British Journal of Anaesthesia, 119 (S1): i34–i43 (2017)

doi: 10.1093/bja/aex393
Clinical Practice

CLINICAL PRACTICE

Fit for surgery? Perspectives on preoperative exercise

testing and training
K. Richardson1,2, D. Z. H. Levett1,2, S. Jack1,2 and M. P. W. Grocott1,2,3,*
1
Anaesthesia and Critical Care Research Area, Southampton NIHR Biomedical Research Centre, University
Hospital Southampton NHS Foundation Trust, Southampton, UK, 2Integrative Physiology and Critical Illness
Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
and 3Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
*Corresponding author. E-mail: mike.grocott@soton.ac.uk

Abstract
There is a consistent relationship between physical activity, physical fitness, and health across almost all clinical contexts,
including the perioperative setting. Physiological measurements obtained during physical exercise may be used to infer the
risk of adverse outcome after major surgery. In particular, data obtained from perioperative cardiopulmonary exercise test-
ing have an expanding role in perioperative care. Such information may be used to inform a variety of changes in clinical
practice, including interventions that may reduce the risk of perioperative adverse events. Specifically, for patients under-
going major cancer surgery there is a complex interplay between different cancer treatments, including neoadjuvant thera-
pies (chemo- and chemo- plus radiotherapy), surgery, and physical fitness, and the modulation of these relationships by
perioperative exercise interventions. Preoperative cardiopulmonary exercise testing provides an objective evaluation of
physical fitness and has been used to provide an individualized risk profile in order to guide collaborative decision-making,
inform the consent process, characterize and optimize co-morbidities, and to triage patients to perioperative care.
Furthermore, studies evaluating exercise interventions aimed at increasing preoperative exercise capacity have established
that training improves physical fitness. However, to date, this literature is largely composed of feasibility and pilot studies
with small sample sizes, which are in general underpowered to assess clinical outcomes. Adequately powered prospective
multicentre studies are needed to characterize the most effective means of improving patient fitness before surgery and to
evaluate the impact of such improvements on surgical and disease-specific (e.g. cancer) outcomes.

Key words: cardiopulmonary exercise testing; exercise testing; exercise training; perioperative; preoperative; physical activity;
physical fitness; physical fitness testing

The relationship between physical activity, physical fitness,
and health is consistent in almost all clinical contexts. This
review explores several themes stemming from this
relationship in the perioperative setting: the use of physical
exercise measurement to infer the risk of adverse outcome
after major surgery; the subsequent applications of such
information in clinical practice; and the role of exercise
interventions in modulating this risk. In particular, we focus
on major cancer surgery and the complex interplay between
different cancer treatments, including neoadjuvant therapies
(chemo- and chemo- plus radiotherapy) and surgery, and
exercise interventions.

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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i34

