Review for 10.1186/s12876-025-03626-3 (2025)

Title: The Role of Exercise-based Prehabilitation in Enhancing Surgical Outcomes for Patients
with Digestive System Cancers: A Meta-Analysis
Version: 1 Date: 17 Nov 2024
Reviewer:  Matthias W. Wichmann
Reviewer's report:
Dear authors - thank you for the opportunity to review your work.
You have performed significant work and your enthusiasm regarding the subject of
prehabilitation is obvious to the reader.
I think that your work should be published but I would suggest a number of changes to your
manuscript. Some of your statements are not supported by the data you provide and some of
your conclusions appear to be too enthusiastic.
In the abstract you state that "prehabilitation plays a significant role". This is certainly not
supported by the lack of high quality studies in this field of surgery. The wording should be
less definite.
In the introduction you state that "Intestinal system tumors may also be stressed by surgery,
which could result in a bad prognosis (4)". I am not sure how 'stress' can be measured in these
tumors. It needs to be explained better, especially how you come to the conclusion that this might
be positively influenced by prehabilitation. If this is not possible the statement should be deleted.
In the introduction you also state that "There are numerous systematic reviews, nevertheless,
and their results are not always consistent." I think this is related to the fact that there are very
few (if any) high quality studies in this field - this should be outlined early in the manuscript as
a major limitation of the work you submitted for publication.
The aim of you research is outlined in the introduction as "Our meta-analysis's objective is to
evaluate RCT results on the impact of exercise-based prehabilitation in the context of digestive
system tumor surgery, with a particular emphasis on key postoperative outcome variables." In
the discussion of your work you state that "The purpose of our study was to examine the effects
of prehabilitation on surgical results.". The goals described in the introduction appear to be a
better match with your work. The goals described in the introduction and the discussion should
be identical.
In the results section you state "Table 1 shows the total number of individuals who took part
(from 15 to 27)" - this should read: (References 15 - 27).
In the results section you state that "A meta-analysis demonstrated that prehabilitation resulted
in a significant reduction in postoperative complications when compared to conventional care.".
Here a list of the most commonly reported complications should be provided - after all your
meta-analysis did not show significant differences with regards the major (life threatening)
complications. This could make your point stronger that the effort of prehabiliation is worth it for
the patient as well as the care provider, despite the fact that the incidence of major complications
is not significantly lower in the patient group undergoing prehabilitation.
In the results section you state that "The results from 12 studies (15-26) including 788
participants indicated that prehabilitation significantly reduced the length of hospital stay". Here
it would be good to provide a number - what is the mean reduction in hospital length of stay?
A clinician/care provider as well as a patient will want to know how much time is saved by the
significant input necessary for prehabilitation as a standard of care.
You describe the significant (but time limited) positive impact of prehabilitation on 6 minutes
walk distance. You fail to provide any evidence that this short term improvement of 6-MWD
is directly related to the better outcome of the patient undergoing prehabilitation. Once again a
number (difference in distance between the two groups) would be helpful.
In the discussion you state that "the high completion rate and reduced dropout rate associated
with prehabilitation programs underscore their feasibility and acceptability". This is certainly
not supported by the literature - otherwise many more patients would be enrolled in prospective
multi-centre studies and high quality data would be available. The existing literature would
suggest that prehablitation is feasible and is accepted by a selected group of highly motivated
patients who are willing to be enrolled in a study.
In the discussion you state that "that prehabilitation approaches are highly effective in lowering
postoperative problems". Once again this appears to be too enthusiastic and should be rephrased.
Your meta-analysis observed a significant reduction in length of stay (how many days?), a
significant reduction of minor complications (which complications?) and a transient significant
improvement of the 6-MWD (how many meters?). This is hardly a 'highly effective' measure
and requires rephrasing.
In the discussion you state that "These outcomes suggest a consensus on the positive impact of
prehabilitation across various surgical disciplines.". From the existing literature and the limited
number of studies in the field I consider the term "consensus" an overstatement. This phrase
needs to be reworded or deleted.
In the discussion you state that "Prehabilitation improves the patient's general ability to withstand
the stress of surgery, resulting in a more effective recovery process.". This is a nice sentence but
it is certainly not supported by your meta-analysis. It should be deleted.
In the discussion you state that "The benefits of prehabilitation extend far beyond medical
outcomes for patients with digestive system tumors, notably enhancing their level of physical
function.". This is also a nice sentence but it is not supported by your meta-analysis. There is a
transient improvement of the 6-MWD - I would not consider this a clear reflection of benefits
extending far beyond medical outcomes. This sentence should be deleted.
In the discussion you state that "Therefore, it is the constructive collaboration of the multimodal
prehabilitation approach that accounts for the improvement in patients' six-minute walk
capabilities.". This should be rephrased because it is impossible to draw the conclusion that the
improved 6-MWD is the consequence of multimodal collaboration. It could be rephrased to "...
multimodal collaboration appears to contribute to the improvement of ...".
Once again thank you for the opportunity to review your extensive and outstanding work. I look
forward to reviewing your revised manuscript.