# What the randomised trials of prehabilitation found, operation by operation

Source: https://onco.cc/technologies/rejuv-rehab-prehabilitation-evidence/  
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## TL;DR

Training before an operation reliably makes people fitter for it. Whether it cuts complications depends on the operation and on who was recruited: a trial in high-risk abdominal surgery halved the proportion with complications, the largest colorectal trial cut severe complications from 29.7 to 17.1 per cent, and pooled home-based programmes improved the walking test and nothing else.

## Summary

Prehabilitation is the oldest idea in this file and the best tested. The pattern across the randomised evidence is consistent once the trials are read in the right order: the fitness gain before surgery is reproducible, and the clinical benefit appears where the baseline risk was high and the programme was supervised.

High-risk abdominal surgery. Barberan-Garcia and colleagues randomised 144 patients aged over 70 or with an American Society of Anesthesiologists score of III or IV facing major elective abdominal surgery, to standard care or standard care plus a personalised programme of motivational interviewing, high-intensity endurance training and physical activity promotion. Endurance time during cycle ergometry rose by 135 per cent. The proportion of patients with any postoperative complication fell by 51 per cent, a relative risk of 0.5 with a confidence interval of 0.3 to 0.8. This is a small trial, and it is the one that most clearly shows where the effect lives.

Colorectal surgery, supervised. The PREHAB trial randomised 251 patients with non-metastatic colorectal cancer in teaching hospitals that already ran enhanced recovery pathways, to four weeks of supervised high-intensity exercise three times a week with nutritional, psychological and smoking-cessation support, or to standard care. Severe complications, defined as a Comprehensive Complication Index above 20, occurred in 21 of 123 (17.1 per cent) against 38 of 128 (29.7 per cent), an odds ratio of 0.47 (0.26 to 0.87). Medical complications fell from 27.3 to 15.4 per cent. The primary functional endpoint did not reach significance: four weeks after surgery the six-minute walking distance difference was 15.6 metres, with a confidence interval of minus 1.4 to 32.6. The trial was stopped early because of the pandemic.

Colorectal surgery, home-based. A 2026 systematic review and meta-analysis of home-based multimodal prehabilitation before colorectal cancer surgery found the preoperative six-minute walk test improved by a mean of 40.61 metres (6.23 to 74.99), and then that the gain did not carry over: no significant difference at four to six weeks or eight weeks after surgery, and no significant effect on total hospitalisation, 30-day complications, emergency department visits, readmission, or anxiety and depression scores. Its own conclusion is that "More intensive or prolonged programs, combined with postoperative rehabilitation, may be necessary to maintain preoperative gains."

Lung surgery. This is the strongest signal in the whole literature. A 2026 meta-analysis of 29 randomised trials and 2,900 surgical participants found exercise-based prehabilitation reduced overall postoperative pulmonary complications with a risk ratio of 0.42 (0.33 to 0.53), pneumonia 0.52, atelectasis 0.36 and respiratory failure 0.37, with no heterogeneity across trials, and shortened stay by 2.22 days. A separate 2026 meta-analysis of 15 randomised trials and 1,129 patients found a mean preoperative six-minute walk gain of 37.58 metres and a pulmonary complication odds ratio of 0.39. The certainty grading in the first of these ranged from moderate to very low, so the direction is clear and the magnitude is not.

Liver surgery. Six studies and 557 patients: overall complications fell, odds ratio 0.55 (0.37 to 0.84), with no significant difference in length of stay, major complications, mortality, readmission or hospital costs.

Gastrointestinal surgery as a whole. Twelve prospective trials and 1,229 patients: six-minute walk improved by 30.1 metres before surgery and 21.5 metres four weeks after, stay was 0.86 days shorter, overall complications fell (risk ratio 0.67) and severe complications fell (0.77), with no effect on operative time, mortality or readmission.

Radical prostatectomy. Sixteen randomised trials and 1,542 participants: prehabilitation reduced urinary incontinence at one month (odds ratio 0.58) and six months (0.52), with a non-significant reduction at three months and no benefit at twelve. It did not improve incontinence severity or erectile function at any time point.

Radiotherapy. The evidence here barely exists. A scoping review covering 21 years found 30 articles and 3,657 participants, 18 of them randomised, mostly small, and adherence or feasibility was the primary outcome in 30 per cent of them. Its conclusion is that adequately powered trials with functional or quality of life endpoints are still needed.

The trials that found nothing are part of the answer, not an embarrassment to it. The home-based colorectal meta-analysis, the twelve-month prostate results and the liver length-of-stay results all point the same way: unsupervised programmes and low-risk patients produce a fitness gain that does not become a clinical one.