Physical fitness, activity, and health
The 2010 World Health Organization Guidelines on physical
activity state that adults should exercise for 150 min each
week, or alternatively for 75 min per week if exercise is per-
formed at higher intensities.1 Many people do not achieve these
goals;2 only 67% of men and 55% of women met these criteria in
England in 2011.2 Moreover, there is a downward trend in activ-
ity with increasing age, with 84% of young males (18–24 yr old)
meeting these goals in comparison with 36% of people >75 yr.
The recommendations within these guidelines are based largely
on observational studies reporting an association between
physical inactivity and all-cause mortality.3 In a systematic
review and meta-analysis of 1 005 791 patients, Ekelund and col-
leagues3 reported that people who spent >8 h seated per day
and exercised <2.5 metabolic equivalent (METS) hours a week
had a 59% increased risk of dying when compared with those
who sat for <4 h per day and participated in >35.5 MET hours
per week. Physical activity is associated with a lower incidence
of several chronic diseases including cardiovascular disease,4
colorectal cancer,5 breast cancer,5 type 2 diabetes mellitus,6 and
cerebrovascular7 and venous thromboembolic events.7
Furthermore, in some chronic diseases, such as chronic obstruc-
tive pulmonary disease (COPD),8 Alzheimer’s disease,9 prostate
cancer,10 and colorectal cancer,11 physical activity has been
associated with slower disease progression and slower declines
in physical and mental functioning.9 Additionally, physical
activity is associated with a lower incidence of hospital admis-
sions in patients with COPD12 and heart failure,13 suggesting
better disease management in such chronic conditions. Overall,
physical inactivity is associated with increased all-cause mor-
tality, whereas physical activity is associated with protection
from many medical conditions and better disease management
in those with chronic medical conditions. Taken together, these
data suggest that reducing sedentary behaviours (i.e. time sit-
ting) and promoting physical activity in our patients, and the
public in general, should be goals for all healthcare
professionals.
Physical fitness, activity, and cancer
There are an estimated 2.5 million cancer survivors in the UK,
and this number is set to increase to >4 million in the next
25 yr.14 Recent studies have characterized physical activity, sed-
entary behaviour, and physical fitness as distinct but interre-
lated constructs that influence the risk of cancer, subsequent
disease progression and tumour recurrence.15–17 Observational
data suggest that physical activity may reduce cancer recur-
rence and death from cancer and other causes,18–20 and conse-
quently, it is recommended that physical activity should be
promoted as part of cancer care pathways.21 22
A systematic review in 2005 and a meta-analysis performed
1 yr later synthesized the evidence supporting the role of physi-
cal activity in cancer outcomes.23 These data showed that
increasing physical activity was acceptable to more than three-
quarters of patients and that when physical activity was con-
ducted concurrently with cancer treatments there were
improved cancer outcomes.24 Several randomized controlled tri-
als have reported that increased physical activity increases
physical fitness and improves quality of life (QoL) after cancer
treatments.25 To date, there have been nine meta-analyses
summarizing these data, but no adequately powered random-
ized controlled trial has been conducted to show that increasing
physical activity, fitness, or functional capacity leads to
Preoperative exercise testing and training | i35
improved surgical or cancer outcomes, or both.25 There is an
urgent need to address this paucity of evidence in the literature.
A recent systematic review by Fong and colleagues25
summarized data from 34 randomized controlled trials evaluat-
ing the effect of physical activity for adult cancer survivors after
completion of the main treatment (not limited to surgery). Their
review included studies predominately evaluating aerobic train-
ing as the intervention, with only four studies also including
resistance training. The meta-analysis included 48 outcomes,
including physiology, body composition, physical function, psy-
chological outcomes, and QoL. Exercise interventions were
associated with improved indices of fitness and physical func-
tion, improved psychological outcomes, and improved QoL
(Table 1). Other studies including patients with prostate, gynae-
cological, colorectal, gastric, and lung cancers have reported an
association between peak oxygen consumption (Vo _ 2 peak), peak
work rate, and clinical outcomes.25 The authors concluded that
the evidence supporting the effects of exercise and physical
activity on cancer outcomes was largely limited to breast cancer
patients, and further randomized controlled trials in other can-
cer cohorts were urgently required.
As a consequence of this evidence, it is now recommended
that regular physical activity is promoted as part of cancer care
pathways.26 It has been shown that on-site supervised exer-
cise,27 home-based exercise programmes,28–30 Web-based exer-
cise programmes,31 and individual, group,15 and peer-support16
interventions can successfully increase physical activity in the
short and medium term. Whether exercise programmes result
in longer-term changes in exercise behaviour (>6 months) is
less clear. For example, the CanChange trial reported that
6 months after a 6 month exercise intervention, the exercise
group performed 30 min more of moderately vigorous activity
per week compared with controls (adjusted between groups;
28.5 min, 95% confidence interval: 3.9–53.1; P¼0.023). This sug-
gests that a longstanding exercise programme may promote
long-term behaviour change.17 Conversely, a lifestyle interven-
tion for older adult cancer survivors found that early improve-
ments in activity levels had diminished at 12 month follow-up
(6 months post-intervention).18 A number of recent reviews
have subsequently highlighted the lack of data on long-term
sustained physical activity behaviour change in cancer survi-
vors.15 19–22 This led Stacey and colleagues22 to conclude in a
systematic review that to date there is ‘little evidence to guide
researchers in helping cancer survivors to maintain health
behaviours after completion of interventions’.
Cardiopulmonary exercise testing
Cardiopulmonary exercise testing (CPET) is a dynamic and inte-
grative test assessing cardiorespiratory capacity by measuring
pulmonary gas exchange through the recording and analysis of
breath-by-breath expired gas data. CPET evaluates the inte-
grated function of the cardiac, circulatory, respiratory, and
muscle metabolic systems in conditions of physiological
stress.32–34 In addition, CPET can identify the cause(s) of exercise
intolerance.33 35 The exercise challenge in the perioperative set-
ting is typically an incremental ramp of increasing work rate to
maximal volitional exertion performed on a cycle ergometer,
although it is possible to use alternative forms of exercise,
including treadmill or hand-crank ergometers.36 37 Among the
long list of CPET-derived variables, the following are most com-
monly used in perioperative practice: anaerobic threshold (AT),
 i36 | Richardson et al.

