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Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: results of a single-center, blinded, randomized controlled trial

Langenbeck's Archives of Surgery volume 407, pages 897–907 (2022)Cite this article

Abstract

Background

Currently, there are solely weak recommendations in the enhanced recovery after surgery (ERAS) protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous groups showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol.

Methods

Between July 2016 and June 2019, a single-center, blinded, randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared.

Results

A total of 107 patients (54 in the prehabilitation enhanced recovery after colorectal surgery [pERACS] group and 53 in the control group) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Baseline characteristics were comparable between the pERACS and control groups. The percentage of colorectal adenocarcinoma was low in both groups (pERACS 32% vs. control 23%, p = 0.384). Almost all patients underwent minimally invasive surgery in both groups (96% vs. 98%, p = 1.000). There was no between-group difference in the primary outcome, as the mean CCI at 30-day postoperative in the pERACS group was 18 (SD 0–43) compared to 15 (SD 0–49) in the control group (p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate, and mortality showed no difference between both groups.

Conclusions

Routine physiotherapeutic prehabilitation has no additional benefit for patients undergoing colorectal surgery within an ERAS protocol.

Trial registration

ClinicalTrial.gov: ID: NCT02746731; Institution Ethical Board Approval: KEK-ZH Nr. 2016–00,229.

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Abbreviations

ASA:

American Society of Anesthesiologists

CCI®:

Comprehensive Complication Index®

ERAS:

Enhanced recovery after surgery

ICU:

Intensive care unit

LOS:

Length of stay

NYHA:

New York heart association classification

pERACS:

Prehabilitation enhanced recovery after colorectal surgery

POD:

Postoperative day

SD:

Standard deviation

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Acknowledgements

The authors wish to thank the study nurses, especially Brigitte Gasser and team, for their excellent support in performing this trial. Further, we would like to thank Cornelia Merki-Künzli MD, for creating the study protocol and the team of the physiotherapy with Marta Kerstan and Michaela Hagen for managing the secuTrial! software on physiotherapeutic side. We would also like to thank Felix Grieder MD, Michel Adamina MD, Hans Gelpke MD, Christian Gingert MD, Georgios Peros MD, Sina Schmidt MD, and Christopher Soll MD who helped with acquisition of patients.

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Author notes

  1. Christoph Tschuor and Stefan Breitenstein share equal contribution as last author.

Authors and Affiliations

  1. Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland

    Severin Gloor, Merima Misirlic, Cornelia Frei-Lanter, Pascal Herzog, Phaedra Müller, Judit Schäfli-Thurnherr, Tenzin Lamdark, Dorothee Schregel, Roland Wyss, Christoph Tschuor & Stefan Breitenstein

  2. Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland

    Severin Gloor

  3. Departement of Surgery, Hospital Zollikerberg, Zollikerberg Zurich, Switzerland

    Cornelia Frei-Lanter

  4. Institute of Physiotherapy, Cantonal Hospital Winterthur, Winterthur, Switzerland

    Ines Unger, David Gisi, Nicola Greco & Giuseppe Mungo

  5. Institute of Physiotherapy, ZHAW School of Engineering, Zurich, Switzerland

    Markus Wirz

  6. Department of HPB Surgery and Liver Transplant, Royal Free Hospital London, London, UK

    Dimitri Aristotle Raptis

  7. Division of Surgery and Interventional Science, University College London, London, UK

    Dimitri Aristotle Raptis

  8. Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

    Christoph Tschuor

  9. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Christoph Tschuor

Authors
  1. Severin Gloor
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  2. Merima Misirlic
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  4. Pascal Herzog
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  9. Roland Wyss
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  10. Ines Unger
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  11. David Gisi
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  12. Nicola Greco
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  13. Giuseppe Mungo
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  14. Markus Wirz
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  15. Dimitri Aristotle Raptis
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  16. Christoph Tschuor
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Contributions

Severin Gloor, Merima Misirlic, Ines Unger, David Gisi, Nico Greco, Giuseppe Mungo, Markus Wirz, Christoph Tschuor, and Stefan Breitenstein conceived and designed the study. Severin Gloor, Merima Misirlic, Cornelia Frei-Lanter, Pascal Herzog, Phaedra Müller, Judit Schäfli-Thurnherr, Tenzin Lamdark, Dorothee Schregel, Roland Wyss, Christoph Tschuor, and Stefan Breitenstein cared for the patient. Ines Unger, David Gisi, Nico Greco, and Giuseppe Mungo performed the physiotherapeutic treatment. Severin Gloor, Merima Misirlic, Cornelia Frei-Lanter, Pascal Herzog, Phaedra Müller, Judit Schäfli-Thurnherr, Tenzin Lamdark, Dorothee Schregel, Roland Wyss, Ines Unger, David Gisi, Nico Greco, Giuseppe Mungo, Christoph Tschuor, and Stefan Breitenstein made the acquisition of data. Dimitri Aristotle Raptis made the statistical analysis. Severin Gloor and Christoph Tschuor wrote the manuscript. Merima Misirlic, Ines Unger, David Gisi, Nico Greco, Giuseppe Mungo, Markus Wirz, Cornelia Frei-Lanter, Pascal Herzog, Phaedra Müller, Judit Schäfli-Thurnherr, Tenzin Lamdark, Dorothee Schregel, Roland Wyss, Dimitri Aristotle Raptis, and Stefan Breitenstein revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Stefan Breitenstein.

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Gloor, S., Misirlic, M., Frei-Lanter, C. et al. Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: results of a single-center, blinded, randomized controlled trial. Langenbecks Arch Surg 407, 897–907 (2022). https://doi.org/10.1007/s00423-022-02449-0

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