## Fields

- Kind: Technology
- Status: established
- Last checked: 2026-10-02
- Tags: rejuvenation; survivorship; rehabilitation; evidence:moderate
- Principle: Surgery imposes a fixed physiological insult. Whether a person recovers from it depends on the reserve they start with, measured as aerobic capacity, muscle mass and nutritional state. Training in the weeks before the operation raises that starting point, which matters most when it was low to begin with. It is the same reason the effect is largest in older, frailer, lung and high-risk abdominal populations and smallest in fit patients having laparoscopic colonic resection.
- Strengths: Pulmonary complications after lung surgery fall by about half across 29 randomised trials with no heterogeneity; Supervised programmes reduced severe complications in the largest colorectal trial; Cheap, safe, and uses weeks that would otherwise be spent waiting
- Limitations: Home-based colorectal programmes improved walking distance and nothing after surgery; The prostate benefit on continence had gone by twelve months; Almost no randomised evidence before radiotherapy; Neoadjuvant treatment removes the window in exactly the patients who would gain most

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Prehabilitation
- PREHAB: multimodal prehabilitation before colorectal cancer surgery (JAMA Surg 2023): https://doi.org/10.1001/jamasurg.2023.0198
- Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery (Ann Surg 2018): https://doi.org/10.1097/SLA.0000000000002293
- Home-based multimodal prehabilitation before colorectal cancer surgery: systematic review and meta-analysis (Support Care Cancer 2026): https://doi.org/10.1007/s00520-026-10535-y
- Preoperative exercise-based prehabilitation for reducing postoperative pulmonary complications after lung cancer surgery (Front Med 2026): https://doi.org/10.3389/fmed.2026.1899789
- Effects of prehabilitation on outcomes among patients undergoing surgery for lung cancer (J Thorac Dis 2026): https://doi.org/10.21037/jtd-2026-0694
- The impact of prehabilitation on clinical outcomes in liver surgery (World J Surg 2026): https://doi.org/10.1002/wjs.70501
- Effect of multimodal prehabilitation on functional capacity and postoperative complications in gastrointestinal cancer surgery (Am J Phys Med Rehabil 2026): https://doi.org/10.1097/PHM.0000000000003006
- The impact of prehabilitation on postoperative outcomes in patients undergoing radical prostatectomy (Support Care Cancer 2026): https://doi.org/10.1007/s00520-026-11182-z
- Prehabilitation in radiation therapy: a scoping review (Support Care Cancer 2024): https://doi.org/10.1007/s00520-023-08262-9

## Connected records

- ideas: [Four weeks of training and nutrition before major cancer surgery, as standard](https://onco.cc/ideas/idea-bio2-prehabilitation-standard/), [Multimodal prehabilitation for older patients before major cancer surgery](https://onco.cc/ideas/idea-acc-prehabilitation-older-surgery/)
- cancers: [Colorectal cancer](https://onco.cc/cancers/colorectal/), [Gastric & gastro-oesophageal junction cancer](https://onco.cc/cancers/gastric/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/), [Oesophageal cancer](https://onco.cc/cancers/esophageal/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- fronts: [Recovery & Rejuvenation](https://onco.cc/fronts/rejuvenation/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/), [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- technologies: [Breathing and exercise capacity after lung resection](https://onco.cc/technologies/rejuv-rehab-respiratory/), [Cancer rehabilitation: the discipline that puts function back](https://onco.cc/technologies/rejuv-rehab-cancer-rehabilitation/), [Enhanced recovery (ERAS) and perioperative nutrition](https://onco.cc/technologies/eras-perioperative-nutrition/), [Geriatric assessment](https://onco.cc/technologies/geriatric-assessment/), [Immunonutrition before cancer surgery](https://onco.cc/technologies/immunonutrition-perioperative/), [Nutrition support and cachexia management](https://onco.cc/technologies/oncology-nutrition/), [Pelvic floor rehabilitation after prostate and rectal surgery and after pelvic radiotherapy](https://onco.cc/technologies/rejuv-rehab-pelvic-floor/), [Prehabilitation before cancer surgery](https://onco.cc/technologies/prehabilitation/), [Recovery after pelvic exenteration](https://onco.cc/technologies/rejuv-recon-pelvic-exenteration/), [The exercise prescription after cancer: the dose the guidelines state](https://onco.cc/technologies/exercise-prescription-after-cancer/), [What a prehabilitation programme actually contains, and how long it needs](https://onco.cc/technologies/rejuv-rehab-prehabilitation-programme/)
- terms: [Prehabilitation (the pre-treatment window)](https://onco.cc/terms/prehabilitation-term/), [Quality of life](https://onco.cc/terms/quality-of-life/), [Sarcopenia](https://onco.cc/terms/sarcopenia/)
- trials: [PREHAB: multimodal prehabilitation before colorectal cancer surgery](https://onco.cc/trials/prehab-trial/)
- bottlenecks: [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/)

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