Prehabilitation prior to surgical resection for gastric cancer seeks to optimise patients’ physical and nutritional status to improve perioperative resilience and outcomes. The current evidence base was described as fragmented, prompting this systematic review to synthesise randomized controlled trial (RCT) evidence on unimodal and multimodal prehabilitation delivered before gastrectomy.
The review was conducted following PRISMA guidelines and was prospectively registered on PROSPERO (CRD420251233981). Electronic databases searched up to August 2025 included MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL. Eligible studies were RCTs of prehabilitation interventions—either unimodal or multimodal—delivered for a minimum duration of seven days prior to gastric cancer resection. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Because of clinical and methodological heterogeneity across trials, the authors did not perform meta-analysis and instead synthesised results narratively.
Fourteen randomized controlled trials met the inclusion criteria. Of these, four evaluated multimodal prehabilitation programmes and ten evaluated unimodal interventions. The unimodal trials comprised nine nutritional interventions and one spirometry-based intervention. Reported intervention durations ranged broadly from seven days to 15 weeks. Details on individual trial sample sizes, exact intervention components, and delivery formats were reported in the primary trials; those specific trial-level details were not exhaustively enumerated in the review abstract.
Across included RCTs, investigators reported 53 unique outcomes mapped to five broad domains: clinician- or observer-reported outcomes, performance outcomes, patient-reported outcomes, biomarkers, and non-health outcomes. The heterogeneity of outcome choice, measurement tools, and timing of assessment contributed to challenges in synthesising data across studies.
The four trials of multimodal prehabilitation suggested potential clinical benefits. Across these studies, multimodal programmes were associated with fewer postoperative complications and improvements in functional capacity in the perioperative period. The review frames these findings as suggestive rather than definitive because of variability in programme components, outcome definitions, and trial quality.
The ten unimodal trials produced mixed results. Short-duration nutritional interventions yielded inconsistent effects on postoperative outcomes overall. Notably, trials of immune-nutrition and targeted nutritional supplementation reported reductions in infectious complications specifically among malnourished patients. The spirometry intervention was represented by a single trial; the abstract does not provide further detail on its specific effects. Overall, unimodal approaches showed variable efficacy depending on the target population (for example, malnourished patients) and the nature and duration of the intervention.
Risk-of-bias assessment identified methodological concerns across the evidence base: seven trials were judged to have some concerns and seven trials were judged to be at high risk of bias. Substantial heterogeneity existed in intervention content (components and duration), outcome selection and reporting, and study quality. These factors limited the ability to perform quantitative synthesis and to draw firm, generalisable conclusions about the effectiveness of prehabilitation for all patients undergoing gastrectomy.
The authors highlight two key gaps that must be addressed to advance the field: first, the development of a disease-specific core outcome set for gastric cancer prehabilitation to standardise outcome selection and reporting; and second, the conduct of adequately powered, risk-stratified randomized trials. Such trials should address patient selection (including nutritional and functional risk profiles), standardise intervention components and duration, and adopt consistent outcome measures to enable meaningful evidence synthesis and implementation guidance.
Prehabilitation prior to gastric cancer surgery demonstrates a potential benefit, particularly with multimodal programmes that combine nutritional, physical, and possibly other components. Short-duration unimodal nutritional interventions show mixed results, though immune-nutrition and targeted supplementation reduced infectious complications in malnourished patients in some trials. The overall evidence base is constrained by substantial heterogeneity and variable methodological quality, with risk-of-bias concerns across included RCTs. The review calls for a disease-specific core outcome set and well-designed, adequately powered, risk-stratified RCTs to strengthen the evidence and inform clinical implementation of prehabilitation in gastric cancer surgery.