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Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37 Page 5 of 18

[18]
preoperative counseling must take place 4 weeks before surgery .

[24]
Despite some less than enthusiastic report , pre-habilitation is becoming a key factor in increasing the
functional capacity of the patient before an operation [25,26] . It has been defined as a multimodal proto-
col involving not only nutritional assessment and support, but also physical exercise. Typically, patients
considered for prehabilitation are recruited in a 3 or 4-week supervised physical training associated with
unsupervised home exercises. This schedule has been demonstrated to be beneficial to improve the cardio-
pulmonary exercise test scores [27,28] and to significantly reduce LOS and length of recovery [28,29] . The effect
[30]
of prehabilitation as opposed to standard rehabilitation is more evident in sedentary people .

It is clear that this protocol is time-consuming and may delay curative surgery for cancer. In particular in
the countries, such as the UK, where cancer targets exist and require the operation to be performed as soon
as possible after the diagnosis, prehabilitation has not been diffusely accepted yet due to the fears that a
[31]
prolonged preoperative interval would impair survival . However, a recent prospective study from UK has
demonstrated that time from diagnosis to surgery - either 4, 8 or 12 weeks - does not impact on survival,
[32]
so the regulatory pathways can safely be changed to accommodate prehabilitation . A few prospective tri-
als are still ongoing and are targeted at assessing the value of physical prehabilitation in patients scheduled
for colorectal surgery [28,33-35] . We are looking forward to evaluating their results. However, it should be uni-
versally clear by now that prehabilitation should be included in every ERAS protocol, possibly adding also
anxiety-reduction techniques which may benefit both the psychological and physical wellbeing of patients
[36]
undergoing major rectal surgery .
Preoperative nutrition
One of the new concepts highlighted by ERAS is that a correct preoperative nutrition can improve post-
operative recovery by reducing the effects of surgical stress. As malnutrition is a negative prognostic factor
[37]
for LOS and complications , nutritional assessment and support have been included in the prehabilitation
programme.

It has been demonstrated that the traditional long fasting before the operation has no advantages in terms of
[38]
possible risk of inhalation and, on the contrary, can be detrimental due to the risk of increasing the physi-
[39]
ologically stress-related insulin-resistance . Randomized controlled trials demonstrated that the administra-
tion of a specific sugary fizzy drink before the operation could reduce postoperative insulin-resistance, other
[23]
than hunger, thirst and anxiety . The preoperative sugar load would improve the metabolism of proteins and
nitrogen and reduces the detrimental catabolic effects of surgical stress on the muscular mass and the healing
process [40,41] , thus reducing the risk of complications and expediting the recovery.

Recent recommendation of the American Society of Anesthesiologists is that patients should have free ac-
cess to fluids up to 2 h before surgery and to solid food up to 6 h before surgery, thus resembling a “normal”
[42]
nutritional pattern . Particular attention has been suggested - at least initially - to diabetic patients, where
sugary drinks can potentially derange their glycaemia. Moreover, patients with complicated type 2 diabe-
tes are known to have an increased risk of delayed gastric emptying, so - at least theoretically - the ERAS
recommendations must be applied with special care.

Immuno-nutrition has been recently introduced as a way to reduce complications and improve recovery. The
SONVI Study compared an immune-enhancing pre and postoperative nutrition with the traditional hyper
caloric hypernitrogenous supplement within an ERAS programme and found that the number of infective
[43]
complications was significantly reduced in the treated group . Immuno-nutrition will be further discussed.