Study design
This study was based on a reanalysis of preoperative data that assessed the effectiveness of a trimodal prehabilitation intervention for elderly CRC patients undergoing colorectal resection[15]. Eligible patients were assigned in a 1:1 ratio to either prehabilitation or a control group. All patients were required to visit the lab for baseline (6 weeks prior to surgery) and before surgery (within 1 week of surgery) measurements, which included a 3-day dietary recall assessment, a 6-min walk test (6MWT) to measure functional walking capacity (Figure 1).
Data Collection
Demographic data including age, sex, height, body weight, body mass index, diagnosis, cancer stage, functional capacity, and other comorbidities were recorded(Table 1).The waiting period for surgery was determined as the term between the date of hospitalization for examination of cancer (first hospitalization) and the date of re-hospitalization for surgery (second hospitalization). Intraoperative data such as operative procedure, operation time and intraoperative blood loss also were recorded. The severity of postoperative complications was classified using the Clavien-Dindo classification system[16]. A major complication was defined as a complication with a Clavien-Dindo grade of 3 or higher. Postoperative infectious complications included intra-abdominal abscess, bacteremia, surgical-site infection, and pneumonia. The discharge criteria were constant throughout the study period. Discharge from the hospital was allowed when patients were estimated without any drainage tube and with stable oral intake.
Prehabilitation programme
Trimodal prehabilitation interventions
The trimodal prehabilitation interventions of both studies included exercise, nutrition, and anxiety-reduction components that began approximately 6 weeks before surgery. Each patient received a baseline appointment with a kinesiologist, dietitian, and an expert trained in psychology all of whom assessed the patient and provided personalized instructions. Prehabilitation group patients received a personalized,supervised,and home-based multimodal program prescribed by a kinesiologist, a nutritionist, and a psychology-trained nurse. The program started after the baseline visit and continued for 6 weeks before surgery.Participation in the prehabilitation program had no effect on surgical waiting time. The program did not continue after surgery.
Exercise Intervention
The home-based exercise regimen involved a prescription of unsupervised total-body exercise of up to 50 min for at least 3 days per week, alternating between aerobic and resistance training. During these sessions, patients performed 30 minutes of moderate aerobic exercise (including a 5-minute warm-up) on a recumbent stepper, 25 minutes of resistance exercises using an elastic band, and 5 minutes of stretching. In addition to the supervised exercise sessions, participants were prescribed a personalized home-based program of aerobic activities (walk daily for a total of 30 minutes as moderate-intensity aerobic activity) and resistance training (elastic band routine 3 times per week) in the hospital once per week before surgery.
Nutrition Intervention
All participants had their nutritional status assessed by a registered dietitian. At baseline,participants were asked to complete a 3-day food diary from which macronutrients were estimated using food exchange lists and compositiontables. Nutritional status was evaluated using the NRS 2002 score and frailty index[16,17]. Patients were advised on how to improve their own daily dietary intake based on the balanced plate concept. Target protein intake was 1.5g/kg of body weight (or adjusted body weight in obese patients) as per the European Society for Clinical Nutrition and Metabolism recommendation for patients with cancer[18]. If the patient did not Meet the protein requirement by diet alone, they were provided with whey protein supplementation. Patients were instructed to use the supplements within 1 hour of their exercise training to maximize muscle protein synthesis[19].Further nutritional counseling included caloric balance, bowel movement regularity.
Psychological Intervention
The study participants had an assessment by a psychology trained nurse. Potential causes of perioperative fatigue, anxiety, and depression were discussed. Study participants were provided with personalized coping strategies and received a compact disc with an audio track containing the instructions to help them perform the exercises at home 3 times a week. The intervention also included counseling regarding smoking and alcohol cessation. The use of nicotine replacement therapy was decided through shared decision-making. A trained psychologist provided patients with relaxation and breathing exercises to reduce anxiety. Patients practiced with the psychologist during the initial visit, after which they were provided with an instructional compact disk for performing these exercises at home.In order to facilitate adherence to the intervention program, all patients in prehabilitation received a standardized instructional booklet, written in easily comprehensible language with pictures and figures, describing all elements of the program in detail. The booklet also contained a diary for patients to document all physical activities performed. For ethical reasons, the control group was provided with an intervention program, similar to prehabilitation. During the preoperative period, patients were given a hospital booklet informing patients on how to prepare for surgery.
Statistical analysis
Data analysis was performed by comparing the prehabilitation group to the control group using SPSS Statistics software. All continuous variables were analyzed using a t-test from independent samples. All categories were described as percentages and were compared using a chi-squared test or Fisher’s exact test, p values<0.05 were considered signifcant.