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High-impact surgery imposes a significant physiological and functional burden and is associated with substantial postoperative morbidity. Multimodal prehabilitation has demonstrated a reduction in postoperative complications and enhanced functional recovery, mainly in abdominal cancer surgery. Common preoperative risk factors shared among patients undergoing high-impact surgery, extending beyond abdominal cancer surgery procedures, suggest the relevance of multimodal prehabilitation to a broader patient population. This stepped wedge trial primarily aims to examine the hospital-wide effect of multimodal prehabilitation, compared to standard preoperative care, on the occurrence and severity of postoperative complications. Secondary and tertiary endpoints include length of hospital stay, physical fitness, nutritional status, mental health, intoxications, and cost-effectiveness of the intervention. The Fit4Surgery (F4S) PREHAB trial is a monocenter stepped wedge trial in an academic hospital. Adult patients, divided into 20 health clusters based on specific diagnoses, will be assessed for eligibility and receive usual preoperative care or multimodal prehabilitation. Patient enrollment commenced in March 2021 and continues up to and including April 2024. The intervention consists of a high-intensity exercise program, a nutritional intervention, psychological support, and smoking and alcohol cessation. The primary outcome will be measured by the Clavien-Dindo classification (grade II or higher) and the Comprehensive Complication Index (CCI). Multimodal prehabilitation potentially reduces postoperative complications and enhances functional recovery. This is the first study to determine the hospital-wide effect and cost-effectiveness of multimodal prehabilitation in patients across various surgical specialties.

Besides improving the quality of care, quality improvement initiatives often also intend to produce cost savings. An example is prehabilitation, which can reduce complication rates and the length of stay in the hospital. However, the process from utilization reductions to actual societal cost savings remains uncertain in practice. Our aim was to identify barriers and facilitators throughout this process. We used the implementation of prehabilitation in a Dutch hospital as a test case. We held 20 semi-structured interviews between June and November 2023. Eighteen stakeholders were affiliated with the hospital and two with different health insurers. Nine interviews were held face-to-face and 11 via Microsoft Teams. The interviews were recorded and transcribed. The first transcripts were inductively coded by two authors, the subsequent transcripts by one and checked by another. Differences were resolved through discussion. We identified 20 barriers and 23 facilitators across four stages: reducing capacity, reducing departmental expenses, reducing hospital expenses and reducing insurer expenses. All participants expected that the excess capacity will be used for other priorities. This was perceived as highly valuable and as an efficiency gain. Other barriers to capture savings included the fear of losing resilience, flexibility, status and revenue. Misalignment between service contracts among hospitals and insurers can hinder the ability to financially incentivize cost reductions. Additionally, some contract types can hinder the transfer of hospital savings to insurers. Identified facilitators included shared savings agreements, an explicit strategy targeting all stages, and labor shortage, among others. This study systematically describes barriers and facilitators that prevent translating quality improvement initiatives into societal cost savings. Stakeholders expect that any saved capacity will be used for other priorities, including providing care due to the increasing demand. Capturing any cash savings does not occur automatically, emphasizing the need for a strategy targeting all stages.

Introduction/BackgroundPrehabilitation is an upcoming strategy to optimise patients’ functional capacity, nutritional status and psychosocial wellbeing in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program in the standard care of gynecological oncology patients at an academic oncology centre in the Netherlands in terms of recruitment and adherence. Feasibility was assessed by the number of patients eligible, recruitment rate, participation rate and adherence to and completion of the programmes’ individual modalities.MethodologyData was derived from the prospective F4S PREHAB trial, a single centre stepped-wedge trial implementing a multimodal prehabilitation programme among all surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine and vulvar cancer at the Radboudumc between May 2022 and September 2023 were considered eligible. The multimodal prehabilitation programme comprised a physical exercise intervention, a nutritional intervention, a psychological intervention and smoking cessation programme.ResultsA total of 152 patients were eligible and approached for participation of which 111 patients consented to participate, resulting in a recruitment rate of 73%. On average, the programme lasted twenty days (range 7–62). Participants attended an average of six exercise sessions, with an adherence of 87%. Participants had on average two sessions with a dietician and respectively 93% and 96% adhered to the prescribed daily protein and vitamin suppletion. Daily protein intake increased from 1.01 g/kg bodyweight at baseline to 1.45 g/kg BW after prehabilitation (P<0.001). Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, three initiated the smoking cessation programme and two managed to quit smoking. A total of 59% adhered to alcohol cessation advise.ConclusionThis study demonstrates that introducing a multimodal prehabilitation programme into the standard care of gynaecological oncology patients is feasible in terms of recruitment and adherence.DisclosuresNone to disclose.Abstract 298 Figure 1

