Effects of Community-based Exercise Prehabilitation for Patients Scheduled for Colorectal Surgery With High Risk for Postoperative Complications: Results of a Randomized Clinical Trial

Abstract

Objective: To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in high-risk patients scheduled for elective colorectal resection for (pre)malignancy.

Summary background data: Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications.

Methods: This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold <11 mL/kg/min at the baseline cardiopulmonary exercise test was the final inclusion criterion. Inclusion was based on a power analysis. Patients in the prehabilitation group participated in a personalized 3-week (3 sessions per week, nine sessions in total) supervised exercise program given in community physical therapy practices before colorectal resection. Patients in the reference group received usual care. The primary outcome was the number of patients with one or more complications within 30 days of surgery, graded according to the Clavien-Dindo classification. Data were analyzed on an intention-to-treat basis.

Results: Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024).

Conclusions: Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.

FIGURE 1

Trial profile. CPET = cardiopulmonary exercise test. MET = metabolic equivalent of task. VAT = ventilatory anaerobic threshold. ^aReasons why patients did not consent to participate: 61 did not feel like it, 19 said they could not cycle, 14 had transportation difficulties, 8 patients believed they were already physically fit for surgery, 7 patients wanted their tumor removed as soon as possible, 5 could not find the time, 90 unknown reasons and/or were not asked to participate, and 46 other reasons. ^bIn the previous version of the study design, a CPET was performed before randomization took place. ^cWait-and-see policy in 1 patient with rectal cancer with complete remission after neoadjuvant therapy and 2 patients withdrew from surgery. ^dWait-and-see policy in 2 patients with rectal cancer with complete remission after neoadjuvant therapy. ^eOne out of these 28 patients withdrew, because he already knew his date of surgery and was not willing to postpone this date, but was included in the analyses according to the intention-to-treat principle. ^fTwo out of these 29 patients withdrew, 1 patient because she was overwhelmed by all appointments, and 1 patient randomized to the usual care group wanted to start training herself, but were included in the analyses according to the intention-to-treat principle.

FIGURE 2

Pre- and post-training VO₂ at the VAT and VO_2peak in patients randomized for prehabilitation. n = 24 for VO₂ at the VAT, as 4 patients did not perform a post-training CPET. n = 16 for VO_2peak, as 4 patients did not perform a post-training CPET and 8 patients did not perform a maximal effort on both CPETs. CPET indicates cardiopulmonary exercise test; VAT, ventilatory anaerobic threshold; VO₂, oxygen uptake; VO_2peak, oxygen uptake at peak exercise.

FIGURE 3

ROC analysis for predicting patients with a postoperative complication, based on the preoperative hemoglobin level and prehabilitation. ROC indicates receiver operating characteristic.