Table 1 Pooled outcomes from a recent systematic review of 34 randomized controlled trials of physical activity for adult cancer survivors
after completion of the main treatment related to cancer (not limited to surgery)25 NA, not applicable

Outcomes (units or plausible range) Pooled estimate P-value Minimal clinical important
(95% confidence interval) difference

Physiological markers
Insulin-like growth factor I (ng ml1) 12.0 (23.3 to 0.5) 0.04 NA
Insulin (pmol litre1) 0.72 (12.0 to 13.5) 0.91 NA
Glucose (mmol litre1) 0.04 (0.32 to 0.24) 0.77 NA
Homeostatic model assessment 0.08 (0.50 to 0.34) 0.71 NA
Body composition
Percentage body fat 0.8 (1.7 to 0.02) 0.06 NA
Body fat (kg) 1.5 (3.3 to 0.3) 0.10 NA
BMI (kg m2) 0.4 (0.6 to 0.2) <0.01 NA
Waist circumference (cm) 0.7 (4.2 to 2.8) 0.69 NA
Waist:hip ratio 0.01 (0.04 to 0.02) 0.59 NA
Lean mass (kg) 0.6 (0.5 to 1.7) 0.26 NA
Weight (kg) 1.1 (1.6 to 0.6) <0.01 NA
Physical functions
Peak heart rate (beats min1) 0.5 (9.5 to 8.5) 0.91 NA
Peak oxygen consumption (ml kg1 min1) 2.2 (1.0–3.4) <0.01 NA
Peak power output (W) 21.0 (13.0–29.1) <0.01 4
6 min walk (m) 29 (4–55) 0.03 25
Bench press (kg, one repetition maximum) 6 (4–8) <0.01 NA
Leg press (kg, one repetition maximum) 19 (9–28) <0.01 NA
Left handgrip (kg) 4.3 (1.5 to 10.2) 0.15 6.2
Right handgrip (kg) 3.5 (0.3–6.7) 0.03 6.2
Sit and reach (cm) 2 (3 to 8) 0.36 NA

Table 2 Cardiopulmonary exercise test variables with important predictive utility in published perioperative case cohorts

Variable Definition Interpretation

Anaerobic or lactate The oxygen uptake above which lactate An index of submaximal or sustainable exer-
threshold (AT/LT) begins to increase and a metabolic acidosis cise capacity. Associated with postopera-
occurs. This is identified by the associated tive morbidity and mortality in the
changes in gas exchange.38 majority of published case series.
_ 2 peak
Vo Highest oxygen uptake value achieved during An index of maximal aerobic exercise
an exercise test.38 capacity. Associated with postoperative
morbidity and mortality in most pub-
lished case series.
_ Vco
Ve= _ 2 Ventilatory equivalent for CO2 is the ratio of An index of the efficiency of gas exchange
minute ventilation to pulmonary CO2 reflecting ventilation–perfusion matching.
production. If elevated, gas exchange efficiency is
reduced reflecting increased dead space.39
It is associated with postoperative mor-
bidity and mortality in some but not all
published case series.

