identified from major databases (PubMed, Embase, Cochrane, Web of Science) up to May 21, 2024. Outcomes assessed included length of hospital stay (LOS), postoperative complications (e.g., pneumonia, anastomotic leakage), functional capacity (6-minute walk distance), and mortality.

Key Findings:

- PR significantly shortened hospital stay (SMD −0.27; P = 0.008).

- PR reduced postoperative pneumonia (RR 0.71; P = 0.005).

- PR improved 6-minute walk distance (SMD 0.95; P < 0.00001).

- No significant differences were found for overall complications, anastomotic leakage, operative time, blood loss, wound infection, in-hospital mortality, or recurrence.

Conclusion:

Prehabilitation offers modest but meaningful benefits for UGIC patients, particularly in reducing pneumonia and accelerating recovery. However, the authors call for larger, high-quality RCTs to confirm these findings.

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2. Detailed Assessment of Strengths and Weaknesses

Strengths:

- Comprehensive methodology: Adherence to PRISMA guidelines, PROSPERO registration, and use of robust statistical tools (Review Manager, Stata).

- Inclusion of both RCTs and high-quality cohort studies, enhancing generalizability.

- Rigorous quality assessment: Cochrane RoB for RCTs and NOS for cohorts, with most studies rated high quality.

- Sensitivity and subgroup analyses to explore heterogeneity (e.g., by cancer type, region, intervention duration).

- Clear, clinically relevant outcomes focused on practical postoperative metrics.

Weaknesses:

- High heterogeneity in key outcomes (e.g., I² = 75% for LOS), potentially due to variability in PR protocols (exercise type, duration, inclusion of nutrition).

- Limited data on gastric and GEJ cancers: Most studies focused on esophageal cancer, limiting conclusions for other UGIC subtypes.

- Potential publication bias, though Egger’s tests were mostly non-significant, funnel plots showed minor asymmetry.

- Lack of blinding in exercise interventions (inherent limitation, but acknowledged).

- Inconsistent PR definitions: Some studies used exercise-only, others multimodal, making direct comparisons difficult.

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3. Comparison with Latest Related Studies

Recent literature supports the general trend that prehabilitation improves functional outcomes but shows mixed results on hard clinical endpoints.

Key Insight:

While Tukanova’s 2022 meta-analysis included both pre- and postoperative rehab and found broader benefits , Li et al. isolate prehabilitation, offering more precise evidence for its standalone value. The 2023 RCT by Bausys in gastric cancer supports reduced complications with home-based PR , aligning with Li’s subgroup suggestion that PR may be more effective in specific contexts.

Graph Concept (Not rendered, but described):

A bar chart comparing risk ratios for pneumonia across studies would show consistent point estimates below 1.0, reinforcing the robustness of this finding.

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4. Brief Scholarly Review and Comment

Expert Opinion:

This meta-analysis is a timely and methodologically sound contribution to the evolving field of perioperative oncology. It clarifies that prehabilitation is not a panacea but a targeted tool—most effective for enhancing cardiopulmonary resilience and reducing pneumonia, a major driver of morbidity after UGIC surgery. The finding that ≥3-week interventions yield better outcomes is clinically actionable.

However, the lack of impact on anastomotic leakage or mortality underscores that PR complements—but does not replace—surgical precision and systemic therapy. Future trials should standardize PR protocols (e.g., trimodal: exercise + nutrition + psychology) and focus on underrepresented populations (e.g., gastric cancer, elderly).

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Patient-Friendly Summary

What this means for patients:

If you’re facing surgery for stomach or esophageal cancer, doing a structured exercise program before your operation—what doctors call “prehabilitation”—can help you recover faster. This review of 16 studies shows that patients who did prehabilitation:

- Spent fewer days in the hospital after surgery.

- Were less likely to get pneumonia, a serious lung infection.

- Were stronger and could walk farther after their operation.

However, it didn’t reduce other risks like wound infections or leaks from the surgical connection in the gut. The best results came from programs that lasted at least 3 weeks.

Bottom line: Prehabilitation is like “training for surgery.” Just as you’d prepare for a marathon, preparing your body for a major operation can lead to a smoother recovery. Talk to your care team about whether a pre-surgery exercise program is right for you.

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