Abstract
There is substantial interest by clinicians to improve the health outcomes of older and frail patients following major surgery, with prehabilitation a potential and important component of future standard patient care. We studied the feasibility of a randomised controlled trial of pre-operative prehabilitation in frail patients scheduled for colorectal surgery in regional Australia. We conducted a single blind, parallel arm, randomised controlled trial in a regional referral centre where colorectal surgical patients aged over 50 were invited to participate and screened for frailty. Frail patients were randomised to undertake either a 4-week supervised exercise program with dietary advice, or usual care. The primary outcome was 6-min-walk-distance at baseline, pre-surgery (4 weeks later) and at follow-up (4–6 weeks post-operation). Secondary outcomes included physical activity level, health-related quality of life, and post-surgical complications. Feasibility outcomes were numbers of patients reaching each stage and barriers or reasons for withdrawal. Of 106 patients eligible for screening during the 2-year study period, only five were able to be randomised, of which one alone completed the entire study to follow-up. Fewer patients than expected met the frailty criteria (23.6%), and many (22.6%) were offered surgery in a shorter timeframe than the required 4 weeks. Physical and psychological aspects of frailty and logistical issues were key for patients declining study participation and/or not complying with the intervention and/or all outcome assessments. Feasibility for a large randomised controlled trial of prehabilitation for frail colorectal patients was poor (~5%) for our regional location. Addressing barriers, examination of a large, dense population base, and utilisation of a frailty-screening tool validated in surgical patients are necessary for future studies to identify the impact of prehabilitation for frail patients.
Highlights
Techniques in surgery and anaesthesia are continuously evolving, such that there are gradual improvements in outcomes, safety, and side-effect profiles over time
The prevalence of frailty in the developed world is increasing with the rate of frailty being 40–50% in patients diagnosed with colorectal cancer [7, 8]
These barriers were: shorter than expected operative times; lower incidence of frailty than expected; patients experiencing physical and psychological effects of frailty and disease; and logistical issue associated with recruitment process and follow-up
Summary
Techniques in surgery and anaesthesia are continuously evolving, such that there are gradual improvements in outcomes, safety, and side-effect profiles over time. Examples of this are the development of minimally invasive procedures and fast-track programmes in colorectal cancer surgery, which have significantly reduced the surgical stress-response, the length of hospital stay. Frailty is a clinically recognisable state of increased vulnerability to poor resolution of homeostasis after a stressor event such as surgery [5, 6] It results from aging-associated decline in reserve and function, as well as a variable burden of comorbidity across multiple physiologic systems, increasing the rate of adverse outcomes [5, 6]. Pre-operative exercise training, known as prehabilitation, is one possible method to gain these improvements
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