Vo _ Vco
_ 2 peak, and ventilatory equivalents for CO2 (Ve= _ 2 ); see
Table 2 for definitions of these variables.
Preoperative cardiopulmonary exercise testing
and outcome after surgery
In 1993, Older and colleagues38 published a pioneering paper,
which has had a major influence on perioperative care, particu-
larly in the UK. In a cohort of 184 elderly patients undergoing
elective major surgery, they reported an association between
preoperative AT and postoperative outcome. Patients with an
AT of <11 ml kg1 min1 had a higher ‘non-surgical’ mortality
rate than patients with an AT  11 ml kg1 min1, particularly if
a low AT was coupled with ECG evidence of ischaemia early in
exercise. Since this seminal study, a large number of observatio-
nal studies have demonstrated an association between low pre-
operative exercise capacity and postoperative outcome
(morbidity and mortality).39 40 Two systematic reviews have
reported an association between preoperative CPET variables
_ 2 peak, and Ve=
(AT, Vo _ Vco
_ 2 ) and postoperative outcome in

intra-abdominal, liver transplant, colorectal, and vascular
patients.39–47 In individual studies, preoperative cardiorespira-
tory fitness has been linked to critical care length of stay,48
short-term morbidity,43 42 short-term survival (30 day mortal-
ity),41 49 intermediate survival (90 day mortality),41 49 and long-
term survival (>90 day mortality).41 46 50 51 The first multicentre
study, conducted by the newly formed Perioperative Exercise
Testing and Training Society (POETTS), reported increased mor-
bidity associated with lower levels of oxygen uptake variables in
colorectal patients, with an area under the receiver operating
curve of 0.79 for AT (cut-off 11.1 ml kg1 min1) and 0.83 for
_ 2 peak 18.2 ml kg1 min1.43
Vo
In summary, adequately powered observational studies reli-
ably support a relationship between poor preoperative cardior-
espiratory function and adverse postoperative outcome. This
literature has some limitations, however, most notably that the
majority of preoperative cardiopulmonary exercise testing stud-
ies have been retrospective, single-site, and unblinded. Single-
centre studies are prone to a greater risk of bias and reflect the
characteristics of the local population and care settings, result-
ing in uncertainty as to whether any findings are applicable to
other populations. Additionally, in unblinded studies, the medi-
cal management of patients may have been changed based
upon CPET results. This confounding by indication may dilute
the relationship between CPET-derived data and outcome.52
The recently completed Measurement of Exercise Tolerance
before Surgery (METS) study has attempted to overcome these
limitations and should provide valuable new data on the rela-
tionship between preoperative cardiorespiratory fitness and
postoperative outcome.53 This multicentre prospective blinded
study set out to recruit 1700 patients undergoing preoperative
CPET and followed them for up to 1 yr after surgery. It should
make an important contribution to the literature when
published.53
The evidence base supporting the use of preoperative cardio-
pulmonary exercise testing to identify high-risk patients contin-
ues to evolve, but the optimal predictive variable remains
controversial.38 40 44 50 54 55 Different cohort studies have used
different variables with different thresholds to identify high-
risk patients. The AT is the variable most consistently reported
to be predictive of outcome, with a threshold of
AT < 11 ml kg1 min1 identifying a high-risk patient group in a
number of cohorts,41 43–46 although lower thresholds have been
reported in more recent studies in liver transplant patients
(<9 ml kg1 min1)48 and pancreatic resection patients
(<9.9 ml kg1 min1).56 The VO _ 2 peak has also been shown to be
predictive of outcome, with a threshold of <15 ml kg1 min1
identifying a high-risk group in the majority of studies.45 49 57 58
However, Vo _ 2 peak has not been reported in all studies because
