Dr. Miller: Prehabilitation. What is that? We're going to talk about that next on Scope Radio.
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Dr. Miller: Hi. I'm Dr. Tom Miller. I'm here with Dr. Dan Vargo. He's a surgeon here at the University of Utah. Dan, what is prehabilitation?
Dr. Vargo: What we are trying to accomplish is to improve patient outcomes with surgery. Can patients do anything to help improve their outcomes with their operations.
Dr. Miller: Well, it sounds like you're going to tell me what those things might be.
Dr. Vargo: We focus on some very specific things. So the first thing is to just stop smoking before surgery. There's no question, there have been multiple studies that have shown that smoking cessation is the number one thing you can do to improve wound infection rates, to improve pulmonary complications.
There's actually an interesting application for a smartphone that it's specific for hernia operations. But it would be applicable to almost any operations where you can type in various risk factors for the patients before surgery, and you can show what their risk of a complication is after surgery.
So it's very easy to punch in smoking as one of the risk factors in that application. And show them what their chance of having a complication after surgery and then eliminating smoking and showing them what their risk is for having a complication. And for things like pneumonia it goes down about six times, for wound infections it goes down about three times.
Dr. Miller: Now, how long before the surgery would they have to quit smoking to show that that's effective?
Dr. Vargo: We typically will recommend about six weeks before surgery.
Another one of the risk factors that we know that patients can work on is their blood sugar control. This is specific for diabetics and we have taken the approach of absolute glucose control before surgery. Bacteria and various things inside your wound need sugar to survive and if you have elevated levels of sugar in your wound after surgery, then that gives them a better chance of setting up shop and causing an infection.
So if we can get patients to have good blood sugar control which we measure with something called a hemoglobin A1C level which most diabetics are already very familiar with. If we can get that level below seven before surgery then people's risk of infection is equivalent to the normal population.
Dr. Miller: So do you end up working with the patient directly on that or do you usually work through their primary care physician or how do you make sure that they get best control of the diabetes?
Dr. Vargo: It's a good question. We work with both actually. We found that for some patients who are very, very good at monitoring their own sugars they are fairly easy to work with. Other folks maybe aren't as compliant with their blood sugar regimen, with their insulin or their medications for their diabetes. We will reach out to their primary care doctors to assist. Then occasionally we actually refer people to our own diabetes center.
Dr. Miller: Now, how about physical exercise? Do you work with them on their stamina?
Dr. Vargo: There is, there is a program, a true prehabilitation program where people will start to increase their activities before surgery. I deal mostly with abdominal wall problems and hernias and a lot of people have actually stopped their physical activity because of the discomfort that they have because of these abdominal wall problems that they have.
So it can be difficult sometimes to get them going with regards to an exercise program. But we have the ability of using things like arm ergometers, even getting people just on a treadmill and starting to walk.
Dr. Miller: You mean things like Fitbit or Jawbone. Some of those products that are out there now.
Dr. Vargo: Exactly, exactly. And have people monitor what they do with the idea that with as little as six weeks of activity before surgery, similar to the smoking cessation, patients will show an improved outcome after surgery with regards to getting back up on their feet, not being as dependent. They have overall better function outcomes after surgery.
Dr. Miller: Now, do you talk to them about medications or medications that they would need to stop prior to surgery so that doesn't have an adverse effect on the outcome?
Dr. Vargo: There are. There are a lot of supplements that patients take now. And being in Utah we have a lot of folks who do engage in trying to improve their own health by taking these supplements and in surgery some of these supplements can actually increase their risk of bleeding.
There are seven or eight that exist that do do that. We talk about the G's for general surgery, ginkgo biloba is one of them, garlic, ginseng, saw palmetto, was another one. But there are some things that patients definitely need to stop before undergoing a bigger operation.
Dr. Miller: So part of prehabilitation is that they work with patients to tell them to go off those medicines before they enter the operating arena.
Dr. Vargo: Exactly, exactly. And then we also work with patients from a nutritional standpoint. As metabolic surgery, gastric bypass type surgery has become more popular, general surgeons are starting to have to operate on folks who've had these procedures. And what we have a much better understanding of now is that these patients come in with some fairly significant metabolic derangements which if you just look at somebody sitting in a chair you would never really recognize.
There are vitamin deficiencies that these patients have coming in, and so there really is some dietary counseling that we go through and some nutritional counseling that we go through. Not just with the gastric bypass patients but actually with all of our patients.
Dr. Miller: So Dr. Vargo, is this prehabilitation concept a local concept or a university concept? Is this more of a national construct that's being rolled out?
Dr. Vargo: It's becoming more and more popular across the country and actually around the world. This past May was the third world congress on these types of programs called Enhanced Recovery After Surgery and there is a listing of guidelines for people who are interested. You can go onto the web and you can look these up. And if you do have a surgery that's being planned for you, you can look through the list of things that you can do to help improve your own outcomes after surgery.
Dr. Miller: Would they Google prehabilitation? Would that be the thing that they would Google?
Dr. Vargo: Either prehabilitation or enhanced recovery after surgery. That would also be something that would work.
Dr. Miller: Now, you've given us the list of a number of things that you're having patients do or consider. In your experience does doing all that result in a better outcome?
Dr. Vargo: It actually does result in a better outcome. There have been multiple studies that have been done that show that patients have a significantly decreased risk of wound infections after surgery. For the elderly patients there's a decreased risk of falls after surgery and the consequences of having falls after surgery. And actually in my own patient population I was able to decrease the wound complication rate by about 50% just by implementing this type of a program.
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