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7 Patient Optimisation for Colorectal Surgery 193
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One specific trial addressed the high incidence of delirium that is reported in
older adults after elective surgery (up to 50%) that not only leads to in-hospital
issues but can lead to longer term cognitive decline. To offset this, Humeidan et al.
[47] introduced ‘Neurobics’, cognitive training as part of prehabilitation. This RCT
excluded any adult with cognitive impairment (<26 on MMSE or <24 if they had
an education level less than high school). For those assigned to the cognitive intervention prior to their elective surgery (general and orthopaedic predominately) they
were asked to complete a total of 10 hours on an electronic tablet that contained
brain exercise games consisting of 5 main categories: memory, speed, attention,
flexibility and problem solving. The control group had usual care. The primary
outcome was delirium between day 0 to discharge or day 7 (whatever came first)
and the study was powered to recruit 242 to demonstrate a 50% reduction in delirium. Although adherence was low [median preoperative exercise time was 4.6
hours (IQR, 1.3–7.4)], the intervention group had a reduced delirium rate (18.7%
versus 13.2%; p-0.04). On regression modelling, the relative risk of delirium was
significantly lower in the intervention group (RR 0.58, 95%CI 0.33–0.99; p =
0.047). Although neurobics is novel, the colorectal surgeon may wish to include
this simple intervention if they have an older adult surgical population.
Older Adults
One criticism levelled at prehabilitation is that many studies have only included
patients that are healthy with low levels of co-morbidity. One overlooked population is the older adult (65 years and above) that typically carry a higher incidence
of multi-morbidity, frailty and poorer post-operative outcomes [81]. The Comprehensive Geriatric Assessment (CGA) is part of the geriatricians’ expertise and has
been proposed to be implemented at the start of the elective surgical pathway. One
of the first pieces of evidence for the CGA comes from 176 patients aged over
65 from a single centre undergoing elective aortic aneurysm repair or lower-limb
arterial surgery [79].
The CGA evaluated and optimised physical, psychological, functional and
social issues in these older patients and was delivered by a multi-disciplinary team
(geriatrician, clinical nurse specialist, social worker, occupational therapist). In the
intervention group the length of stay after surgery was significantly shorter (3.32
days versus 5.53, 95% CI 0.46–0.79; p < 0.001) with a lower incidence of complications including: delirium (11% versus 24%), cardiac (8% versus 27%) and
bladder/ bowel (33% versus 55%). Perhaps even more importantly for patients,
the intervention group were less likely to require discharge to a higher level of
care (4.7% versus 13.2%). In a follow-up publication, these authors concluded
that the reduction in length of stay primarily accounted for overall health care
utilisation costs of £1165 less for the CGA patients.
In the colorectal setting, in 2018 Barbaran-Garcia et al. reported on a RCT
looking at prehabilitation in high-risk patients undergoing elective colorectal, hepatobiliary or gastric cancer surgery. High risk was classified as American Society
of Anesthesiologists (ASA) score of III/ IV and/ or over the age of 70 years.
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Using a combination of motivational interviews, high intensity endurance training and physical activity promotion, this group found significant improvements in
aerobic capacity (using a cycling sub-maximal VO2 test) and a reduction in postoperative complications (their primary aim) by 51% in the prehabilitation group
when compared to the controls. They then followed up this work assessing the
post- discharge impact and cost implications for this prehabilitation programme
[7]. For the 30 days after surgery, the prehabilitation group reported a lower hospital readmission rate (3% versus 18%, p = 0.009). At 3 months after surgery,
aerobic capacity remained significantly higher in the prehabilitation group compared to the controls and was at a level that was still significantly higher than
their baseline value (i.e., before prehabilitation had started). This suggests that
the prehabilitation group continued to have increased levels of physical activity
after surgery which was confirmed by the higher levels reported from the selfreported questionnaires (Yale Physical Activity Survey, YPAS and the physical
activity component of the Short Form-26) and 6 months. Although not assessed in
this work it is possible that prehabilitation provides a teachable moment for longterm lifestyle change. For costings the group reported a total cost of 778 euros
per patient for prehabilitation (CPET, motivational interview, pedometer device
and group endurance exercise training sessions). When follow up visits and readmission were costed for up to 30 days after surgery, there were no significant
cost-savings with prehabilitation.
Systematic Reviews and Meta-analyses
Barbaren-Garcia et al. [6] was included in a systematic review and meta-analysis
assessing prehabilitation in elective abdominal cancer surgery in older patients
[22]. Identification of 9 studies that had selected high-risk, frail or older adults
found that interpretation was limited by bias and heterogeneity of the interventions
and the outcome measures reported, leading the authors to conclude that exercise,
nutrition and prehabilitation may reduce morbidity, but data specific to older adults
was currently sparse. Certainly, older adults may have different needs (older adults
can be anabolic resistant or have higher levels of sarcopenia for examples), and
we would expect the evolving evidence to provide insight.
The limitations of low number of studies and varied methodology was also
stated in a Cochrane review from 2018 that concluded that exercise training is
probably not harmful and probably reduces fatigue [59]. This review included
RCTs comparing the effects of exercise training with usual care on physical fitness, safety, HRQoL, fatigue and post-operative outcomes in people undergoing
multimodal cancer treatment, including surgery. Eleven RCTs that included 1067
participants were analysed (568 underwent an exercise intervention and 499 usual
care control group) with a range of pathologies but breast cancer predominating
(73% of participants).