early concerns about the safety of maximal exercise tests meant
that submaximal exercise tests were used in many older stud-
ies. In submaximal tests, patients were stopped above the anae-
_ 2 peak.38 59 The Ve=
_ Vco
_ 2
robic threshold but before reaching Vo
has been reported to be predictive of adverse outcome in some
perioperative cohorts,51 59 but not others,60 with thresholds
varying from 3459 to 42.57 This variability in the predictive
_ Vco
threshold of Ve= _ 2 merits further exploration. The differen-
ces in thresholds reported in different cohorts may reflect dif-
ferent surgical cohorts, differences in perioperative care
pathways, or differential access to critical care resources.
Patients who are referred for a CPET but are unable to com-
plete it are also known to be at high risk of an adverse out-
come.41 61 This has been reported in both thoracotomy patients
and patients undergoing colorectal resections.41 61 In the
Preoperative exercise testing and training | i37
colorectal cohort, patients unable to perform a CPET or who
failed to demonstrate an AT had significantly longer length of
stay and increased 2 yr mortality when compared with patients
who completed the test.41 Reasons for the inability to do a CPET
included both physical (i.e. lack of mobility owing to being
wheelchair bound) and cognitive (e.g. being unable to adhere to
test instructions) impairment.61 Thus, failure to complete a test
provides useful risk information even when an objective meas-
ure of fitness cannot be achieved.
Cardiopulmonary exercise testing data guiding
perioperative care
Preoperative CPET was initially used to guide perioperative care
through patient risk assessment informing allocation to an
appropriate level of postoperative care (ward vs critical care),50 54
and the majority of CPET centres within the UK use CPET for this
purpose.62 63 More recently, the breadth of practice informed by
CPET data has expanded substantially and now includes inform-
ing collaborative/shared decision-making, identification of
underlying cardiopulmonary co-morbidities, and shaping exer-
cise interventions as part of prehabilitation programmes. CPET
surveys of current UK practice have reported that the periopera-
tive management of patients is modified based on CPET-derived
data in a variety of ways, including: ensuring an experienced
team of senior clinicians manages the patients’ perioperative
care (i.e. consultant-delivered care), delaying surgery, optimizing
co-morbidities, downgrading surgeries (e.g. de-functioning colos-
tomy instead of major colorectal resection), and institution of
more invasive intraoperative monitoring.62 63 The potential for
CPET variables to guide prehabilitation interventions is being
increasingly explored, and exercise prehabilitation is being intro-
duced in some centres. The perioperative management of
patients identified as ‘high risk’ by CPET is currently not standar-
dized across the UK.62 63 Further studies are required to evaluate
the effects of modifying care pathways for high-risk patients
based on CPET-derived data.
Postoperative disposition (ward vs intensive care)
Preoperative CPET has been used to triage patients to the appro-
priate postoperative ward (e.g. ward vs critical care bed).54 64 In a
landmark study, Older and colleagues54 prospectively triaged
patients to the intensive care unit, the high-dependency unit, or
a normal ward based upon their AT, evidence of any exercise-
induced ischaemia, and specific high-risk procedure categories.
There were no cardiorespiratory-related deaths in the group
deemed as ‘fit’ for the normal ward after surgery, in comparison
to 4.6% in patients deemed as ‘unfit’, as defined as an AT
<11 ml kg1 min1. A subsequent case–control study in the UK
has also supported the use of CPET to triage patients’ periopera-
tive care.65 Colorectal surgical patients deemed unfit on the
basis of AT (AT < 11 ml kg1 min1) were assigned to manage-
ment in critical care or on the general surgical ward. Patients
