Authors (including presenting author) :
Sung HLS(1)(2), Yu MC(1)
Affiliation :
(1)Department of Surgery, Tseung Kwan O Hospital, (2)The Nethersole School of Nursing, The Chinese University of Hong Kong
Introduction :
Colorectal cancer ranks second most prevalent forms of cancer in Hong Kong and surgery is still the primary management of colorectal cancer. Enhanced Recovery After Surgery (ERAS) protocol is a multimodal coordinated strategy with focused intra- and postoperative strategy in pursuit of optimal postoperative complication, reduced length of hospital stay (LOS) and accelerated recovery. Despite of the promising result from launching ERAS protocol, given the growing interest in enhancing surgical outcomes and patients’ fitness, prehabilitation program has been advocated to be integrated or a complementary program in parallel with ERAS protocol.
Although the ERAS protocol and prehabilitation have ben shown to be beneficial in the literature studies, there is a lack of clear evidence in the existing literature discussing the clinical impacts of the synergistic effect for implementing ERAS protocol and prehabilitation. Hence, a systematic review of the existing randomized controlled trials is conducted to develop a robust evidence for our clinical practice.
Objectives :
To evaluate the effects of prehabilitation with ERAS protocol for adults scheduling colorectal cancer surgery in context of (1) Gastrointestinal (GI) function, (2) Overall postoperative complications, (3) Length of stay (LOS), (4) Functional capacity, (5) Nutritional status, (6) Psychological well-being
Methodology :
A comprehensive search and review on the available literature evidence was performed from the inception to April 2024 under the framework of PICO: P (Population): Adult patients scheduling for colorectal cancer surgery for any indication; I (Intervention): any single or combined interventions aimed to improve patients’ outcomes of functional capacity, nutritional status and psychological needs preoperatively, were deemed to meet the criteria as prehabilitation; C (Comparator): as per the usual practices of care as in the local ERAS protocol and not received any additional counseling or interventions exercises, nutrition and/ or mental health in the purpose of prehabilitation; O (Outcome): GI function/ recovery, postoperative complications, (LOS), functional capacity, nutritional status and mental status.
Seven English electronic databases including MEDLINE (incorporated with PubMed), EMBASE, PsyINFO, CINAHL, Cochrane Library, SCOPUS, Web of Science, were searched from October 2023 to April 2024. The bibliographies of relevant records including eligible trials reporting prehabilitation with ERAS were also retrieved. Additional manual searching with google scholar for full text were also performed. Search terms included (“prehab*” or “preoperative rehab*” or “preoperative exercise”), (“colon*” or “rectal” AND “tumor” or “cancer”, “surgery” or “resection”), (“enhanced recovery” or “ERAS”), (“nutrition*” or “ileus” or “gastrointestinal” AND “function” or “recover” or “motility” or “length of stay” or “complication”).
The risk of bias in the studies was independently assessed using The Cochrane Risk of Bias 2.0 tool (RoB2) by 2 authors.
Total 7103 records were identified in the seven databases and 12 records of RCT were included in this review after duplication removal and content screening.
Result & Outcome :
Among the included studies, one was cluster RCT conducted in Canada and European countries, four were individual RCT in Asia, three in European countries, three in Canada and one in United States. Five were deemed as high risk and some concern respectively and only two were at low risk in overall risk of bias . A total of 1232 colorectal cancer patients were recruited in this review and the sample size of each studies ranged from 21 to 251, no significant difference at number of each group and gender distribution were revealed. Most studies were community based or at out patient clinic, and two studies were conducted during hospitalization. Intervention(s) duration was from one week up to two months, and four week regimen was the most common that provided in six studies. Unimodal prehabilitation programme was provided in four studies, where one study focused on optimization of nutritional status, and two studies were exercises alone intervention. A bimodal programme of nutrition and intensity training was conducted in one study, and eight studies utilized multimodal approach of prehabilitation, consisting of nutritional therapy, physical training and psychosocial interventions.
Heterogeneity of patients' outcomes have been demonstrated in this review. GI recovery were measured in total three studies: reduced time to flatus between intervention and control groups (p< 0.001; p=0.032, paired t test) in two studies and shorten time for first bowel (P< 0.001, paired t test) in one studies. Overall postoperative complications were assessed in nine studies but only three demonstrated significant difference among intervention and control group (p< 0.05; p=0.016; p=0.02, paired t test). Only one study demonstrated reduced LOS between group (p< 0.001, paired t test) over the 11 studies. Functional capacity were measured all eight studies with exercises component and most of them revealed an improvement except one only showed no significant difference when compared with the ITT and PP analysis. Only one study showed better nutritional recovery in interventions (p=0.002, paired t test) among the three reported studies. All eight studies suggested an improvement in psychological well being in context of anxiety, depression and quality of life, but none of them demonstrated statistical differences.
Conclusion: Prehabilitation may be a promising intervention to improve the patients' outcomes; however, low certainty evidence and great heterogeneity on the clinical outcomes implies further rigorous studies is needed. Additionally, theory driven innovative should be considered in promoting better care delivery and effectiveness of intervention.
