Penn Medicine is proud to announce the launch of the PeRioperative Evaluation and Planning (PREP) Program. Led by colon and rectal surgeon Nicole Saur, MD, Director of Geriatric Surgery at Pennsylvania Hospital, the program is a multidisciplinary, multiphase pathway for optimization of older patients undergoing surgery.
Why PREP, Why Now?
In the United States, older persons receiving colon and rectal surgery often face a therapeutic conundrum in which treatment is based upon chronological age alone rather than individual fitness for surgery or personal preferences. It's a concern Dr. Saur confronts as a surgeon in the complex treatment paradigm for colorectal cancers.
"Often times, fit patients are excluded from the standard of care because they're older," she says. "At the same time patients who are younger, but less fit, are receiving advanced surgery because they're seen as ready for surgery."
Unfortunately, the outcomes in younger, less fit surgery patients may be poorer than those of fit patients excluded from the same procedures by age. Beyond the potential for over- and under-treatment of patients, there are other, far more nuanced concerns. Individuals who might be physically and cognitively appropriate for age-defined surgery, for example, may not wish to have certain procedures.
"A lot of patients would rather have a permanent colostomy than the possibility of incontinence after major rectal cancer surgery — but not all patients," Dr. Saur explains. So you can't really make assumptions. It's not one-size-fits-all."
Managing the needs and expectations of older patients in anticipation of surgery and thereafter is the purpose of the recently introduced PeRioperative Evaluation and Planning (PREP) Program at Penn Medicine. The program incorporates a timeline in three distinct phases (see figure above) that combine in a perioperative pathway. Uniting the three is an enhanced recovery after surgery (ERAS) protocol that has the ultimate goal of returning the patient to preoperative levels of independency, dignity, and optimal well-being.
Preoperative Care
The PREP Program's multimodality preoperative phase is enhanced by the development of a personalized care plan. A constant at every stage of the PREP Program, this template for care encourages shared decision-making and communication.
In older adults, reliable clinical and cognitive assessment are essential before surgery to determine degree of frailty, and stratify risk. PREP Program Geriatricians play a key role in the success of PREP throughout its phases, and conduct the initial objective tests on patients before surgery to evaluate their function, cognitive and nutritional status, and activity level.
The Value of Geriatric Care
"Geriatricians are really skilled providers in identifying unseen vulnerabilities in geriatric patients," says Dr. Saur. In addition to performing initial assessments in the preoperative setting, adds Dr. Saur, PREP Program Geriatricians are involved in the multi-disciplinary cancer tumor board if patients have a malignancy (an important assurance that the patient's goals are being recognized and accounted for) and in the evaluation and care of patients post-operatively.
Prehabilitation: Improving Functional Capability
Another aspect of the preoperative phase, prehabilitation, offers the opportunity to optimize whatever abnormalities are found in the frailty screening, Dr. Saur continues, whether in nutrition, in activity, or in social support to identify needed additional resources after surgery. While some patients can go straight to surgery, other patients need significant optimization. Still others, Dr. Saur says, aren't able to be optimized and become candidates for adapted care.
Medical prehabilitation includes the management and optimization of comorbid conditions (e.g., anemia, cardiopulmonary disease, diabetes, thyroid disorders). Lifestyle modifications (smoking, alcohol) and reduction of polypharmacy are important for reduction of complications. Nutritional optimization can potentially decrease ileus incidence and severity, improve appetite, promote normoglycemia, attenuate the perioperative inflammatory response, and provide sufficient protein intake for anabolic metabolism to maintain lean body mass.
Communications with patients to learn their goals and wishes before surgery can ascertain expectations and the degree of compromise they are willing to undertake to prolong life.
"We've really worked out a great system of communication that puts the patient and their care team or their care partners at the center to make sure that we understand their goals are and what resources they have and what they might need as they go through the care continuity," Dr. Saur explains.
Recognizing that communication can be hampered by a variety of issues in the elderly population, the PREP Program seeks to accommodate hearing loss, the complexity of conveyed information, patient capacity to consent, and cognitive concerns, and to recognize the significance of other persons (partners, children) with needs and concerns of their own for the elderly patient.
Intraoperative Considerations
Minimally invasive colorectal surgery is not expressly contraindicated in older patients and has been shown to be beneficial for its association with faster clinical postoperative progression, decreased perioperative complications, and shorter length of stay.
Penn Medicine is ideally suited in this regard for older adults with pancreatic or gastric cancers given that the complexity and demands of surgery and anesthesia for these procedures are best performed at specialty centers with experienced surgeons.
PREP and the Postoperative Patient
The PREP Program's postoperative pathway for the older patient augments the ERAS protocol while in hospital, as well as personalized geriatric co-management, social support, and rehabilitation to restore daily living skills and mobility thereafter. The geriatric team is active in the hospital to ensure that delirium is caught early, that falls are prevented and that other potential complications are addressed or avoided.
"Postoperatively, the PREP program's lead nurse helps coordinate care to make sure that patients are getting optimal physical therapy evaluations and treatment while they're in the hospital, and that other supportive care services are involved when needed," Dr. Saur says. "The goal is to get patients home, hopefully, but if not, to wherever is the most supportive environment for them postoperatively."
For more information about the PeRioperative Evaluation and Planning (PREP) Program at Penn Medicine, contact: Nicole Saur, MD, at Nicole.Saur@pennmedicine.upenn.edu.