Discussion
colorectal cancer
COLORECTAL CANCER, COMPLICATIONS, POSTOPERATIVE COMPLICATIONS
The present study aimed to investigate the effect of multimodal prehabilitation on immediate postoperative recovery in patients with low functional capacity. Patients in the intervention group had a 21.9 (95% c.i. 4.5–39.3) point higher recovery score during the first 3 postoperative days when compared with patients in the control group. This difference is above the minimal clinically relevant difference of 8, suggesting that undergoing multimodal prehabilitation can improve immediate postoperative recovery in vulnerable patients with colorectal cancer.To the authors' knowledge, no previous studies have estimated the effect of prehabilitation in the early postoperative period in any population, which makes interpretation of the results into the clinical setting difficult. However, the improvement found in QoR-15 score associated with the multimodal intervention was of the same magnitude between moderate to good recovery, a difference which in previous studies has shown to reduce the risk of complications and improve resumption of recreational and occupational activitiesPrevious studies have shown that it is possible to improve functional capacity prior to surgery through physical training and to reduce complicationsThis study has several important limitations. First, the study participants and testers were not blinded, which may have influenced the results. All baseline testing was conducted prior to randomization, thereby blinding all baseline test results; however, both testers and patients were aware of the overall study hypothesis, which could have led to response bias. Secondly, there was an imbalance between the groups in regards to gender, with more males in the intervention group. While the influence of sex and WHO performance status on the QoR-15 score is unknown, previous studies have shown that both male sex and increasing WHO performance status provide a higher risk of postoperative complications after colorectal cancer surgeryThe primary strength of the study is the rigid adherence to both minimally invasive surgery and the ERAS care pathway for all of the included patients, reflected in both the surgical treatment, the low occurrence of complications and short length of stay, despite only including ‘high’-risk patients with low functional capacity. The study demonstrates the effect of prehabilitation as an adjunct to the highest standard of care. Study participants had a very high degree of both adherence and compliance with the intervention, with a lower than expected number of dropouts. However, because all patients that discontinued after inclusion in the intervention group did not receive surgery, we were not able to conduct an intention-to-treat analysis, and only a per-protocol analysis was performed.Further confirmatory studies with larger sample sizes to avoid imbalance issues are needed, as are studies establishing which patients will benefit from prehabilitation as an adjunct to the current ERAS care pathway for colorectal cancer, and to estimate the effect on both postoperative complications and long-term outcomes.