BACKGROUND & AIMS: Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving surgical outcomes. The aim of this systematic review and meta-analysis was to determine the impact of prehabilitation on postoperative outcomes in frail and high-risk patients undergoing major abdominal surgery. METHODS: Embase, Medline, CINAHAL and Cochrane databases were searched from January 2010 to January 2023 for randomised clinical trials (RCTs) and observational studies evaluating unimodal (exercise) or multimodal prehabilitation programmes. Meta-analysis was limited to length of stay (primary end point), severe postoperative complications (Clavien-Dindo Classification ≥ Grade 3) and the 6-minute walk test (6MWT). The analysis was performed using RevMan v5.4 software. RESULTS: Sixteen studies (6 RCTs, 10 observational) reporting on 3339 patients (1468 prehabilitation group, 1871 control group) were included. The median (interquartile range) age was 74.0 (71.0-78.4) years. Multimodal prehabilitation was applied in fifteen studies and unimodal in one. Meta-analysis of nine studies showed a reduction in hospital length of stay (weighted mean difference -1.07 days, 95 % CI -1.60 to -0.53 days, P < 0.0001, I2 = 19 %). Ten studies addressed severe complications and a meta-analysis suggested a decline in occurrence by up to 44 % (odds ratio 0.56, 95 % CI 0.37 to 0.82, P < 0.004, I2 = 51 %). Four studies provided data on preoperative 6MWT. The pooled weighted mean difference was 40.1 m (95 % CI 32.7 to 47.6 m, P < 0.00001, I2 = 24 %), favouring prehabilitation. CONCLUSION: Given the significant impact on shortening length of stay and reducing severe complications, prehabilitation should be encouraged in frail, older and high-risk adult patients undergoing major abdominal surgery.

Department of Agricultural Food and Nutritional Science University of Alberta Edmonton Canada https twitter com DrCarlaPrado

Department of Agricultural Food and Nutritional Science University of Alberta Edmonton Canada; Department of Kinesiology and Health Sciences University of Waterloo Waterloo Canada https twitter com KathFord_RD

Nottingham Digestive Diseases Centre Division of Translational Medical Sciences School of Medicine University of Nottingham Queen's Medical Centre Nottingham UK

Nottingham Digestive Diseases Centre Division of Translational Medical Sciences School of Medicine University of Nottingham Queen's Medical Centre Nottingham UK; National Institute for Health Research Nottingham Biomedical Research Centre Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK

Nottingham Digestive Diseases Centre Division of Translational Medical Sciences School of Medicine University of Nottingham Queen's Medical Centre Nottingham UK; National Institute for Health Research Nottingham Biomedical Research Centre Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK; Department of Military Internal Medicine and Military Hygiene Faculty of Military Health Sciences University of Defence Hradec Kralove Czech Republic; 3rd Department of Internal Medicine Metabolic Care and Gerontology University Hospital and Faculty of Medicine in Hradec Králové Charles University Prague Hradec Králové Czech Republic https twitter com PavelSkorepa

Nottingham Digestive Diseases Centre Division of Translational Medical Sciences School of Medicine University of Nottingham Queen's Medical Centre Nottingham UK; National Institute for Health Research Nottingham Biomedical Research Centre Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research School of Life Sciences University of Nottingham Queen's Medical Centre Nottingham UK; Division of Surgery Perelman School of Medicine University of Pennsylvania Philadelphia PA USA

School of Health Sciences University of Nottingham Queen's Medical Centre Nottingham UK https twitter com Dom_OConnor1

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