Background Abdominal surgery represents a physiologic stress and is associated with a period of recovery during which functional capacity is often diminished. “Prehabilitation” is a program to ...increase functional capacity in anticipation of an upcoming stressor. We reported recently the results of a randomized trial comparing 2 prehabilitation programs before colorectal surgery (stationary cycling plus weight training versus a recommendation to increase walking coupled with breathing exercises); however, adherence to the programs was low. The objectives of this study were to estimate: (1) the extent to which physical function could be improved with either prehabilitation program and identify variables associated with response; and (2) the impact of change in preoperative function on postoperative recovery. Methods This study involved a reanalysis of data arising from a randomized trial. The primary outcome measure was functional walking capacity measured by the Six-Minute Walk Test; secondary outcomes were anxiety, depression, health-related quality of life, and complications (Clavien classification). Multiple linear regression was used to estimate the extent to which key variables predicted change in functional walking capacity over the prehabilitation and follow-up periods. Results We included 95 people who completed the prehabilitation phase (median, 38 days; interquartile range, 22–60), and 75 who were also evaluated postoperatively (mean, 9 weeks). During prehabilitation, 33% improved their physical function, 38% stayed within 20 m of their baseline score, and 29% deteriorated. Among those who improved, mental health, vitality, self-perceived health, and peak exercise capacity also increased significantly. Women were less likely to improve; low baseline walking capacity, anxiety, and the belief that fitness aids recovery were associated with improvements during prehabilitation. In the postoperative phase, the patients who had improved during prehabilitation were also more likely to have recovered to their baseline walking capacity than those with no change or deterioration (77% vs 59% and 32%; P = .0007). Patients who deteriorated were at greater risk of complications requiring reoperation and/or intensive care management. Significant predictors of poorer recovery included deterioration during prehabilitation, age >75 years, high anxiety, complications requiring intervention, and timing of follow-up assessment. Conclusion In a group of patients undergoing scheduled colorectal surgery, meaningful changes in functional capacity can be achieved over several weeks of prehabilitation. Patients and those who care for them, especially those with poor physical capacity, should consider a prehabilitation regimen to enhance functional exercise capacity before colectomy.
Background Evidence suggests that multimodal prehabilitation programs comprising interventions directed at physical activity, nutrition, and anxiety coping can improve functional recovery after ...colorectal cancer operations; however, such programs may be more clinically meaningful and cost-effective if targeted to specific subgroups. This study aimed to estimate the extent to which patients with poor baseline functional capacity improve their functional capacity. Methods Data for 106 participants enrolled in a multimodal, prehabilitation program before colorectal operations were analyzed. Low baseline functional capacity was defined as a 6-minute walking test distance (6MWD) of less than 400 m. Participants were categorized as higher fitness (6MWD ≥ 400 m, n = 70) or lower fitness (6MWD <400 m, n = 36). Changes in 6MWD over the preoperative period, and 4 weeks and 8 weeks after the operation were compared between groups. Secondary outcomes included patient-reported physical activity and health status, postoperative complications, duration of hospital stay, and readmissions. Less-fit patients were then compared with subjects in the rehabilitation arm of the original studies who had a baseline 6MWD <400 m. Results Participants with lower baseline fitness had greater improvements in functional walking capacity with prehabilitation compared to patients with higher fitness (+46.5 standard deviation 53.8 m vs +22.6 standard deviation 41.8 m, P = .012). At 4 weeks postoperatively, patients with lower baseline fitness were more likely to be recovered to their baseline 6MWD than those with higher fitness. (74% vs 50%, P = .029). There were no differences in secondary outcome. Less-fit patients had a greater improvement through all the preoperative period compared to the control group. Conclusion Patients with lower baseline walking capacity are more likely to experience meaningful improvement in physical function from prehabilitation before and after a colorectal cancer operation.
Abstract Background A previous comprehensive prehabilitation program, providing nutrition counseling with whey protein supplementation, exercise, and psychological care, initiated 4 weeks before ...colorectal surgery for cancer, improved functional capacity before surgery and accelerated functional recovery. Those receiving standard of care deteriorated. The specific role of nutritional prehabilitation alone on functional recovery is unknown. Objective This study was undertaken to estimate the impact of nutrition counseling with whey protein on preoperative functional walking capacity and recovery in patients undergoing colorectal resection for cancer. Design We conducted a double-blinded randomized controlled trial at a single university-affiliated tertiary center located in Montreal, Quebec, Canada. Colon cancer patients (n=48) awaiting elective surgery for nonmetastatic disease were randomized to receive either individualized nutrition counseling with whey protein supplementation to meet protein needs or individualized nutrition counseling with a nonnutritive placebo. Counseling and supplementation began 4 weeks before surgery and continued for 4 weeks after surgery. Main Outcome Measure The primary outcome was change in functional walking capacity as measured with the 6-minute walk test. The distance was recorded at baseline, the day of surgery, and 4 weeks after surgery. A change of 20 m was considered clinically meaningful. Results The whey group experienced a mean improvement in functional walking capacity before surgery of +20.8 m, with a standard deviation of 42.6 m, and the placebo group improved by +1.2 (65.5) m ( P =0.27). Four weeks after surgery, recovery rates were similar between groups ( P =0.81). Conclusion Clinically meaningful improvements in functional walking capacity were achieved before surgery with whey protein supplementation. These pilot results are encouraging and justify larger-scale trials to define the specific role of nutrition prehabilitation on functional recovery after surgery.