managed on the ward had a significantly greater incidence of
major cardiac events than those managed in critical care.65
These studies support the notion that CPET data can be used to
identify the appropriate postoperative care environment for
patients and that this may reduce postoperative morbidity.
Prospective, randomized multicentre studies are needed to con-
firm whether these findings are robust when evaluated using
more rigorous study designs.
 i38 | Richardson et al.
Undiagnosed cardiopulmonary disease/optimizing co-
morbidities
Preoperative CPET assesses the patient’s functional capacity
and aerobic fitness through resting spirometry and a
standardized incremental exercise test. Such spirometry can
also identify whether patients have either undiagnosed or
poorly managed obstructive or restrictive lung disease, and the
exercise test can evaluate whether this is limiting the patient’s
exercise capacity. Furthermore, in the presence of abnormal
exercise capacity, CPET can identify the dominant limiting fac-
tor: a cardiac, respiratory, or musculoskeletal limitation.66 This
information can then be used to assess whether a patient
requires optimization before surgery through specialist advice
or referral for the optimization of poorly controlled co-morbid-
ities, such as heart failure or COPD. Recent cohort studies have
reported that different patterns of complications may be
observed in association with abnormalities in different CPET
_ Vco
_ 2 has been linked
variables. In particular, an elevated VE=
with postoperative respiratory complications.42 Such data may
be used to direct preoperative prehabilitation interventions for
those at increased risk of specific complications. A recent
Cochrane review has concluded that preoperative inspiratory
muscle training reduces the incidence of postoperative pulmo-
nary complications in cardiac and abdominal surgical
patients.67 It is interesting to speculate whether CPET might be
used to identify patients at high risk for respiratory complica-
tions in particular, and who may therefore benefit from preop-
erative inspiratory muscle training. Further studies are needed
to evaluate the benefits (if any) of preoperative CPET-directed
co-morbidity management on general and organ-specific post-
operative outcomes.
Collaborative decision-making
In an increasingly elderly and co-morbid population, the deci-
sion to operate is complex. Multidisciplinary input from a wide
variety of clinicians is increasingly required to weigh up the
likelihood of harm or benefit from surgery or other treatment
modalities for an individual patient. Perioperative physicians,
surgeons, physicians, intensivists, anaesthetists, oncologists,
and geriatricians are required to contribute to a truly collabora-
tive decision. The decision should be made in partnership with
the patient in a truely shared decision-making process.68 CPET
data can contribute to this process by providing an individual-
ized evaluation of co-morbidities and perioperative risk, and the
notion of being ‘fit for surgery’ is readily understandable by
patients. Such an approach is relatively untested in clinical
studies and merits formal investigation.
Prehabilitation
Prehabilitation is ‘an intervention to enhance functional capacity
in anticipation of a forthcoming physiological stressor’.69 Within
the perioperative setting, this ‘stressor’ is the physiological chal-
lenge of surgery and anaesthesia. Preoperative exercise training
has been shown to increase AT70 71 and Vo _ 2 peak,69 71 both CPET
variables that are associated with postoperative outcome.31 41–46
There is some evidence to suggest that in addition to improving
fitness, preoperative exercise training can improve postoperative
outcome in patients undergoing elective major surgery.72–74
Preoperative exercise training has been shown to be effective in
reducing the incidence of postoperative complications,72 and in
decreasing the length of hospital stay after elective cardiac and
vascular surgery.72 75 Barakat and colleagues72 demonstrated a