Introduction/BackgroundPrehabilitation, a preoperative optimization intervention, remains in its infancies within gynaecological oncology. Little is known about the direct effects of such programmes on functional capacity. It is paramount to evaluate these effects to subsequently determine the relation with postoperative outcomes. Therefore, this study aims to assess the direct effect of multimodal prehabilitation on functional status for gynaecological oncology patients.MethodologyThis was an analysis of the F4S PREHAB trial, a monocentre stepped-wedge trial, to assess the direct effect of multimodal prehabilitation on functional capacity. Participants were patients scheduled for surgical treatment for ovarian, endometrial or vulvar cancer between May 2021 and September 2023 at the Radboudumc, Nijmegen, The Netherlands. Multimodal prehabilitation included an exercise, nutritional and psychological component, a smoking cessation programme and screening for frailty and comorbidities. We compared functional capacity before and after participation in the programme. Aspects of functional capacity assessed were estimated VO2max, indirect 1-Repetition Maximum tests (1-RM), Timed Chair Stand Test (5CST), grip strength and PG-SGA scores. Multivariate analyses were used to correct for possible confounding factors such as age, BMI, ASA-score, comorbidities, haemoglobin and histology.ResultsA total of 107 participants were included in the intervention group. Median duration of the programme was twenty days (range 7–62). When assessing the effect of multimodal prehabilitation on physical fitness, significant improvements in VO2max were seen by 0.83 ml/kg/min (P=0.017), in indirect 1-RM by 16 kg (p<0.001), and grip strength by 1.2kg (p=0.008). The results from the Timed Chair Test (5-CST) significantly shortened by half a second (p=0.001). Significantly more participants had a low risk on malnutrition after multimodal prehabiliation compared to before (62% vs 70%; p=0.005), and a significant reduction by 1 point in PG-SGA score was found (p=0.002).ConclusionThis study demonstrates that multimodal prehabiliation has the ability to improve functional capacity preoperatively for gynaecological oncology patients.DisclosuresNone to disclose.

Introduction/BackgroundSurgical treatment for gynaecological malignancies is associated with significant risks. Prehabilitation programmes in colorectal and abdominal cancer surgery have been shown to reduce complications and shorten length of stay, but its effects remain unclear for gynaecological cancer patients. This is one of the first studies to evaluate the effect of a multimodal prehabilitation programme on postoperative complications and hospital stay in gynaecological cancer patients.MethodologyThis was a prospective cohort study with participants from the F4S PREHAB trial, a stepped-wedge trial implementing a multimodal prehabilitation programme. All patients undergoing elective surgery as part of treatment for ovarian, uterine and vulvar cancer at the Radboudumc between May 2021 and April 2024 were considered for participation. As part of the stepped-wedge trial design, the intervention started May 2022. Prior to this, participants received standard pre-operative care. The multimodal prehabilitation programme comprised an exercise intervention, with three-times weekly individual exercise sessions, a nutritional intervention, and a psychological intervention and smoking cessation if indicated. The primary outcome of this study is postoperative complications, defined by the Clavien-Dindo classification (I-V) and Comprehensive Complication Index (CCI). Complications will be calculated after 30 days of follow-up. Further outcomes include length of hospital stay, length of intensive care unit stay, 30-day emergency room visits, and readmissions.ResultsData collection will be complete in February and preliminary data will be ready to be presented at the conference. We expect the study population to encompass around 200 patients.Conclusion-DisclosuresNone to disclose.

Multimodal prehabilitation programs to improve physical fitness before surgery often include nutritional interventions. This study evaluates the efficacy of and adherence to a nutritional intervention among colorectal and esophageal cancer patients undergoing the multimodal Fit4Surgery prehabilitation program. The intervention aims to achieve an intake of ≥1.5 g of protein/kg body weight (BW) per day through dietary advice and daily nutritional supplementation (30 g whey protein). This study shows 56.3% of patients met this goal after prehabilitation. Mean daily protein intake significantly increased from 1.20 ± 0.39 g/kg BW at baseline to 1.61 ± 0.41 g/kg BW after prehabilitation (p < 0.001), with the main increase during the evening snack. BW, BMI, 5-CST, and protein intake at baseline were associated with adherence to the nutritional intervention. These outcomes suggest that dietary counseling and protein supplementation can significantly improve protein intake in different patient groups undergoing a multimodal prehabilitation program.

Prehabilitation is an upcoming strategy to optimize patient’s functional capacity, nutritional status, and psychosocial well-being in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program into the standard care of gynecological oncology patients at an academic hospital in terms of recruitment, adherence, and safety, which were assessed by the number of patients eligible, recruitment rate, participation rate, and adherence to individual modalities. Data were derived from the F4S PREHAB trial, a single-center stepped-wedge trial implementing a multimodal prehabilitation program among various surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine, and vulvar cancer at the Radboudumc, an academic hospital in The Netherlands, between May 2022 and September 2023 were considered eligible for the F4S PREHAB trial and, consequently, were included in this cohort study. The multimodal prehabilitation program comprised a physical exercise intervention, nutritional intervention, psychological intervention, and an intoxication cessation program. A total of 152 patients were eligible and approached for participation of which 111 consented to participate, resulting in a recruitment rate of 73%. Participants attended an average of six exercise sessions and adhered to 85% of possible training sessions. Respectively, 93% and 98% of participants adhered to the prescribed daily protein and vitamin suppletion. Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, two managed to quit smoking. A total of 59% adhered to alcohol cessation advice. No adverse events were reported. This study demonstrates that introducing a multimodal prehabilitation program into the standard care of gynecological oncology patients is feasible in terms of recruitment and adherence, with no serious adverse events.

