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172 P. A. Sutton and S. T. O’Dwyer
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Patient Optimisation for Colorectal
https://t.me/med1917
Surgery
Carly N. Bisset and Susan J. Moug
Abstract
This chapter discusses preassessment and prehabilitation in the context of the
current evidence, including gaps in our knowledge, and provides guidance
for colorectal teams considering starting or optimising their prehabilitation
programme.
Keywords
Patient optimisation•Colorectal surgery•Preoperative assessment
Multidisciplinary care•Prehabilitation•Comorbidity management
Nutritional assessment•Smoking cessation•Exercise interventions
Enhanced recovery pathways
Key Points
•
•
•
7
•
Colorectal surgery places significant physiological and mental stress on each
patient. Patients and their families have to deal with complications which may in
turn lead to poorer quality of life, critical illness, prolonged hospital stay, risk of
death, and increasing healthcare costs.
•
Unfit patients with dietary issues and psychological conditions will have worse
outcomes. Expecting ERAS to support them on their surgical journey is too late.
C. N. Bisset · S. J. Moug (B)
Department of Surgery, Royal Alexandra Hospital, Paisley, Scotland
e-mail: susan.moug@ggc.scot.nhs.uk
C. N. Bisset
e-mail: carly.bisset4@nhs.scot
S. J. Moug
Golden Jubilee University National Hospital, Clydebank, Scotland
University of Glasgow, Glasgow, Scotland
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_7
179
180 C. N. Bisset and S. J. Moug
https://t.me/med1917
•
As new evidence is published, we are adapting to a proactive individualised patient
approach that attempts to reduce complications and the associated reduction in
quality of life for our colorectal patients.
•
Regardless of pathology, all patients undergoing colorectal resection should have
the opportunity to undergo early assessment and identification of any medical
issues including anaemia, diabetes, smoking and alcohol to allow the opportunity
for optimisation.
•
For those patients that report poor functional status, diet or low psychological
wellbeing, prehabilitation can provide a personalised prescription that can support
and lead to improvements that may reduce the risk of complications afterwards.
•
Evidence continues to be published that personalised multi-modal prehabilitation
can improve surgical and patient outcomes after surgery, but more work is needed
to improve our understanding of the underlying mechanisms and subsequently
how best to prescribe prehabilitation for each individual patient.
7.1 Introduction
This chapter discusses preassessment and prehabilitation in the context of the
current evidence, including gaps in our knowledge, and provides guidance for colorectal teams considering starting or optimising their prehabilitation programme.
7.2 Definition of Patient Optimisation: Preassessment
and Prehabilitation
Patient optimisation is essential for all patients undergoing elective colorectal
surgery. Irrespective of the pathologies treated, benign or malignant, colorectal
surgery places significant physiological and mental stress on each patient and consequently carries significant short, medium and long-term risks. Patients and their
families have to deal with complications which may in turn lead to poorer quality of life, critical illness, prolonged hospital stay, risk of death, and increasing
healthcare costs [103].
In relation to mortality, national mortality rates for all types of elective colorectal surgery are reported in Scotland via the Scottish Government supported
National Enhanced Colorectal Recovery Initiative (NERCI; https://learn.nes.nhs.
scot/10038). Mortality is reported nationally as 2%, a figure that has fallen since
the focus on the introduction and maintenance of enhanced recovery after surgery
(ERAS) principles [51]. For patients undergoing cancer surgery, the National
Bowel Cancer Audit of England and Wales (NBOCA), reassuringly also report a
low mortality of 3.1% [74]. However, for patients considered ‘high-risk’, the picture is quite different. Using a predicted risk of death of 5% or greater, Pearse et al.
[81] reported 12, 704 elective surgical procedures (including colorectal surgery)
finding an overall mortality rate of 0.44%. However, they found that 12.5% of elective patients fell into this high-risk category and that group accounted for 83.8% of
7 Patient Optimisation for Colorectal Surgery 181
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Fig. 7.1 Functional abilities after elective colorectal surgery. Adapted from Clegg et al., Lancet
[19]
all deaths. This led to guidance from The Royal College of Surgeons of England
on the identification and management of the higher risk general surgical patient
[94, 95].