significant reduction in postoperative complications and length
of stay in abdominal aortic aneurysm surgery patients random-
ized to a 6 week preoperative exercise intervention. Arthur and
colleagues75 demonstrated a 1 day reduction in length of hospital
stay after coronary bypass graft surgery in patients participating
in a preoperative moderate-intensity exercise intervention for
>10 weeks. A recent systematic review and meta-analysis of the
preoperative exercise training literature in non-small cell lung
cancer patients identified four preoperative exercise interven-
tion studies and reported a significant reduction in length of stay
and postoperative complications with preoperative exercise
training.74 Moreover, preoperative exercise led to an improve-
ment in QoL and reduced dyspnoea.74 However, these interven-
tions were largely unstructured, focusing on walking exercise.76
Thus, more structured interventions may promote greater post-
operative benefits. Of note, the incidence of adverse events dur-
ing preoperative exercise training is very low.77 78
The majority of preoperative exercise training studies have
used moderate-intensity training interventions.70 75 79 Exercise
prescription intensities have ranged from 40 to 85% heart rate
reserve,80–82 50–60% maximal oxygen uptake,79 40–70% func-
tional capacity,75 or have focused on rating patients perceived
effort of 12–14 on the Borg scale.70 83 However, high-intensity
interval training (HIIT) regimes have been shown to provide
superior cardiorespiratory gains within a shorter period of time
in comparison to moderate-intensity exercise training regimes
in non-surgical clinical populations.84 HIIT is an emerging train-
ing regime that encompasses exercising at high intensity (e.g.
_ 2 peak,
high percentage maximal heart rate, percentage AT, VO
or peak power output)85–89 for a short period of time (e.g. 30 s to
4 min).85–89 Weston and colleagues84 conducted a meta-analysis
of 10 studies reporting cardiorespiratory alterations associated
with HIIT interventions (e.g. >80% heart rate)90–92 in comparison
with moderate-intensity exercise regimes. They identified a
3.03 ml kg1 min1 greater increase in VO _ 2 peak in those patients
assigned to HIIT in comparison to moderate-intensity exercise.
It is interesting to speculate if preoperative HIIT may confer
greater cardiorespiratory gains within the time-limited preoper-
ative period, which may in turn translate to better postoperative
benefits. Several recent and upcoming prehabilitation studies
have opted for high-intensity exercise training regimes.93–95
Dunne and colleagues95 showed that as little as 4 weeks preop-
erative HIIT significantly increased cardiorespiratory capacity:
AT and Vo _ 2 peak increased by 1.5 and 2.0 ml kg1 min1, respec-
tively, in liver resection patients, but no clinical outcome meas-
ures were reported in this study. Preoperative HIIT led to a
significant increase in Vo_ 2 peak after approximately eight exer-
cise sessions in patients undergoing thoracic surgery.96 During
the preoperative period, Vo _ 2 peak increased by 1.2 ml kg1 min1
in the intervention group but declined by 1.3 ml kg1 min1 in
the usual care group. Each HIIT session consisted of two 10 min
HIIT bouts, encompassing 15 s sprints at peak power output fol-
lowed by 15 s rest (1:1). In patients awaiting lung cancer surgery,
preoperative HIIT led to a lower incidence of postoperative res-
piratory complications when compared with usual care.94
However, this did not translate into any between-group differ-
ences in 1 yr survival.94 This study provides tentative evidence
for the role of preoperative HIIT in improving postoperative out-
come. Preoperative HIIT studies are starting to emerge and have
provided evidence for cardiorespiratory gains. However, further
preoperative HIIT research is warranted.
An important consideration in relationship to preoperative
exercise training is the variability in adherence and physiologi-
cal response to the intervention. Community-based