Background Adoption of the laparoscopic approach for colorectal cancer treatment has been slow owing to initial case study results suggesting high recurrence rates at port sites. The use of ...laparoscopic surgery for colorectal cancer still raises a number of concerns, particularly with the technique’s complexity, learning curve and longer duration. After exploring the scientific literature comparing open and laparoscopic surgery for the treatment of colorectal cancer with respect to oncologic efficacy and short-term outcomes, the Comité de l’évolution des pratiques en oncologie (CEPO) made recommendations for surgical practice in Quebec. Methods Scientific literature published from January 1995 to April 2012 was reviewed. Phase III clinical trials and meta-analyses were included. Results Sixteen randomized trials and 10 meta-analyses were retrieved. Analysis of the literature confirmed that for curative treatment of colorectal cancer, laparoscopy is not inferior to open surgery with respect to survival and recurrence rates. Moreover, laparoscopic surgery provides short-term advantages, including a shorter hospital stay, reduced analgesic use and faster recovery of intestinal function. However, this approach does require a longer operative time. Conclusion Considering the evidence, the CEPO recommends that laparoscopic resection be considered an option for the curative treatment of colon and rectal cancer; that decisions regarding surgical approach take into consideration surgeon experience, tumour stage, potential contraindications and patient expectations; and that laparoscopic resection for rectal cancer be performed only by appropriately trained surgeons who perform a sufficient volume annually to maintain competence.
Abstract Background Many surgical innovations are costly but may result in faster patient recovery. Economic analyses of these innovations require utility measures that reflect the construct of ...“postoperative recovery.” We investigated the validity of Short Form 6D (SF-6D) utility value as a measure of postoperative recovery in patients undergoing elective colorectal resection. Materials and methods Patients undergoing elective colorectal resection completed the Short Form 36 and the 6-min walk test at baseline (before surgery) and at 4 and 8 wk postoperatively. SF-6D utilities were derived from the Short Form 36. Longitudinal validity (responsiveness) was assessed using standardized response means (SRM). Construct validity was assessed by comparing the difference in mean SF-6D between patients with and without complications (discriminant) and by correlating the SF-6D with other measures of recovery (convergent). Results A total of 191 patients were included (58% male; mean age 63.0 (SD 14.2) y, 81% malignancy, and 54% laparoscopic). SF-6D values dropped significantly from baseline to 4 wk after surgery (SRM −0.54, P < 0.001) and returned to baseline by 8 wk (SRM −0.12, P = 0.111). At 4 wk after surgery, the SF-6D was lower in patients with complications than in those without (mean difference −0.047, 95% CI −0.088, −0.006). At all time points, the SF-6D correlated significantly with the physical and mental component scales of the SF-36 (Pearson r 0.67–0.80, all P < 0.001) and the 6-min walk test ( r 0.21–0.29, all P < 0.05). Conclusions The SF-6D is a valid measure of postoperative recovery following elective colorectal resection and may be used to measure quality-adjusted life years for cost-effectiveness analyses of surgical technologies and interventions hypothesized to impact recovery.
Introduction Laparoscopic colectomy (LC) offers significant improvements compared to its open counterpart, but adoption has been slow, in part related to training challenges. The purpose of this ...research was to create and validate a tool to measure intraoperative performance during LC: The Global Operative Assessment of Laparoscopic Skills – Colon Module (GOALS-CM). Methods Novice and experienced surgeons from 4 North American institutions were evaluated by the attending surgeon, a trained observer and by self-assessment during LC using GOALS-CM. Interrater reliability and internal consistency of items were assessed using intraclass correlation coefficients (ICC) and Cronbach's alpha respectively. Construct validity of GOALS-CM was estimated by comparing median scores for novice and experienced operators using Student's t-test. Results Sixteen LCs (8 right, 4 left, 3 sigmoid and 1 total) were evaluated for 9 novices and 3 experts using GOALS-CM. Internal consistency of test items was high (0.91) as was interrater reliability for observers and attendings ( Table 1 ). Participants and attendings demonstrated an ICC of only 0.30. The median observer score (interquartile range) for experts (2929-30) was significantly higher than for the novices (2118.5-24; p<0.01). n Interrater reliability p Observer 1 vs Observer 2 9 0.92 <0.01 Observer 1 vs Attending 13 0.86 <0.01 Observer 2 vs Attending 8 0.87 <0.01 Participant vs Attending 15 0.30 0.13 Conclusions GOALS-CM is a valid and reliable assessment of performance by experienced surgeons and observers during LC. Novice participants may not have insight into their own skills for this procedure. GOALS-CM may contribute to the definition and identification of competency for LC, and offers specific, detailed feedback to focus training and enhance the efficiency of learning.
PDF
