Unmet needs in surgical prehabilitation: a narrative review

To date, surgery remains the only curative treatment for many pathological conditions, and the number of surgical procedures is expected to increase in the coming years. Continuous advances in medical care now allow invasive procedures to be planned even for elderly and frail patients who were previously considered unsuitable for surgery. Combined with the general aging of the population, this has resulted in an increase in the number of frail patients undergoing surgery, who are more prone to postoperative complications and significant functional decline. It is, therefore, crucial to utilize the entire preoperative period not only to stratify preoperative risk but, shifting from a reactive to a proactive approach, also to optimize patients’ functional capacity through multimodal prehabilitation programs. After an initial assessment, surgical patients should receive a personalized, multidisciplinary optimization program aimed at improving their physical, nutritional, and psychological status. Clinical and scientific interest in prehabilitation has grown substantially in recent years. However, several unmet needs about prehabilitation still remain. In this narrative review we examine and discuss the current state of the art in prehabilitation, focusing specifically on unanswered questions and possible future developments.

Prehabilitation; Anesthesia; Surgery; Cancer; Preoperative care

[1] Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. The Lancet. 2008; 372: 139–144.
[2] Nepogodiev D, Picciochi M, Ademuyiwa A, Adisa A, Agbeko AE, Aguilera ML, et al. Surgical health policy 2025–35: strengthening essential services for tomorrow’s needs. The Lancet. 2025; 406: 860–880.
[3] Blitz JD. Preoperative evaluation in the 21st century. Anesthesiology. 2023; 139: 91–103.
[4] Bedford JP, Redfern OC, O’Brien B, Watkinson PJ. Perioperative risk scores: prediction, pitfalls, and progress. Current Opinion in Anaesthesiology. 2025; 38: 30–36.
[5] Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A, et al.; METS Study Investigators. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. The Lancet. 2018; 391: 2631–2640.
[6] Valadkhani A, Sebghati S, Piehl J, Bell M. Impact of preoperative functional capacity on postoperative mortality and morbidity: a prospective cohort study. Anesthesiology. 2026; 144: 525–534.
[7] Fleurent-Grégoire C, Burgess N, McIsaac DI, Chevalier S, Fiore JF Jr, Carli F, et al. Towards a common definition of surgical prehabilitation: a scoping review of randomised trials. British Journal of Anaesthesia. 2024; 133: 305–315.
[8] Shinall MC Jr, Arya S, Youk A, Varley P, Shah R, Massarweh NN, et al. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surgery. 2020; 155: e194620.
[9] Milder DA, Pillinger NL, Kam PCA. The role of prehabilitation in frail surgical patients: a systematic review. Acta Anaesthesiologica Scandinavica. 2018; 62: 1356–1366.
[10] Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. British Journal of Anaesthesia. 2022; 128: 434–448.
[11] Lamperti M, Romero CS, Guarracino F, Cammarota G, Vetrugno L, Tufegdzic B, et al. Preoperative assessment of adults undergoing elective noncardiac surgery: updated guidelines from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology. 2025; 42: 1–35.
[12] Raichurkar P, Denehy L, Solomon M, Koh C, Pillinger N, Hogan S, et al.; Prehabilitation Expert Collaborative. Research priorities in prehabilitation for patients undergoing cancer surgery: an international Delphi study. Annals of Surgical Oncology. 2023; 30: 7226–7235.
[13] McIsaac DI, Gill M, Boland L, Hutton B, Branje K, Shaw J, et al.; Prehabilitation Knowledge Network. Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews. British Journal of Anaesthesia. 2022; 128: 244–257.
[14] Syed A, Menezes T, Bisenius A, Sic A, Knezevic NN. The burden of preoperative stress: biological mechanisms and postoperative outcomes. Brain Sciences. 2026; 16: 219.
[15] Hirst N, Solomon MJ, McBride K, Dhillon H, Bai Z, Alexander K, et al. Prehabilitation including psychological interventions reduces overall postoperative complications following cancer surgery: a systematic review and meta-analysis of randomised controlled trials. Supportive Care in Cancer. 2025; 33: 1070.
[16] Li N, Liu X, Wang Y, Song R, Xie X. Multimodal prehabilitation is an effective strategy to reduce postoperative complications and improve physical function and anxiety in patients with colorectal cancer undergoing elective surgery: a systematic review and network meta-analysis. Frontiers in Medicine. 2025; 12: 1619959.
[17] Zhao B, Zhang T, Chen Y, Zhang C. Effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer: a systematic review and meta-analysis. Supportive Care in Cancer. 2023; 32: 15.
[18] Cambriel A, Choisy B, Hedou J, Bonnet MP, Fellous S, Lefevre JH, et al. Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis. BJS Open. 2023; 7: zrad129.