interventions69 tend to have substantially lower levels of adher-
ence to intervention than hospital-based interventions.97
Furthermore, even when patients have high adherence, varia-
bility in response is marked,97 and further investigation of the
determinants of response to exercise interventions is an impor-
tant area for future studies.
Neoadjuvant therapies
Neoadjuvant chemotherapy (NAC) and chemoradiotherapy
(NACRT) to promote tumour downsizing before surgery have
become a standard of care for several locally advanced cancers.
However, NAC and NACRT have also been associated with
decreased physical activity and fitness,98 99 cachexia/
sarcopenia,78 100 reduced QoL, and poor sleep quality,101 in addi-
tion to specific toxicity102 and other adverse events.103 Data
from the Fit-4-Surgery programme have shown that NAC (in
oesophagogastric cancer patients) and NACRT (in rectal cancer
patients) have detrimental effects on physical fitness, with a
consequent adverse effect on patient outcomes after surgery
(Fig. 1).98 99 The interactions between these interventions are
likely to alter the risk–benefit equation for each treatment ele-
ment for each patient. In patients with poor fitness at diagnosis,
the benefits of neoadjuvant chemotherapy may be outweighed
A 14
VO2 at AT (ml kg–1 min–1)
12
10
Control
Exercise
8 to guide collaborative decision-making, to inform the consent
Pre-NACRT Post-NACRT Week 6
B interventions aimed at increasing preoperative exercise
20
VO2 at peak (ml kg–1 min–1)
18
16
14
Control
Exercise
12
Pre-NACRT Post-NACRT Week 6
Fig 1 Line diagram showing fitted means and 95% confidence interval for
_ 2 ) at AT (in millilitres per kilogram per minute; A) and V_
oxygen uptake (Vo
o2 at peak (in millilitres per kilogram per minute; B) at baseline (pre-
NACRT), week 0 (post-NACRT), and week 6 for the exercise (dashed line) and
control groups (continuous line).103
Preoperative exercise testing and training | i39
by the additional perioperative risks incurred from the associ-
ated reduction in physical fitness that this therapy can produce.
Multidisciplinary teams will increasingly be needed to help
weigh up the harms and benefits of the various treatment
options for individual patients.
In patients undergoing rectal cancer surgery, an in-hospital
structured responsive exercise training programme (SRETP)
delivered after neoadjuvant chemoradiotherapy improved AT
by 2.1 ml kg1min1 in the intervention group (Fig. 1).97 This HIIT
training programme encompassed 2–3 min bouts alternating
between moderate- (50% of anaerobic threshold) and high-
intensity (50% of the interval between anaerobic threshold and
_ 2 peak) intervals performed for 30 min three times per week.97
VO
In addition to improving fitness, SRETP improved health-related
QoL.104 105 Furthermore, it has been hypothesized that exercise
may modulate the tumour microenvironment and thus have
specific effects on tumour progression.106 Further studies are
needed to elucidate the mechanisms and magnitude of any
such effects.106
A recent systematic review focusing on exercise interven-
tions in patients with cancer undergoing the ‘dual hit’ of neoad-
juvant cancer treatments and major cancer surgery identified
only four studies (two breast, one lung, and one rectal cancer).78
The authors concluded that exercise training was safe and toler-
able when conducted concurrently with neoadjuvant cancer
treatments. In addition, there was reasonable overall adherence
with exercise training programmes (66–96%). However, the
outcomes of all of these studies were limited to physical fitness
variables and did not encompass surgical or cancer outcomes.
Conclusions
In summary, exercise capacity and physical activity are associ-
ated with substantial health benefits in general and specifically
in the perioperative context. Preoperative CPET provides a
means of objectively evaluating fitness and can be used to pro-
vide individualized risk stratification, which can in turn be used
process, to characterize and optimize co-morbidities, and to tri-
age patients to perioperative care. Studies evaluating exercise
capacity have established that training improves physical fit-
ness. However, to date they have largely encompassed feasibil-
ity and pilot studies with small sample sizes and consequently
have been largely underpowered to assess clinical outcomes.
Further multicentre prospective studies are needed to charac-
terize the most effective means of improving patient fitness
before surgery and to evaluate the impact of such improve-
ments on surgical and disease-specific (e.g. cancer) outcomes.
Authors’ contributions
All authors contributed to this review, focusing on at least one
of the main sections (e.g. prehabilitation).
First draft from M.P.W.G.’s lecture slides and review of final
draft: K.R.
Critical editing, additional contributions, and review of final
draft: D.Z.H.L., S.J.
Prepared and delivered this topic as an invited lecture at the
RCoA Anniversary meeting 2017; critical editing and review of
final draft: M.P.W.G.
 i40 | Richardson et al.
Declaration of interest
D.Z.H.L. is president of the Perioperative Exercise Testing and
Training Society (POETTS). S.J. serves on the POETTS committee.
M.P.W.G. is a board member of CPX International (formerly The
International Society for Exercise Intolerance Research and
Education (ISEIRE)). K.R. has no conflict of interest to declare.
Funding
The Fit-4-Surgery research program is supported by funding
from NHS England, the National Institute of Health Research
(NIHR) Research for Patient Benefit program, the Southampton
NIHR Biomedical Research Centre, the Southampton NIHR/
Wellcome Clinical Research Facility, the National Institute of
Academic Anaesthesia (Royal College of Anaesthetists BOC
Research Chair: MPWG), and the British Lung Foundation.
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