Similar to an athlete training for a competitive event, preparing for surgery requires physical, mental and nutritional optimization.

The more physically fit and nutritionally prepared a patient is for surgery, the higher the level of clinical success.

Patients who undergo a Prehabilitation exercise program have improved outcomes and faster recovery.

Prehab Improves:

*Pre-surgery muscle strength⁽¹⁾

*Post-operative functional performance⁽²⁾

*Faster return to sports⁽³⁾

*Improved patient reported outcomes

Early post-op function is predictive of speed of functional recovery and overall success of rehab.

Combining prehabilitation exercises with preop nutritional supplementation synergistically optimize a patient for a rapid functional recovery. The first two weeks after surgery is the most opportune time to intervene to mitigate muscle loss.

Injury and surgery elicit a significant stress response triggering an elevation in catabolic hormones.

↑Muscle Breakdown

↑Insulin Resistance

The traditional approach to pre-operative preparation involves a relatively prolonged period of pre-op food and water fasting.

This is no longer recommended by ERAS protocols, as more recently it
has been recognized that this approach induces the body’s starvation response which further exacerbates the catabolic effects of surgery.

Stress of Surgery + Fasted State (NPO) = "Hyper-Catabolic" Insulin Resistant State

Depending upon the degree of surgical invasiveness, this response can last for up to 2–4 weeks.⁽¹²⁾ Post-surgical insulin resistance can impair immune function, as well as increase the risk of infection and complications.⁽¹³⁾⁽¹⁴⁾⁽¹⁵⁾

Carb loading elicits a "fed state" which in turn enhances insulin sensitivity and mitigates complications.

Improved nutritional status prior to surgery primes the body to prepare for the stress of surgery.

Special attention should be given to nutritional intake in the 24hr period prior to surgery as well as the 1st 2wks post-op.⁽³⁾

biker woman refreshing drinking water at her morning exercise

Carb loading prior to an athletic competition has been long established to improve performance.

More recently this concept has been clinically studied and demonstrated to significantly improve surgical outcome measures as part of ERAS protocols.

Multiple studies have demonstrated the beneficial effects of mitigating the catabolic stress of surgery by providing patients:

*Carbohydrate loading the evening before and morning of surgery

*Key Amino Acids prior to surgery⁽⁴⁾

  • Carbohydrate Loading Improves:

    *Muscle Strength

    *Lean Body Mass

    *Patient Well Being 

  • Carbohydrate Loading Reduces:

    *Insulin Resistance 

    *Length of Stay

    *90-Day Readmission Rates

    *Nausea & Vomiting

    *Protein & Nitrogen Loss

    *Hunger, Thirst and Anxiety

  • Amino Acid Loading Reduces:

    *Surgical Stress Response

    *Inflammatory Serum Markers

    *Interleukin-6 (IL-6)

    *C-reactive protein (CRP)

    *Lymphocyte ratio

    *Granulocyte ratio⁽⁵⁾

The COMBINED oral intake of amino acids and carbohydrate have a SYNERGISTIC effect that elicits a greater anabolic trigger.

A mixture containing both carbohydrates and amino acids elevate insulin concentrations before surgery to achieve a metabolically fed state. The added benefit of supplying amino acids have a greater anabolic effect than carbohydrate regimens alone.⁽⁸⁹⁾⁽⁹⁰⁾⁽⁹¹⁾

3-wk Perioperative Recovery Bundle

References:

(ref 1#) Shahril R. Shaarani, The American Journal of Sports Medicine, 2013

(ref #2) Giesche F, Niederer D, Banzer W, Vogt L (2020) Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport- related and self-reported knee function: A systematic review. PLoS ONE 15(10): e0240192

(ref #3) Howard, E.E.; Margolis, L.M.; Fussell, M.A.; Rios, C.G.; Meisterling, E.M.; Lena, C.J.; Pasiakos, S.M.; Rodriguez, N.R. Effect of High-Protein Diets on Integrated Myofibrillar Protein Synthesis before Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Pilot Study. Nutrients 2022

(ref #4) Miyachi, T.; Tsuchiya, T.; Oyama, A.; Tsuchiya, T.; Abe, N.; Sato, A.; Chiba, Y.; Kurihara, S.; Shibakusa, T.; Mikami, T. Perioperativeoral administration of cystine and theanine enhances recovery after distal gastrectomy: A prospective randomized trial. JPEN J.Parenter. Enter. Nutr. 2013, 37, 384–391. 

(ref #5) Miyachi, T.; Tsuchiya, T.; Oyama, A.; Tsuchiya, T.; Abe, N.; Sato, A.; Chiba, Y.; Kurihara, S.; Shibakusa, T.; Mikami, T. Perioperativeoral administration of cystine and theanine enhances recovery after distal gastrectomy: A prospective randomized trial. JPEN J. Parenter. Enter. Nutr. 2013, 37, 384–391.

(ref #89) van Loon LJ, Saris WH, Verhagen H, Wagenmakers AJ: Plasma insulin responses after ingestion of different amino acid or protein mixtures with carbohydrate. Am J Clin Nutr 2000; 72:96–105 

(ref #90) Perrone F, da-Silva-Filho AC, Adôrno IF, Anabuki NT, Leal FS, Colombo T, da Silva BD, Dock-Nascimento DB, Damião A, de Aguilar-Nascimento JE: Effects of preoperative feeding with a whey protein plus carbohydrate drink on the acute phase response and insulin resistance. A randomized trial. Nutr J 2011; 10:66 

(ref #91) Schricker T, Meterissian S, Donatelli F, Carvalho G, Mazza L, Eberhart L, Wykes L, Carli F: Parenteral nutrition and protein sparing after surgery: Do we need glucose? Metabolism 2007; 56:1044–50