SCODA: A Low-Cost Prehabilitation Strategy to Improve Outcomes After Cytoreductive Surgery in a Low-Resource Setting

Abstract

Background: Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) remains the standard of care for peritoneal surface malignancies but carries significant postoperative risks. In low- and middle-income countries (LMICs), the challenge is magnified by limited access to high-cost enhanced recovery programs. The SCODA (Surgical Complication Optimization through Diet and Activity) program was developed as a low-cost prehabilitation intervention to improve outcomes in resource-constrained settings. Methods: This retrospective cohort study included 169 patients undergoing CRS ± HIPEC at a single academic center in Morocco between 2015 and 2023. Patients treated before SCODA implementation (pre-SCODA group, n = 83) were compared to those enrolled in the SCODA program (SCODA group, n = 86). SCODA included oral iron supplementation, a protein-rich food-based diet, and progressive walking sessions over 90 days. Perioperative outcomes, including pulmonary complications, major morbidity (Clavien-Dindo ≥ 3b), transfusions, ICU stay >3 days, and 90-day mortality, were analyzed using univariate and multivariate logistic regression models. Results: The SCODA group had significantly fewer pulmonary complications (2% vs. 13%, p = 0.008), reduced major morbidity (9% vs. 21%, p = 0.031), fewer transfusions (8% vs. 20%, p = 0.024), and shorter ICU stays (median 1.5 vs. 5 days, p < 0.001). Ninety-day mortality was also lower in the SCODA group (5.8% vs. 12.4%, p = 0.046). SCODA participation remained an independent protective factor in multivariate analyses for all endpoints except major complications. Conclusions: The SCODA program is a feasible and effective prehabilitation strategy for improving surgical outcomes after CRS/HIPEC in LMICs. Its low-cost, food-based, and activity-centered design may support broader implementation in resource-limited environments and inform future perioperative care policies in oncology.

Keywords: HIPEC; cytoreductive surgery; low- and middle-income countries (LMICs); postoperative complications; prehabilitation.

Figure 1

Overview of the SCODA (Surgical Complication Optimization through Diet and Activity) Program. Caption: The SCODA program is a 90-day, low-cost prehabilitation intervention designed for patients undergoing cytoreductive surgery with or without HIPEC. It includes three core components: (1) daily 90 min walking sessions to improve cardiopulmonary fitness, (2) a hypercaloric and protein-rich diet to address preoperative malnutrition and sarcopenia, and (3) oral iron supplementation (ferrous sulfate 325 mg/day) to optimize hemoglobin levels and reduce transfusion requirements. The program is adapted for feasibility in low- and middle-income countries.

Figure 2

Comparison of postoperative complication rates, transfusion requirements, prolonged ICU stays, and 90-day mortality between patients managed before and after SCODA program implementation. Significant reductions in all outcomes are observed in the SCODA group.