How the Princess of Wales will be reducing her risks after surgery and how to prepare for an operation

Despite ongoing advances in medical technology, blood clots (thrombosis) continue to be a significant cause of concern, especially afterabdominal or pelvic surgery. The Princess of Wales' risk of thrombosis, either in the back of the leg (Deep Vein Thrombosis) or in the lung (Pulmonary Embolus), is less than 1%. However, published data reports that The Princess still has a risk 100 times greater in the first six postoperative weeks compared to women who have not undergone surgery. The risk remains 20 times higher for up to 12 weeks.

The Princess would have been given blood-thinning injections and not being overweight, a non-smoker, and someone who takes exercising seriously, further reduces her probability of a clot. The Princesswill have also embarked on an active rehabilitation program, usually supervised by an experienced physiotherapist. It's reassuring to hear that The Princess is taking time off Royal Duties until April, as these may involve traveling long distances or flying, both of which could increase the risk of blood clots.

What can reduce our risks after surgery

The emphasis on reducing surgical risks is not just after but in the weeks prior to an operation. The term "prehabilitation" has been coined to address dietary and exercise changes that can help prevent blood clots, as well as other adverse events. I was fortunate to be part of a collaboration between The Royal College of Anaesthetists and Macmillan, which examined international evidence for the benefits of a well conducted prehabilitation programme:

Benefits of prehabilitation before surgery:

Professor Mike Grocott, Consultant Anaesthetist in Southampton, says: "My patients tell me how prehabilitation offers them the opportunity to take control of their own care." Some hospitals have started formal supervised prehabilitation programs, but unfortunately, most only offer a booklet, some verbal advice, or nothing at all. It's clear that the full potential of a formal, supervised program for both patients and hospitals has not yet been exploited. The financial benefits for the NHS were recently highlighted in a quote from Dr. Maria Pufulete from the University of Bristol: “With around 1.5 million major surgical procedures carried out in the UK each year, at an annual cost of about £5.6 billion, it’s important that patients have the best chance of recovery without further costly complications.”

How to prepare for surgery - Practical prehabilitation tips

The time available for prehabilitation depends on the type of surgery. Many operations such as hysterectomies, gall bladder removal, hip or knee replacements can be planned months in advance, allowing plenty of time to lose weight and get fitter. More urgent operations such as those for cancer don't facilitate a weight loss plan but can still allow improved diet and exercise levels.

So, what are the most important changes to make if you know you are going to need an operation? More exercise. Regular exercise encourages the blood to be pumped through the veins and reduces the risk of it stagnating and hence clotting. There are plenty of other biochemical changes that help prepare the body for the stress of surgery:

We should all try to increase activity levels every day by avoiding sedentary habits such as sitting for long periods of time. More physical activity can be incorporated into everyday life, for example, by using stairs instead of the lift, getting off the bus one stop earlier, or even walking or cycling to work. It's a good idea to join a formal exercise class, dance, walking, running, or cycling group. If affordable, a personal trainer can help with motivation and ensure the type of exercise is safe.

Cut down or stop drinking alcohol: Drinking more than 4 units per day (equivalent to 2 pints of beer or large glasses of wine) doubles the risk of complications after surgery. Ideally, it would be better to have no alcohol for a month before surgery, but even cutting down will still improve the health of the liver, which is vital for healing after surgery. There are various useful resources to help lower alcohol intake.

Quit Smoking: Cigarettes dramatically increase the risk of chest infection and other complications. Many hospitals have a ‘quit smoking’ service that can help you and the NHS website has some links to useful resources.

Improve gut health: The trillions of friendly bacteria in the gut, lungs, skin, and elsewhere challenge and support the immune system, helping to protect the body from pathogenic (Bad) bacteria. Excess chronic inflammation of the gut wall, caused by too many pro-inflammatory (bad) bacteria over time, will thin and damage its integrity. This causes nutrients such as vitamins, minerals, phytochemicals, and proteins to leak out of the body, depriving the body of these essential building blocks for tissue repair and defence against infection. Many factors adversely affect the gut flora, including processed sugar, artificial sweeteners, smoking, and antibiotics, which are often given at the time of surgery. Try to eat some probiotic (healthy) bacteria-rich foods every day, such as fermented and pickled foods, kimchi, or kefir. In addition, clinical studies have demonstrated that boosting their intake via a probiotic supplement can improve outcomes of elective abdominal surgery. The best data comes from supplements which also contain prebiotics (synbiotics). Although some hospitals encourage probiotics prior to admission, they are not classed as drugs so cannot be prescribed by doctors.

Lose weight (if overweight or obese). If overweight, reduce portion sizes, don't snack between meals or eat anything late in the evening. Try to eat less fat and sugar, follow measures to improve your gut health although side other measures to reduce calorie intake and increase energy expendature.

Ensure adequate Vitamin D levels. Vitamin D is vital for the whole body and mind, not just the bones. Vitamin D supports the immune system, which is why people with low Vitamin D are more likely to suffer the consequences of covid-19 caught after a hospital admission. There is evidence from published medical studies that people with low vitamin D recover slower and are more likely to have longer stays in intensive care. Regular sun exposure (without burning) is the best way to maintain vitamin D levels, but this is impractical for most people throughout the year. It would be sensible to take a Vitamin D supplement, especially if combined with a probiotic, which enhances its absorption.

Consume enough Vitamin C. Vitamin C helps the body make collagen, an important protein used to create skin, cartilage, tendons, ligaments, and blood vessels. Vitamin C is needed for healing wounds and for repairing and maintaining bones and teeth. It also helps the body absorb iron from food, and as there may be some blood loss during surgery, it will aid in the restoration of new blood stores. Most of us know that vitamin C is found in fruits such as oranges, apples and lemons, but it is also present in vegetables such as peppers, kale and broccoli. Herbs are rich in vitamin C, particularly coriander, thyme, and mint, as well as spices such as chili, paprika, and black pepper. Vitamin C does not last in the body very long, so we have to eat at least 5 of these types of foods every day to maintain adequate levels and probably more in the run-up to surgery.

Ensure optimal mineral intake. Minerals are essential for the formation of proteins, bones, and cartilage required for tissue repair. They are also needed for the production of hormones, immune factors, and antioxidant enzymes that protect us from infection and trauma, including surgery. Studies report that up to 75% of us have suboptimal levels of one or more essential trace minerals caused by modern intensive farming, overcleaning, and processing. Try to diversify the diet by eating different fruits and vegetables and protein sources such as shellfish and crab, and protein-rich plants including quinoa, buckwheat, chickpeas and beans. Nuts and seeds are rich in, so try to eat a handful of walnuts, pistachios, Brazils, hazelnuts, pumpkin, sunflower, and unsalted peanuts every day. For people who don't regularly eat these foods or just want some more reassurance, a well-designed multi-mineral supplement covering all the essential minerals at sensible levels, including iodine, would be appropriate.

Try to get enough sleep. Sleep slows down metabolism, allowing the restoration of energy stores, reducing oxidative toxins, providing more time for cell repair, and improving immune function. Ideally, we should aim for 7-8 hours a night, which may be easier said than done with the worry of an upcoming operation. Sleep hygiene habits can help, particularly stopping alcohol, exercising in the mornings, maintaining regular night time schedules, and avoiding blue light or stimulating electronics before bed. Dietary tips, such as avoiding caffeine in the afternoon and processed sugar in the evening, have been shown to work. Strategies to ensure better gut health and adequate vitamin D and phytochemical-rich foods are important. Some over-the-counter supplements can help, but there are pitfalls especially with sedating varieties such as antihistamines.