Prehabilitation for Frail Patients Undergoing Colorectal Surgery: Lessons Learnt From a Randomised Feasibility Study

Abstract

There is substantial interest by clinicians to improve the health outcomes of older and frail patients following major surgery, with prehabilitation a potential and important component of future standard patient care. We studied the feasibility of a randomised controlled trial of pre-operative prehabilitation in frail patients scheduled for colorectal surgery in regional Australia. We conducted a single blind, parallel arm, randomised controlled trial in a regional referral centre where colorectal surgical patients aged over 50 were invited to participate and screened for frailty. Frail patients were randomised to undertake either a 4-week supervised exercise program with dietary advice, or usual care. The primary outcome was 6-min-walk-distance at baseline, pre-surgery (4 weeks later) and at follow-up (4–6 weeks post-operation). Secondary outcomes included physical activity level, health-related quality of life, and post-surgical complications. Feasibility outcomes were numbers of patients reaching each stage and barriers or reasons for withdrawal. Of 106 patients eligible for screening during the 2-year study period, only five were able to be randomised, of which one alone completed the entire study to follow-up. Fewer patients than expected met the frailty criteria (23.6%), and many (22.6%) were offered surgery in a shorter timeframe than the required 4 weeks. Physical and psychological aspects of frailty and logistical issues were key for patients declining study participation and/or not complying with the intervention and/or all outcome assessments. Feasibility for a large randomised controlled trial of prehabilitation for frail colorectal patients was poor (~5%) for our regional location. Addressing barriers, examination of a large, dense population base, and utilisation of a frailty-screening tool validated in surgical patients are necessary for future studies to identify the impact of prehabilitation for frail patients.

Recovery of surgery in the elderly (ROSE) program: The efficacy of a multi‐modal prehabilitation program implemented in frail and pre‐frail elderly undergoing major abdominal surgery

“…Non-attendance was a major limiting factor in a feasibility study by Furyk et al, where prehabilitation attendance was limited by factors such as the physical effects from frailty and the ability of frail elderly to surmount logistical issues related to travel due to their reduced independence. 32 In our study, the lack of transport, the burden of multiple hospital appointments within a short period of time and a lack of knowledge on the importance of prehabilitation were reasons cited for patients lost to follow-up and not being able to attend supervised prehabilitation sessions prior to surgery. The control cohort also was "less frail" and had less comorbidities and might have the impression that prehabilitation was not necessary or important to their recovery from surgery.…”

Prehabilitation in Modern Colorectal Cancer Surgery: A Comprehensive Review

“…Among 20 available studies on prehabilitation for CRC patients, there are 10 randomized controlled trials (RCTs) [ 26 , 27 , 30 , 31 , 32 , 37 , 38 , 39 , 40 , 43 ], 9 pilot studies [ 16 , 17 , 29 , 33 , 34 , 35 , 36 , 41 , 44 ] and 1 retrospective cohort study [ 42 ]. Table 3 summarizes the reported outcomes of selected studies.…”

“…Timely nutritional intervention can improve prognosis as well as decrease rates of morbidity and mortality among cancer patients [ 52 ]. Thus, dietary interventions appear to be a good part of multimodal prehabilitation programs in CRC management [ 17 , 27 , 37 , 39 , 40 , 41 , 42 ].…”

“…Currently, eight studies [ 17 , 27 , 37 , 38 , 39 , 40 , 41 , 42 ] investigated the effect of different nutritional interventions. They included personalized dietary counseling, whey protein supplementation, or a complete diet by providing daily meals.…”

“…They included personalized dietary counseling, whey protein supplementation, or a complete diet by providing daily meals. All but one [ 39 ] trial found at least some beneficial effect of nutritional support resulting in increased muscle mass and reduced fat mass. These studies indicate that multimodal prehabilitation, which includes nutritional support, could be superior to unimodal prehabilitation in terms of functional status improvement.…”