Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer

Abstract

IMPORTANCE Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes.OBJECTIVE To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation. DESIGN, SETTING, AND PARTICIPANTSThis single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,Ն2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019. INTERVENTIONS Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway. MAIN OUTCOMES AND MEASURESThe primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures. RESULTSOf 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups. CONCLUSIONS AND RELEVANCEIn frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively.TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02502760

<p>Associations of Postoperative Complications Assessed by Clavien–Dindo Classification and Comprehensive Complication Index with Long-Term Overall Survival in Elderly Patients after Radical CRC Resection</p>

“…Since then, several studies have investigated the clinical value of the CCI in CRC. Carli et al 35 used the CCI to measure 30day POCs as primary outcome to compare effects of multimodal prehabilitation with postoperative rehabilitation in frail patients undergoing CRC resection. Dumitra et al 36 explored the relationship of two POC-grading schemas (CDC and CCI) with postoperative quality of life after elective CRC surgery, and found there was a more consistent relationship between the CCI and postoperative health-related quality of life than CDC grades.…”

Comparison of Footsteps Using Connected Bracelets with the Timed Up-and-Go Test and the 6-Minutes Walking Test in a Prospective Colorectal Surgery Cohort

“…Recently, some reviews showed that prehabilitation improved significantly functional capacity and self-reported physical activity but the impact on postoperative complications was limited [19]. Furthermore, a recent randomized trial has shown that a multimodal prehabilitation program did not affect postoperative outcomes in frail patients undergoing colorectal cancer resection [20]. Thus, even in a vulnerable population, the effects of prehabilitation and preoperative physical activity may be limited.…”

Improving stamina and mobility with preop walking in surgical patients with frailty traits –OASIS IV: randomized clinical trial study protocol

“…Other studies have also specifically targeted frail older patients for prehabilitation. Carli et al showed that in frail patients undergoing colorectal cancer resection, multimodal prehabilitation involving exercise, nutritional, and psychological interventions did not improve 30-day postoperative outcomes [ 18 ]. Waite et al attempted a pilot home-based prehabilitation program directed at frail patients undergoing coronary artery bypass grafting (CABG) or valve surgery, showing the potential to improve functional ability and reduce in-hospital length of stay; results of the randomized trial are still pending [ 19 ].…”