Before your operation — prehabilitation, optimization, and the 6-week window

The five-step prehabilitation protocol

1. 1

   Stop smoking, ideally 6 weeks before

   Smoking abstinence reduces wound complications, pulmonary infections, and overall morbidity. The 6-week mark is when measurable benefit appears. Earlier is better. We refer to local cessation programs and offer nicotine replacement therapy when needed.

2. 2

   Stop alcohol, also 6 weeks before

   Regular alcohol consumption raises post-operative complication rates including infection, bleeding, and cardiac events. Stopping for 6 weeks before elective surgery reduces these risks. Patients who cannot stop on their own are referred to support programs.

3. 3

   Treat anaemia with intravenous iron

   Iron deficiency anaemia is common in cancer, chronic disease, and heavy menstrual bleeding patients. IV iron corrects it in 2 to 4 weeks and reduces transfusion risk. We screen ferritin and transferrin saturation in addition to haemoglobin so the diagnosis is precise.

4. 4

   Nutritional supplementation 7 to 10 days

   For malnourished or sarcopenic patients (low muscle mass, often hidden under high BMI), oral nutritional supplements with high-calorie and high-protein content for 7 to 10 days before surgery improves outcomes. We assess nutritional status and prescribe specific products with branched-chain amino acids when indicated.

5. 5

   Exercise plus mental preparation 4 to 6 weeks

   Structured physical activity, even moderate walking and resistance bands, builds cardiovascular reserve and muscle mass. Mental preparation including expectations, breathing techniques, and post-op visualisation reduces peri-operative anxiety. Together with nutrition, this is "prehabilitation". The longer the window, the more benefit.

Comorbidity optimisation matrix

Specifics on diabetic optimization, including HbA1c targets, GLP-1 stop windows, and the role of HOMA-IR, are on the diabetic patients page. Cardiac patients with elevated risk are detailed on the cardiac patients page.

Pre-operative information — the first ERAS element

The original ERAS Study Group, led by Henrik Kehlet and colleagues in 2001, listed pre-operative information as element one of the protocol — before fasting, before the carbohydrate drink, before any drug. The reasoning has held up across two decades of trials: a patient who knows what is going to happen recovers faster, requires less analgesia, and has a smaller stress response than a patient who is taken into the operating room with no map of the next 72 hours.

The pre-operative information visit at the Ghalwash practice covers six areas, on paper, given to you to take home:

• What the operation does — anatomically, in plain language, with a printed diagram. Why this operation. What alternatives exist.
• What the day of surgery looks like — fasting, the carbohydrate drink, arrival time, who you will meet, where the family waits, when they can see you.
• What recovery looks like, hour by hour — wake up, sit up, first meal, first walk, first night, day 1 targets, when the tubes come out.
• Pain and what we will do about it — the multimodal protocol, what you will feel, what to ask for if pain escalates.
• Discharge criteria, written — the four objective criteria, so you know when you go home rather than guessing.
• Warning signs after discharge and the direct phone number — what to call about, what is normal.

Two complementary strategies: reduce stress, build resilience

This is why a fit patient still benefits from the carbohydrate drink, and a frail patient still benefits from prehabilitation even if their surgery is small. The two ideas compound regardless of starting condition.

Frequently asked questions