Prehabilitation before thoracic surgery: do we need it, and does it make a difference?

Purpose of review Prehabilitation is increasingly used before thoracic surgery to increase physiological reserve, but whether improved functional capacity translates into better postoperative outcomes remains uncertain. This review examines the physiological rationale, recent evidence, and appropriate role of prehabilitation in noncardiac thoracic surgery. Recent findings Preoperative exercise and multimodal programs consistently improve functional capacity, including 6-min walk distance and cardiopulmonary fitness. Thoracic-specific meta-analyses suggest reductions in postoperative pulmonary complications and hospital stay; however, individual randomized trials remain heterogeneous, and a recent fragility analysis of prehabilitation trials in cancer surgery showed that statistically positive complication outcomes typically hinged on a single event. Functional improvement does not necessarily mediate reductions in complex postoperative morbidity, and similar medium-term recovery may be achievable with postoperative rehabilitation. Optimal patient selection remains uncertain. Summary Prehabilitation can increase physiological reserve, but it cannot neutralize the multidimensional stress of major noncardiac thoracic surgery. A risk-adapted approach is preferable to universal implementation. Prehabilitation should exploit an existing oncologically acceptable waiting period, avoid delaying definitive surgery, and be integrated with early postoperative rehabilitation.