[19] Gustafsson UO, Rockall TA, Wexner S, How KY, Emile S, Marchuk A, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025; 184: 109397.
[20] McIsaac DI, Kidd G, Gillis C, Branje K, Al-Bayati M, Baxi A, et al. Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials. The BMJ. 2025; 388: e081164.
[21] Minnella EM, Awasthi R, Loiselle SE, Agnihotram RV, Ferri LE, Carli F. Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: a randomized clinical trial. JAMA Surgery. 2018; 153: 1081–1089.
[22] Pesce A, Fabbri N, Colombari S, Uccellatori L, Grazzi G, Lordi R, et al. A randomized controlled clinical trial on multimodal prehabilitation in colorectal cancer patients to improve functional capacity: preliminary results. Surgical Endoscopy. 2024; 38: 7440–7450.
[23] Molenaar CJL, Minnella EM, Coca-Martinez M, Ten Cate DWG, Regis M, Awasthi R, et al.; PREHAB Study Group. Effect of multimodal prehabilitation on reducing postoperative complications and enhancing functional capacity following colorectal cancer surgery: the PREHAB randomized clinical trial. JAMA Surgery. 2023; 158: 572–581.
[24] Bai Z, Koh C, Solomon M, Shahab R, Hirst N, Alexander K, et al. Prehabilitation in frail patients undergoing cancer surgery: a systematic review and meta-analysis. Annals of Surgical Oncology. 2025; 32: 7707–7722.
[25] McIsaac DI, Lee S, Fergusson D, Gillis C, Khadaroo RG, Meliambro A, et al. Home-based prehabilitation for older surgical patients with frailty: a randomized clinical trial. JAMA Surgery. 2026; 161: 113–123.
[26] Berardi G, Cucchetti A, Colasanti M, Angrisani M, Moschetta G, Chiappori D, et al. Prehabilitation with exercise and nutrition to reduce morbidity of major hepatectomy in patients with sarcopenia: the PREHEP randomized clinical trial. JAMA Surgery. 2025; 160: 1068–1075.
[27] Berkel AEM, Bongers BC, Kotte H, Weltevreden P, de Jongh FHC, Eijsvogel MMM, et al. Effects of community-based exercise prehabilitation for patients scheduled for colorectal surgery with high risk for postoperative complications: results of a randomized clinical trial. Annals of Surgery. 2022; 275: e299–e306.
[28] McIsaac DI, Hladkowicz E, Bryson GL, Forster AJ, Gagne S, Huang A, et al. Home-based prehabilitation with exercise to improve postoperative recovery for older adults with frailty having cancer surgery: the PREHAB randomised clinical trial. British Journal of Anaesthesia. 2022; 129: 41–48.
[29] D’Amico F, Dormio S, Veronesi G, Guarracino F, Donadello K, Cinnella G, et al.; PREHAB Study Group. Home-based prehabilitation: a systematic review and meta-analysis of randomised trials. British Journal of Anaesthesia. 2025; 134: 1018–1028.
[30] Sun Y, Tian Y, Cao S, Li L, Yu W, Ding Y, et al. Supervised multimodal prehabilitation and clinical outcomes in older patients with frailty and gastric cancer: the GISSG+2201 randomized clinical trial. JAMA Surgery. 2026; 161: 223–233.
[31] Berrio-Valencia MI, Al-Bayati M, Baxi A, Branje K, Chitiva-Martinez I, Hladkowicz E, et al.; Canadian Prehabilitation Knowledge Network. Adherence to prehabilitation in adult surgical patients: a systematic review, meta-analysis, meta-regression, and qualitative synthesis. British Journal of Anaesthesia. 2025; 135: 582–593.
[32] Alsuwaylihi A, Skořepa P, Prado CM, Gomez D, Lobo DN, O’Connor D. Exploring the acceptability of and adherence to prehabilitation and rehabilitation in patients undergoing major abdominal surgery: a systematic review and meta-analysis. Clinical Nutrition ESPEN. 2024; 63: 709–726.
[33] Shelton E, Barreto NB, Bidwell S, Folk-Tolbert M, Shelton A, Trickey AW, et al. Engagement and adherence with a web-based prehabilitation program for patients awaiting abdominal colorectal surgery. Journal of Gastrointestinal Surgery. 2021; 25: 3198–3207.
[34] Groen LC, Timmers TG, Daams FD, Doodeman HJ, Schreurs HW, Bruns ER. Fit4Surgery app: home-based prehabilitation app for older patients undergoing elective colorectal cancer surgery. European Journal of Surgical Oncology. 2025; 51: 109691.
[35] Arias López MDP, Ong BA, Borrat Frigola X, Fernández AL, Hicklent RS, Obeles AJT, et al. Digital literacy as a new determinant of health: a scoping review. PLOS Digital Health. 2023; 2: e0000279.
