Structured prehabilitation before gastrectomy for gastric cancer: a systematic review and meta-analysis of randomized trials

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Previous reviews suggest that prehabilitation may improve perioperative outcomes, but heterogeneity in cancer site, surgery, and study design limits direct applicability to gastrectomy. Recent randomized trials have expanded the evidence on prehabilitation before gastrectomy for gastric cancer. We assessed the perioperative and functional effects supported by this evidence, their certainty, and the extent to which current data can inform program design and implementation. We searched seven databases from inception to 17 June 2026 and screened the reference lists of eligible studies and relevant reviews. We limited the meta-analysis to randomized trials in gastric cancer and summarized separately one study that used predictable allocation based on odd and even admission order. We used random-effects models for six core outcomes, assessed risk of bias for each outcome, and rated certainty using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The review was prospectively registered in PROSPERO (CRD420261344889). Six randomized trials involving 972 randomized participants formed the quantitative evidence base, while one quasi-randomized study was retained for structured narrative synthesis. The pooled estimates favored structured prehabilitation for 30-day overall postoperative complications (risk ratio 0.56, 95% confidence interval 0.42 to 0.74), pulmonary complications (risk ratio 0.41, 95% confidence interval 0.24 to 0.70), and postoperative hospital stay (mean difference −1.48 days, 95% confidence interval −2.10 to −0.86). Certainty was moderate for all three outcomes. Evidence for Clavien–Dindo grade III–V complications and 30-day readmission remained inconclusive. Preoperative 6-minute walk distance was higher with prehabilitation, but heterogeneity was substantial (I 2 = 90%) and the estimate was sensitive to model choice and study omission. The quasi-randomized study reported favorable functional and nutritional findings but was judged to be at serious risk of bias. Structured prehabilitation probably reduces overall and pulmonary complications and shortens postoperative hospital stay after gastrectomy. These pooled estimates represent average effects across clinically heterogeneous programs, and their applicability may vary by treatment pathway, program duration, and patient population; current evidence does not yet define an optimal program, treatment-responsive subgroup, or standardized implementation strategy. International Prospective Register of Systematic Reviews (PROSPERO), CRD420261344889.