BackgroundDebate persists on the optimal management of incisional hernias due to paucity of accurate recurrence rates. Reoperation rates implicate a severe underestimation of the risk of a recurrence. Therefore, long-term postoperative clinic visits allowing physical examination of the abdomen are deemed necessary. However, these are time and costs consuming. Aim of this study was to develop and evaluate a new screenings method for recurrent hernias, the ‘PINCH-Phone’ (Post-INCisional-Hernia repair-Phone).MethodsThe PINCH-Phone is a telephone questionnaire. In this multicenter prospective study, the PINCH-Phone was answered by patients after incisional hernia repair. Afterwards the patients were seen at the clinic and physical examination was done to detect any recurrences.ResultsThe PINCH-Phone questions were answered by 210 patients with a median postoperative follow-up of 36 months. Fifty-six patients were seen after multiple incisional hernia repairs. In 137 patients who had replied positively to one or more questions, 28 recurrent incisional hernias were detected at physical examination. Six recurrences were noted in 73 patients who had replied negatively to all questions. The overall sensitivity and specificity of the PINCH-Phone were 82% and 38%, respectively.ConclusionThe PINCH-Phone appears a simple and valuable screenings method for recurrences after incisional hernia repair and, hence, is recommended for implementation.

Background The reported recurrence rates after laparoscopic inguinal hernia repair are 0–4 %. It is unclear which technique could best be offered to a patient with a recurrent hernia after a previous posterior repair. The purpose of this retrospective study was to determine the safety, feasibility, and reliability of a repeated laparoscopic repair (TAPP) for a recurrent hernia after a previous posterior inguinal hernia repair. Methods The study group contains 2,594 consecutive transabdominal inguinal hernia repairs (TAPP). Of these, 53 repairs were attempted in 51 patients for recurrent hernias after a previous posterior repair. During the follow-up period, patients were examined for recurrences and for presence of a port-site hernia. Pain was scored by the visual analogue pain scale (VAS). Results Fifty-one patients underwent a TAPP repair for a recurrent inguinal hernia after previous posterior hernia repair. Two patients presented a bilateral recurrent inguinal hernia. In two thirds of the patients, the recurrence was located caudally or medially from the previously placed mesh. Two attempted repairs had to be converted to an open technique due to severe adhesions. One intraoperative complication was encountered when the vas deferens was ligated during surgery due to adhesions of the previous placed mesh. Nine patients encountered an adverse event postoperatively, but none of them were serious events. No mesh infections were reported. The mean follow-up was 70 (range, 1–198) months. At follow-up, no recurrences were found at physical examination. Four patients developed a port-site hernia. Four patients had complaints of postoperative pain and were restricted in daily activities due to groin pain. The mean VAS score (scale 0–100), including the four patients with persistent pain, was 5.7 (range, 0–61). Conclusions It is concluded that repeated laparoscopic hernia repair (TAPP) is a definite repair for recurrent inguinal hernias. The procedure is feasible, safe, and reliable.

Background: Surgery for complex primary and metastatic colorectal cancer (CRC), such as liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), in academic settings has led to improved survival but is associated with complications up to 75%. Prehabilitation has been shown to prevent complications in non-academic hospitals. This pilot study aimed to determine the feasibility and potential efficacy of a multimodal prehabilitation program in patients undergoing surgery in an academic hospital for complex primary and metastatic CRC. Methods: All patients awaiting complex colorectal surgery, liver resection, or HIPEC from July 2019 until January 2020 were considered potentially eligible. Feasibility was measured by accrual rate, completion rate, adherence to the program, satisfaction, and safety. To determine potential efficacy, postoperative outcomes were compared with a historical control group. Results: Sixteen out of twenty-five eligible patients (64%) commenced prehabilitation, and fourteen patients fully completed the intervention (88%). The adherence rate was 69%, as 11 patients completed >80% of prescribed supervised trainings. No adverse events occurred, and all patients expressed satisfaction with the program. The complication rate was significantly lower in the prehabilitation group (37.5%) than the control group (70.2%, p = 0.020). There was no difference in the type of complications. Conclusion: This pilot study illustrates that multimodal prehabilitation is feasible in the majority of patients undergoing complex colorectal cancer, liver resection, and HIPEC in an academic setting.