[36] Chen J, Hong C, Chen R, Zhou M, Lin S. Prognostic impact of a 3-week multimodal prehabilitation program on frail elderly patients undergoing elective gastric cancer surgery: a randomized trial. BMC Gastroenterology. 2024; 24: 403.
[37] Fleurent-Grégoire C, Burgess N, Denehy L, Edbrooke L, Engel D, Testa GD, et al. Outcomes reported in randomised trials of surgical prehabilitation: a scoping review. British Journal of Anaesthesia. 2024; 133: 42–57.
[38] Myers AM, Barlow RC, Baldini G, Campbell AM, Carli F, Carr EJ, et al. International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research. British Journal of Anaesthesia. 2024; 132: 851–856.
[39] Finizio E, Amedei A, Russo E, Nannini G, Niccolai E, Bertorello S, et al. Prehabilitation in GI cancer: serum cytokines and relationships with nutritional and functional status. Clinical Nutrition ESPEN. 2025; 69: 1130.
[40] Sun Y, Tian Y, Li Z, Cao S, Liu X, Han H, et al. Multimodal prehabilitation to improve functional abilities and reduce the chronic inflammatory response of frail elderly patients with gastric cancer: a prospective cohort study. European Journal of Surgical Oncology. 2025; 51: 109563.
[41] Cambriel A, Tsai A, Choisy B, Sabayev M, Hedou J, Shelton E, et al. Immune modulation by personalized vs standard prehabilitation before major surgery: a randomized clinical trial. JAMA Surgery. 2026; 161: 20–30.
[42] Kammerer T, Mahú I, Schier R. Prehabilitation and inflammation. Annals of Nutrition & Metabolism. 2025; 81: 234–244.
[43] Wang S, Li H, Teng L, Yao G, Fan Y. The impact of individualized short-term prehabilitation on perioperative complications and inflammatory markers in pancreaticoduodenectomy: a single-center historical cohort study. Frontiers in Medicine. 2026; 13: 1741597.
[44] Borsati A, Toniolo L, Ciurnelli C, Bettariga F, Riva ST, Frada P, et al. Cardiac autonomic dysfunction in patients with cancer: exploring the role of physical exercise. Journal of Cancer Research and Clinical Oncology. 2025; 151: 197.
[45] Aragón-Benedí C, Ortega-Lucea S, Pascual-Bellosta A, Corcoy-Bidasolo M, Longas-Vailen J, Martinez-Ubieto J; PreANI Study Research Group. Use of heart rate variability to assess functional capacity in multimodal rehabilitation programs in adult surgery: PreANI Study protocol. Revista Española de Anestesiología y Reanimación. 2025; 72: 501849.
[46] Giovanni Landoni, Università Vita-Salute San Raffaele. Surgical Prehabilitation on Autonomic Nervous System (TUNE) (ClinicalTrials.gov identifier: NCT06398301). 2025. Available at: https://clinicaltrials.gov/study/NCT06398301 (Accessed: 28 May 2026).
[47] Giovanni Landoni, Università Vita-Salute San Raffaele. Prehabilitation to Improve Heart Rate Variability (PRIME) (ClinicalTrials.gov identifier: NCT06744413). 2025. Available at: https://clinicaltrials.gov/study/NCT06744413 (Accessed: 28 May 2026).
[48] Rombey T, Eckhardt H, Kiselev J, Silzle J, Mathes T, Quentin W. Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations. BMC Medicine. 2023; 21: 265.
[49] Rampal T, Tribe S. Barriers to implementation of prehabilitation. British Journal of Hospital Medicine. 2025; 86: 1–24.
[50] Oyedele TJ, Komolafe PD, Ogunlana OJ, Odunsi NT, Ezenwoba C, Ogunrinde EA, et al. Prehabilitation in resource-limited settings: a narrative review of feasibility and barriers in surgical practice in Sub-Saharan Africa. International Journal of Surgery: Global Health. 2026; 9: e00610.
[51] Chen Y, Sebio-García R, Iglesias-Garcia E, Reguart N, Martinez-Palli G, Bello I. Prehabilitation for patients undergoing neoadjuvant therapy prior to cancer resection: a systematic review and meta-analysis. Supportive Care in Cancer. 2024; 32: 749.
[52] van der Hulst HC, van der Bol JM, Bastiaannet E, Portielje JEA, Dekker JWT. The effect of prehabilitation on long-term survival and hospital admissions in older patients undergoing elective colorectal cancer surgery. European Journal of Surgical Oncology. 2024; 50: 108244.
[53] Madsen HJ, Gillette RA, Colborn KL, Henderson WG, Dyas AR, Bronsert MR, et al. The association between obesity and postoperative outcomes in a broad surgical population: a 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery. 2023; 173: 1213–1219.