Meta-analysis of the impact of prehabilitation on patients undergoing upper gastrointestinal tract tumor surgery

Table 1 Basic characteristics of the included studies

Ref.	Quality	Study design	Number (T/C)	Age (T/C, years), mean ± SD	Participants	Intervention		Time	Location	Outcome1
						T	C
Minnella et al[16], 2018	B	RCT	26/25	67.3 ± 7.4/68 ± 11.6	Esophagogastric resections	Aerobic: 30 minutes moderate - Borg: 12-13, continuous training: 3 day/week. Resistance exercise: Moderate intensity; 3 sets of 8-12 reps with resistance band 1 day/week for 4 weeks)	Standard care as per ERAS	36 days (17-73)	Home	1, 2, 3, 4, 5, 10
						Nutrition: Provide dietary advice and whey protein supplementation
Swaminathan et al[11], 2020	B	RCT	29/29	56.03 ± 14.95/56.82 ± 11.27	Gastrectomy	Start inspiratory muscle training based on motivational lung capacity measurement 7 days before surgery, twice a day	Standard care as per ERAS	7 days	Hospital	3, 5
Mazzola et al[22], 2017	A	UCT	41/35	75 (44-90)/75 (59-91)	Frail patients undergoing surgery of the upper gastrointestinal tract	Exercise: Inspirational lung capacity measurement 3 times per day, 30 minutes moderate intensity walking 3 times per week, lasting for 2 weeks	Receiving no special preoperative care	5-7 days	Hospital	3, 4, 5, 10
						Nutrition: 5-7 days prior to surgery, oral immune nutrition supplementation ± nasal jejunum feeding ± total parenteral nutrition
Valkenet et al[17], 2018	B	RCT	121/120	63.7 ± 7.5 /62.7 ± 8.9	Esophagectomy	Inspiratory muscle training ≥ 2 weeks, twice a day	Standard care as per ERAS	≥ 2 weeks	Home	3, 4, 5, 8, 11
Allen et al[10], 2022	B	RCT	26/28	65 ± 6/62 ± 9	Esophagogastric resections	Exercise: 2-3 times a week, with 1 hour of aerobic, resistance, and flexibility training each time	Standard care as per ERAS	15 weeks	Home + hospital	4, 5, 8, 9, 11
						Nutrition: Calorie and protein intake under the guidance of a nutritionist
						Psychological: Targeted medical guidance 6 times
Yamana et al[18], 2015	B	RCT	30/30	68.33 ± 7.64/65.9 ± 9.5	Esophagectomy	Inspiratory, abdominal and lower limb muscle training ≥ 1 week	Receiving no special preoperative care	≥ 7 days	Hospital	4, 5
Christensen et al[23], 2019	A	UCT	21/29	63.9 ± 8.2/65.5 ± 7.3	Surgery for adenocarcinoma of the gastro-esophageal junction	Approximately 75 minutes of high-intensity aerobic exercise and resistance training twice a week	Standard care as per ERAS	9 weeks	Home + Hospital	4, 5, 8
Liu et al[19], 2020	B	RCT	26/24	62.04 ± 5.12/64.58 ± 5.87	Esophagectomy	Preoperative nutritional support one week in advance and home enteral nutrition one month in advance	Standard care as per ERAS	5w	Home+ Hospital	(3, 4, 5, 6, 7, 8, 10, 11)
Dai et al[20], 2022	B	RCT	48/46	55.21±9.87/ 54.73±9.26	Gastrectomy	Exercise: Aerobic exercise for about 20 minutes three times a week, a group of resistance exercise per day, 2-3 respiratory muscle training sessions per day	Standard care as per ERAS	6-8 days	Hospital	1, 2, 3, 4, 5, 6, 7, 8
						Nutrition: Calorie and whey protein intake under the guidance of a nutritionist
						Psychology: Personalized Psychological Counseling
Li et al[24], 2021	A	UCT	84/84	59.23 ± 6.13/58.1 ± 4.76	Surgery for esophageal gastric junction adenocarcinoma	Exercise: Approximately 30 minutes of moderate intensity aerobic exercise three times a week, 30 minutes of resistance training once a week, and 2-3 respiratory muscle training sessions per day	Standard care as per ERAS	9-11 weeks	Home + Hospital	1, 2, 4, 5, 6, 7
						Nutrition: Medication treats symptoms, adjusts body mass, and balances diet
Guo et al[21], 2018	B	RCT	50/50	62.94 ± 6.35/64.88 ± 5.85	Esophagectomy	Exercise: Climbing stairs, walking, using an inhaler to assist in inspiratory muscle training, and abdominal breathing training	Standard care as per ERAS	7-9 days	Hospital	4, 5, 11
						Nutrition: Enteral nutrition after admission, carbohydrate intake 12 hours before surgery
						Psychology: Pre health compound case education
Xie et al[25], 2019	A	UCT	128/128	61.54 ± 8.12/62.82 ± 7.93	Esophagectomy	Exercise: Coughing, blowing balloons, walking, and training with respiratory function exercise equipment	Standard care as per ERAS	Hospitalization until surgery	Hospital	5, 6, 7, 11
						Nutrition: Enteral nutrition 3 days before surgery, carbohydrate intake 12 hours before surgery
						Psychology: Pre health compound case education
Li et al[26], 2019	A	UCT	34/30	60.43 ± 10.21/61.30 ± 11.12	Esophagectomy	Exercise: Climbing stairs, 6-minute walk test, and respiratory function training	Standard care as per ERAS	7 days	Hospital	4, 5, 6, 7
						Nutrition: High protein diet should be given 7 days before surgery, semi liquid and enteral nutrition powder should be given 3 days before surgery, and carbohydrates should be supplemented 1 day and on the same day before surgery

¹Outcome: 1: Preoperative six-minute walk distance (m); 2: Six-minute walk distance at 4 weeks after surgery (m); 3: Length of stay (day); 4: 30-day mortality after surgery; 5: Post-operative complications (Clavien-Dindo ≥ III); 6: Albumin at 1 day before surgery (g/L); 7: Albumin at 7 days post-surgery (g/L); 8: Quality of life; 9: VO₂ max at anaerobic threshold: Maximal oxygen uptake at anaerobic threshold; 10: Re-admission rates; 11: ICU stay.

T: Trial; C: Control; RCT: Randomized controlled trial; UCT: Uncontrolled clinical trial; ERAS: Enhanced recovery after surgery.

Table 2 Linear regression analysis of the implementation time of pre-rehabilitation and outcome indicators

Outcome	R2	P value
Preoperative 6MWD	0.61	0.43
6MWD at 4 weeks after surgery	0.72	0.36
Post-operative complications	0.20	0.23
Length of stay	0.03	0.72
ICU stay	0.71	0.16
30-day mortality after surgery	0.22	0.43
ALB at 1 day before surgery	0.49	0.30
ALB at 7 days post-surgery	0.52	0.48

6MWD: Six-minute walk distance; ICU: Intensive care unit; ALB: Albumin.