Psychological factors, prehabilitation and surgical outcomes: evidence and future directions.

The pre-operative optimisation of comorbidities is increasingly recognised as an important element of the pre-operative pathway. These efforts have primarily focused on physical comorbidities such as anaemia and the optimisation of exercise and nutrition. However, there is a growing recognition of the importance of psychological morbidity. Increasingly, evidence suggests that psychological factors have an impact on surgical outcomes in both the short and long term. Pre-operative anxiety, depression and low self-efficacy are consistently associated with worse physiological surgical outcomes and postoperative quality of life. This has led to the emergence of psychological prehabilitation and the trimodal approach to prehabilitation, incorporating psychological intervention as well as exercise and nutritional optimisation. However, there is currently insufficient evidence to be sure that pre-operative psychological interventions are of benefit, or which interventions are most effective, because their impact has been mixed. There is an urgent need for high quality, contemporaneous prospective trials with baseline psychological evaluation, well-described interventions and agreement on the most appropriate psychological, quality of life and physiological outcomes measures.