For all our patients, surgery results in a functional deterioration (Fig. 7.1).
Clearly for the healthier patient this will be short lived with a quicker return to
their baseline. However, for the more higher risk patient, this deterioration can be
significant and lead to long term deterioration in function that may require increasing support and/ or significantly reduce the patient’s quality of life. To allow shared
decision-making and optimisation prior to surgery (or neo/adjuvant therapy), issues
must be identified early for each patient. This chapter discusses the two key aspects
of this optimisation: pre-assessment and prehabilitation.
7.2.1 Pre-assessment
Pre-operative assessment (i.e. pre-assessment) of patients undergoing elective
surgery is a key aspect of enhanced recovery after surgery (ERAS) protocols,
which has multiple benefits for patients and the wider health service. There is
a growing body of evidence demonstrating that pre-operative functional capacity
(i.e. the physiological reserve of the patient to endure physiological stress incurred
by surgery and its’ complications) has a direct effect on post-operative outcomes
Hennis et al. [44], Levett et al. [56]. Pre-assessment may therefore facilitate the risk
stratification of patients, which facilitates discussion of the potential risks and benefits of surgery, enhancing shared decision-making with patients and their relatives.
182 C. N. Bisset and S. J. Moug
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Information gathered at pre-assessment may contribute to the quantification of risk
through using pre-operative risk calculators (such as an anastomotic leak calculator
or National Surgical Quality Improvement (NSQIP) calculator) [9, 87]. The NSQIP
calculator was developed by the American College of Surgeons to aid discussions
regarding patient-specific risk and informed consent by incorporating 20 comorbidities (e.g. hypertension, body mass index etc.) as well as data on the planned
procedure. This calculation then generates a prediction of 18 specific outcomes
in the 30 days following surgery, such as: cardiac complication, predicted length
of stay and discharge destination [American College of Surgeons Risk Calculator]
[3] Secondly, pre-assessment review offers the opportunity to identify and mitigate
potentially modifiable risk factors, including identification of undiagnosed medical
problems [40], or optimisation of known comorbidities (such as diabetes, chronic
obstructive pulmonary disease, and ischaemic heart disease) [113]. Furthermore,
pre-assessment review may identify patients with cognitive impairment, which may
inform discussions with patients and their relatives of the risk of cognitive change
post-operatively [111]. From a health economics perspective, pre-assessment may
contribute to reducing the number of same-day cancellations and under-utilised
theatre lists [27, 77].
Structure of Pre-assessment Clinic
The pre-assessment clinic is typically managed by a senior nurse with experience
of pre-assessment. A nurse, or other appropriately trained healthcare professional, may see the patient for a structured pre-assessment interview, with routine
screening tests and bloods. This may prompt selected case discussions with an
anaesthetist or a full anaesthetic assessment. If there are no further concerns
from tests such as ECG and bloods, the patient may be deemed suitable for
surgery. Abnormalities would initiate discussion either with the responsible surgeon or anaesthetist depending on the problem, and may require contact with the
patient’s GP to initiate treatment. Common morbidities, current medication, preop investigations, signposting to other services e.g. smoking cessation, diabetic
review, clarifying patient functional status and activities of daily living/needs (e.g.
mobility, hearing aids, additional support). In more recent times, there has been a
movement towards ‘virtual’ preassessment, where interviews took place either by
telephone or video consultation [37, 101]. Such telehealth appointments offer multiple benefits, including an overall reduction in cost and resources and convenience
for patients who may live some distance from hospital facilities, or who may have
difficulties with mobility or access to the internet [38]. However, challenges in its
implementation remain, including the ability of telehealth consultations to reliably
address the needs of complex patients with multiple health conditions, and the
inability to physically examine patients [39].
It is only following comprehensive pre-assessment, that pre-optimisation (i.e.
interventions which may reduce the risk of complications) may occur prior to surgical intervention. For example, a variety of health parameters may be improved
following interventions instigated in the pre-assessment setting. Interventions
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