This study describes the health outcomes for patients who underwent major elective surgery after participating in a presurgical optimisation programme led by a liaison nurse. The results were compared with those obtained for a control group receiving the usual medical care before surgery. Complications, length of hospitalisation and number of hospital readmissions in each group were recorded and compared.
Health professionals working with presurgical optimisation programmes have reported that the implementation is made difficult by the necessary organisational complexity (32), insufficient time and inadequate training (33). Programmes that involve many professionals can be inefficient due to delays in patient treatment resulting from a lack of communication and incorrect referrals (34). Unlike other national presurgical optimisation programmes developed by the Spanish Multimodal Rehabilitation Group (GERM), the model used here requires only two health professionals. The other models employ several specialists (such as haematologists, endocrinologists, cardiologists, pulmonologists, and physiotherapists) and need an average of 5 visits per patient (1). In the protocol carried out at the Infanta Cristina University Hospital of Parla (Madrid) described in this article, the assessment, management, and coordination of patient care is centrally controlled by the liaison nurse in collaboration with the hospital internist. Thus, the optimisation process can begin in less than 48 hours after adding the patient to the SWL. In other models, the nurse takes part only in the coordination and follow-up of interventions, and the assessment of the patient needs is carried out by medical specialists (9). It has been reported that a healthcare professional acting as a coordinator facilitates implementation (32). Empowering a nurse (with adequate training and supervision) to assume roles historically performed by other medical professionals expedites access to therapies and simplifies the management of complex patients (27). The results obtained here show that presurgical optimisation significantly reduces the frequency of immediate and remote complications after surgery (p < 0.001). This is in agreement with another clinical study of patients undergoing major abdominal surgery, whose postoperative complication rate was 31% after preoperative optimisation and 62% in the control group without such treatment (35). In that study, both the intervention and control groups followed recommendations for physical activity and were given nutritional counselling and smoking cessation tips. They were also advised to reduce alcohol intake and received intravenous iron injections in cases of anaemia. Additionally, the intervention group participated in individualised high-intensity resistance training programmes on a stationary bike and took part in motivational talks to increase adherence (35).
It has been shown that surgical patients with anaemia carry an increased risk of postoperative complications and have a higher mortality rate than those without this condition (36). Treating anaemia before surgery reduces the number of postoperative complications and blood transfusions (37) and accelerates the recuperation of mobility (38). These findings concur with the results of the current study, in which the handling of anaemia as a part of clinical optimisation probably contributed to improved postoperative evolution of the intervention group.
Suture dehiscence and infectious wound complications were less frequent among the programme participants than in the control group. This is in agreement with a meta-analysis published in 2021 showing that improving nutritional status and quitting smoking reduce the frequency of wound infection by 29% and 72%, respectively (39).
Hyperproteic and hypercaloric oral supplementation with 100% lactoprotein serum, leucine, and vitamin D might also be associated with a decrease in the number of postoperative complications (40). This finding concurs with the conclusions of Perry et al. (2021) in a meta-analysis of 10 clinical studies including 643 patients (41). The analysis has shown that postoperative complications decreased in the group supplemented with lactoprotein serum (22%) compared to the control group (32%) (p = 0.01) (42). Leucine is the only branchedchain amino acid that stimulates the mTOR signalling pathway and, thereby, protein synthesis in the muscle (43). Vitamin D is key in lowering the anabolic threshold for postprandial stimulation of muscle protein synthesis by leucine, which contributes to preserving or increasing muscle mass in older patients (44). Thus, it can be argued that the combined administration of these nutritional elements in an oral nutritional supplement helps the recovery of muscle mass and muscular trophism – which is necessary for the early mobilisation of patients after surgery.
Cancer patients who receive oral nutritional supplementation have also shown better clinical evolution, fewer complications, and need fewer health resources than those who have not received such treatment (45)(46). For example, patients who received a leucine-enriched supplement to accompany a physical exercise programme showed increased grip strength compared to the control group without supplementation (47). Another study has compared the recovery of functional capacity of patients in a presurgical optimisation programme with that of a standard care group. The programme consisted of four interventions: high-intensity resistance and strength training, protein-rich nutrition and supplementation, smoking cessation and psychological support. Four weeks after surgery, the average functional capacity of patients in the intervention group (as measured by a 6-minute walk test) rose above baseline, while it decreased in the control group (48).
Likewise, the intake of carbohydrate drinks two hours before surgery stimulates the release of insulin and ghrelin. It reduces the number of catabolic processes, mitigating the transient increase in insulin resistance that elective surgeries usually produce (49). High endogenous glucose levels may increase the risk of surgical complications (50), prolonging hospitalisation (51, 52). The European Society for Clinical Nutrition and Metabolism recommends reducing preoperative fasting to two hours (18); this advice was followed for the intervention group in this study.
Several meta-analyses vary in their conclusions regarding the reduction of hospitalisation time of patients participating in presurgical optimisation programmes. In one such analysis of 9 randomised clinical trials, there were no differences between patients who participated in a presurgical optimisation programme and those who did not (53). However, Lambert et al. (2021) reported a 1.78-day reduction in hospital stays among patients enrolled in presurgical optimisation programmes compared to those receiving standard care (54). These results agree with those obtained in the current study, where the hospitalisation in the intervention group was reduced by 3.29 days compared to the control group.
The results of this research must be interpreted in the context of its limitations, typical of the design of retrospective observational studies. Thus, a process to randomly assign the clinical histories to the group’s undergoing study was not followed. Instead, convenience sampling was used based on the patients on the surgery waiting list, which could affect the probability of being studied. Moreover, the degree of motivation of a patient voluntarily participating in research can differ significantly from that of other patients. In this study, the patients in the intervention group could have had different motivations to follow the medical recommendations for preoperative optimisation than those in the control group. A subgroup analysis of individuals sharing, for example, similar nutritional status or comorbidities (both of which are related to the subsequent surgical recovery) was not performed.
Despite the limitations, the study presents favourable results obtained by implementing a presurgical optimisation programme led by a liaison nurse, designed to reduce the number of postoperative complications and decrease the length of hospitalisation after a major elective surgery. The findings are in accord with data reported by other studies of similar interventions. Although these designs have low internal validity, their external validity is high because they reflect standard clinical practice and the value of the interventions that can be carried out in this context.