An umbrella review in 2022 included 55 systematic reviews on prehabilitation
studies in patients undergoing all types of surgery [64]. This group found that
there was moderate evidence that prehabilitation of any form leads to improvement in functional recovery. For post-operative outcomes, there was only low
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certainty evidence available. Prehabilitation encompasses many different specialties, patients and pathologies making it not surprising that there is significant
reported variation. To overcome these limitations, core standards and core outcome sets for prehabilitation have been proposed [35, 64]. If widely accepted,
they should reduce heterogeneity and reporting bias improving communication and
allowing meta-analysis to be performed to potentially expedite our understanding
of prehabilitation research. Such work has recently been completed: Defining Standards in Colorectal Optimisation Study (DiSCO) [82]. This international study has
completed 2 rounds of Delphi methodology and 2 virtual consensus days including
patients as stakeholders. The final manuscript has been accepted for publication by
the British Journal of Surgery (2024).
7.3.4 The Future of Prehabilitation
Throughout this chapter we have discussed the research findings and the clinical
implications of prehabilitation for patients undergoing surgery and further treatments for colorectal conditions. It should be clear to the colorectal surgeon and
the supporting team, that prehabilitation should be considered for all your patients.
The underlying message is old, the more unfit your patients are with dietary
issues and psychological conditions the worse their outcomes will be. Waiting for
ERAS to support them on their surgical journey is too late and accepts the widely
documented deteriorations in functional capacity, nutrition and psychological wellbeing. Clearly ERAS has an essential part to play within the prehab-into-rehab
continuum and may also be appropriate for patients that require minimal prehabilitation. However, with low physical fitness reported worldwide, 39% of people
overweight (with 14% obese), and the world recovering from a global pandemic,
addressing our patients needs preoperatively may not improve their outcomes but
could potentially start to address these significant and progressive public health
issues if these changes are adopted beyond the end of their treatment [10, 115].
However, it should also be clear that many unknowns remain both in prehabilitation research and clinical implementation. Prehabilitation is a complex
intervention where the heterogeneity of the published literature leads to systematic
reviews, meta-analyses and umbrella reviews all concluding low certainty evidence. Future development needs to focus on adoption of core standards and core
outcome set to overcome these limitations and expedite future work and learnings.
It is hoped that the publication of DiSCO will fill that gap [82].
Other key areas are trying to understand the possible mechanisms underpinning
whether prehabilitation will work. In mice models, [104] has shown that exercise
changes vascular supply to established breast tumours enhancing the blood supply
with tumours growing slower and a reduction in myeloid-derived suppressor cells,
compared to the sedentary mice. In the colorectal setting, West et al. [110] reported
tumour regression using MRI in patients undergoing NACRT for rectal cancer.
In comparison to a sedentary control group, the exercise group experienced an
increase in V02 (using CPET) and a significantly greater tumour regression using
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ypTRG after 6 weeks prehabilitation programme focussing on exercise. Clearly
this is early work and Sibley et al. [89] summarise further possibilities that could
be explored.
For the surgical team, starting a prehabilitation programme can be overwhelming when the research landscape does not provide clarity. Unlike the pragmatic,
evidence based oncological surgical pathway, prehabilitation requires separate
assessment tools (although there can be overlap with pre-assessment) and a holistic, personalised approach that differs greatly from a standard clinical pathway.
Combining enthusiasm, funding, resources and expertise requires a new multidisciplinary team (might include an exercise physiologist or working close with a
psychologist) to ensure that time to surgery is not unnecessarily delayed, but also
not expedited if the patient has potentially significant gains from prehabilitation. In
addition, the prehabilitation team has to develop motivational strategies, perhaps
an aspect the team may not be experienced in. The EXERT trial (Exercise During and After Neoadjuvant Rectal Cancer Treatment explored exercise motivation
in patients with rectal cancer undergoing exercise/prehabilitation during and after
NACRT [5]. Patients reported barriers including treatment side-effects that may or
may not be exacerbated by the programme, in addition to a lack of motivation.
However, there are evidence of successful implementation of prehabilitation programmes such as ERAS+ from Manchester, England (www.erasplus.co.uk) that
provides a multi-modal prehabilitation-into-rehabilitation programme for patients
undergoing major surgery across eight hospital sites. Support and guidance for
colorectal teams is available with Davis et al. [23] reporting on the learnings from
an international group of prehabilitation experts with recommendations for those
considering starting their own prehabilitation programmes and online advice from
the Centre for Perioperative Care (https://www.cpoc.org.uk/).
In addition to the already mentioned WESfit, other trials will publish in the
next 5 years, meaning promising new insights into prehabilitation. PREPARE ABC
(Supportive Exercise Programmes for Accelerating Recovery after major abdominal cancer surgery trial) is randomising patients undergoing colorectal surgery
to one of three arms: hospital supervised exercise, home supported exercise or
treatment as usual [84]. Another RCT is international, recruiting 714 patients
undergoing colorectal surgery for cancer. Using multi-modal prehabilitation, one
group will be randomised to 4 weeks of prehabilitation and compared to a no
prehabilitation control group. The primary outcomes are 6MWT and complications after surgery. Again, quality of life is being analysed and cost-effectiveness
analysis will be performed [100].
7.4 Conclusion
Prehabilitation (nutrition, physical exercise/activity and psychological support) is
in evolution. With the majority of work in cancer populations, it has been established as safe and feasible, and should be considered for all colorectal patients to
minimise the expected deteriorations in physical function, nutrition and wellbeing
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after any treatment, especially surgery. As a multi-modal complex intervention,
comparison between research studies is difficult and acceptance of core standards
and core outcomes for prehabilitation could expedite understanding. 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, especially older adults. Other
barriers to clinical implementation remain. The presence of a ‘one size does not
fit all’ approach requires culture change, time and resources to allow implementation of prehabilitation into the modern colorectal surgery pathway. However, with
longer waiting times on a background of negatively influencing social determinants of health and poor lifestyle choices, prehabilitation could have a significant
future proactive role for the care of our colorectal patients.
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