Efficacy of prehabilitation interventions on exercise capacity of patients undergoing major abdominal and cardiothoracic surgery: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND: Prehabilitation has reported improvements in exercise capacity, as measured by the six-minute walking test (6MWT), in people undergoing major abdominal and cardiothoracic surgery, although there is no evidence about which component of prehabilitation is most effective for improving exercise capacity. METHODS: A network meta-analysis (NMA) was performed to determine the effects of different components of prehabilitation on exercise capacity in people undergoing major abdominal or cardiothoracic surgery. A literature search was performed from baseline to September 2025. Randomized controlled trials on the effectiveness of prehabilitation programs on exercise capacity presurgery and recovery postsurgery were included. We assessed the risk of bias via the Cochrane risk of bias (RoB 2.0) tool and the quality of the evidence via the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. Pairwise meta-analyses and NMAs were performed for direct and indirect evidence. RESULTS: Thirty-eight studies were included in this NMA. The effects associated with improvements in exercise capacity presurgery scores were greatest for the moderate-intensity exercise group versus control group (Effect size ES: 0.93 95 % CI: 0.46, 1.40), followed by the multimodal group (exercise+ nutrition + psychological intervention) versus the control group (ES: 0.50, 95 % CI: 0.15, 0.86). The effects associated with 6MWT recovery postsurgery score were greatest for the exercise+ nutrition group versus the control group (ES: 1.08, 95 % CI: 0.00, 2.16), followed by the moderate-intensity exercise group versus the control group (ES: 0.55, 95 % CI: 0.08, 1.01), and the multimodal group versus the control group (ES: 0.35, 95 % CI: 0.03, 0.68). CONCLUSIONS: Moderate-intensity exercise, followed by multimodal exercise, should be considered the most effective strategy for improving exercise capacity in people undergoing major abdominal and cardiothoracic surgery. Exercise plus nutrition is the most effective intervention to improve 6MWT recovery postsurgery, followed by moderate-intensity exercise and multimodal interventions. Owing to the importance of this outcome, as a predictor of both postsurgical complications and recovery capacity after surgery, it is essential to know the most effective intervention to improve it.