Prehabilitation programs for patients scheduled for esophagectomy

Patients diagnosed with esophageal cancer often face a demanding treatment pathway that typically culminates in esophagectomy, one of the most physiologically stressful operations in modern surgical practice. Recovery can take many months, and the period before surgery offers a precious window to strengthen the body and mind for what lies ahead.

Prehabilitation, sometimes called "prehab," refers to a structured set of interventions delivered during the weeks before a scheduled operation. The aim is to build physiological reserve, improve nutritional status, and reduce anxiety so that patients enter surgery in the best possible condition. For esophagectomy candidates, this proactive approach has gained strong momentum in surgical circles worldwide, and Australia has become an active contributor to the evidence base.

What prehabilitation involves

Prehabilitation is not a single intervention but a coordinated bundle that typically combines exercise training, nutritional optimisation, psychological support, and management of anaemia or other reversible risk factors. Exercise prescription usually centres on aerobic capacity, resistance work, and inspiratory muscle training, since postoperative pulmonary complications remain a leading cause of morbidity after esophagectomy.

Nutritional counselling is equally central. Many patients present with dysphagia and significant weight loss, and dietitians work to stabilise lean body mass before surgery through fortified oral intake, supplements, or, when needed, enteral feeding. Psychological support addresses anxiety, fear of surgery, and the social disruption that a long recovery can bring, often drawing on cognitive-behavioural techniques and mindfulness practices.

The Australian clinical context

Australian centres have been quick to embed prehabilitation into upper gastrointestinal cancer pathways. In Sydney, Royal Prince Alfred and Concord hospitals run combined cardio-oncology and pre-surgical conditioning clinics, while Peter MacCallum in Melbourne has published widely on multimodal prehab for upper GI malignancies. Brisbane's Princess Alexandra and Perth's Sir Charles Gairdner are also advancing similar models, often in partnership with university exercise physiology departments.

The local healthcare environment shapes how these programs are funded and accessed. Medicare rebates under the Chronic Disease Management plan can cover a portion of physiotherapy and dietetic input, while private health insurers such as Bupa, Medibank, and HCF increasingly recognise prehabilitation as a value-adding service for major surgery. Patients in regional and remote areas of New South Wales, Queensland, and Western Australia face additional barriers, which has spurred telehealth-delivered exercise and dietetic consultations as a practical workaround.

Building the multidisciplinary team

A successful prehabilitation program depends on close collaboration between surgeons, anaesthetists, exercise physiologists, dietitians, psychologists, and specialist nurses. Australian professional bodies, including Exercise and Sports Science Australia and Dietitians Australia, have issued guidance on exercise prescription and nutritional care for cancer patients, which helps align local protocols with international standards.

Nurse-led coordination has proven especially valuable. A dedicated prehab coordinator can triage referrals, schedule baseline assessments, and track adherence, freeing clinicians to focus on medical decision-making. This role is increasingly embedded within the Enhanced Recovery After Surgery frameworks now standard across many Australian public hospitals.

Exercise and nutrition optimisation in practice

Programs typically run for four to six weeks before surgery, although the optimal duration is still being studied. Common elements include:

• Supervised aerobic sessions two to three times weekly, often using cycle ergometers or walking programs calibrated to heart rate reserve
• Resistance training targeting major muscle groups to offset the catabolic effects of neoadjuvant chemotherapy
• Inspiratory muscle training with threshold devices to reduce postoperative pneumonia risk
• Individualised nutrition plans emphasising protein intake of 1.2 to 1.5 grams per kilogram of body weight daily

For patients unable to attend in person, hybrid models combine home-based exercise with periodic telehealth reviews and remote monitoring through wearable devices. Australian physiotherapists and exercise physiologists have been particularly inventive in adapting programs for older adults and those with significant comorbidities, often using low-cost equipment and culturally appropriate resources.

Research, outcomes and clinical priorities

Outcome data from Australian and international cohorts suggest that prehabilitation shortens hospital stay, lowers pulmonary complication rates, and improves functional walking capacity in the weeks following esophagectomy. Quality of life scores at three and six months also tend to favour patients who participated in structured prehab, though larger randomised trials remain in progress.

For clinicians and researchers eager to engage with the latest evidence, the ISDE congress is an important gathering point. Authors presenting work on prehabilitation, enhanced recovery, and survivorship are typically featured alongside workshops on nutrition and physiotherapy. Those planning to attend can find details through the official registration page, where virtual and in-person options are listed.

When planning a prehabilitation pathway, several practical factors deserve attention:

• Baseline assessment should include cardiopulmonary exercise testing, grip strength, gait speed, and validated nutritional screening tools such as the PG-SGA
• Smoking cessation and alcohol reduction programs should be integrated, as both influence surgical risk
• Cultural and linguistic diversity across Australia means that resources in languages other than English, including Mandarin, Vietnamese, and Arabic, can improve engagement in cities like Sydney and Melbourne
• Family involvement is often crucial, particularly for elderly patients or those travelling from rural areas for surgery

The strongest argument for prehabilitation is its capacity to transform the perioperative experience for esophagectomy patients. By investing structured effort in the weeks before surgery, patients enter the operating theatre with greater physiological reserve and leave hospital with fewer setbacks. For Australian clinicians, embedding prehabilitation within existing multidisciplinary and telehealth networks offers a realistic route to scale, while ongoing research shared through forums such as the ISDE congress will continue to refine who benefits most and how best to deliver these programs.