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Page 2 of 10 Mohan et al. Hepatoma Res 2020;6:13 I http://dx.doi.org/10.20517/2394-5079.2019.53

screening programs for Hepatitis B, increasing awareness and advances in imaging technology facilitating
early diagnosis, surgery has an increasing role in management of hepatocellular carcinoma. Age-related
comorbidities increase operative morbidity and impacts peri-operative outcomes. Enhanced recovery
after surgery (ERAS) programs emphasize on intra-operative and post-operative care standardization
with minimal guidance on pre-operative phase except nutritional optimization and carbohydrate loading.
Pre-operative phase provides an opportunity for surgeons to optimize patients to meet up for impending
physiologic stress imposed by surgery. In this paper, we discuss the role of prehabilitation program in
elderly patients scheduled for liver resection and also discuss the current protocol of Recovery Of Surgery
in Elderly (ROSE) program.

AGEING
Along with greying of hair, development of cataracts, degenerative bone disorders and declining cognition,
ageing leads to a myriad of other physiologic changes in organ systems. Atherosclerosis, hypertension and
decreased cardiac output are noted in the cardiovascular systems. Impaired gas exchange, reduction in
vital capacity and reduced expiratory flow rates are noted in pulmonary system. Furthermore, decline in
lean body mass, createnine clearance reduction, hepatic drug metabolism impairment and gastrointestinal
motility reduction are noted. This functional and metabolic alteration is compounded with polypharmacy
for managing chronic illnesses. Figure 1 shows age related physiologic changes in organ systems. Frailty
[2]
and sarcopenia are common in elderly too .

FRAILTY AND SARCOPENIA
Frailty is a pre-disability syndrome in the elderly when exposed to stressors with increased risk of disability
or need for hospitalization. The European Working Group on Sarcopenia in Older People has defined
[3]
sarcopenia as progressive, generalized loss of skeletal mass with associated functional losses . Low skeletal
[4]
[5]
muscle mass and low functional capacity associated with sarcopenia lead to increased post-operative
complications as well as reduced long term survival. As such the elderly are vulnerable, especially when
[6]
faced with peri-operative stress. Morley et al. , reported that sarcopenia and frailty are closely linked to
ageing. They reported decreased hand grip strength, walking speed and weight in the elderly and concluded
lack of muscle usage as one of the reasons which impacts outcomes. Prehabilitation aims to mitigate the
drawbacks of frailty.

PREHABILITATION
Rehabilitation is integrated in routine clinical medicine. It focuses on recovery following a surgical stressor.
Prehabilitation is defined as the process of augmenting functional capacity before surgery with aim of
reducing post-operative morbidity and/or mortality. This is done through a personalized regimen of
aerobic, functional and strength training. It aims to optimize pre-operative functional cardiorespiratory
and nutritional reserves. As the scope of prehabilitation overlaps with concept of rehabilitation and
rehabilitation is integral to orthopaedic surgery, orthopaedic teams were early adopters of prehabilitation .
[7]
[8]
Rooks et al. reported 108 patients scheduled for total hip arthroplasty and total knee arthroplasty
and showed improvements in preoperative and post-operative muscle strength and reduced need for
[7]
inpatient rehabilitation. In a systemic review by Coudeyre et al. , prehabilitation contributed to reduced
hospitalization and improved discharge conditions in patients with total hip arthroplasty and total knee
arthroplasty. A pilot randomized study including 30 elderly patients above 65 years old undergoing total hip
arthroplasty showed that home based physical therapy was feasible to implement and it improved 6-min
[9]
walk test as compared to standard care. Prehabilitation is also implemented in urology and colorectal
surgery. Au et al. reported increased inpatient physical activity on post-operative day 1 in patients
[10]
[11]
undergoing radical prostatectomy. A randomized controlled trial by Painter et al. included 167 patients