Nationwide Implementation of Multimodal Prehabilitation and Complications After Colorectal Cancer Surgery

Importance: Surgical resection is the cornerstone of curative treatment for colorectal cancer but can be associated with postoperative morbidity. Multimodal prehabilitation may improve preoperative fitness; its effect remains unclear because small sample sizes, heterogeneity, and selective populations have limited prior studies, highlighting the need for real-world evidence. Objective: To evaluate the effectiveness of a multimodal prehabilitation program in unselected patients undergoing colorectal cancer resection. Design, Setting, and Participants: In this multicenter cohort study, patients undergoing colorectal cancer surgery who participated in a multimodal prehabilitation program were compared with historical controls from the same centers using propensity score matching accounting for age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, surgical procedure, and operative approach. A total of 18 hospitals in the Netherlands participated in a nationwide implementation between 2020 and 2023. All adults who underwent elective colorectal cancer resection were eligible. Study data were analyzed from June 2014 to June 2023 for the control group and from April 2020 to June 2023 for the prehabilitation group. Exposures: The program included high-intensity exercise 3 times per week, nutritional support, psychological counseling, and optimization of comorbidities including anemia, frailty management, and smoking cessation when indicated. Main Outcomes and Measures: Outcome parameters were overall, medical, and surgical complications, length of hospital stay, and rates of readmission and intensive care admissions. Results: In total, 2384 patients were included (mean SD age, 70 11 years; 1254 male 53%; 1192 patients per group). Overall complication rates were lower in the prehabilitation group (356 of 1181 30.1% vs 446 of 1181 37.8%; odds ratio OR, 0.71; 95% CI, 0.60-0.84) as were medical complications (182 of 1181 15.4% vs 290 of 1181 24.6%; OR, 0.56; 95% CI, 0.46-0.69) and surgical complications (253 of 1181 21.4% vs 294 of 1181 24.9%; OR, 0.82; 95% CI, 0.68-1.00). Median (IQR) length of hospital stay was 1 day shorter (4 3-6 days vs 5 4-8 days; P < .001), whereas rates of readmission and intensive care admission were reduced. Reduction in complication rates in the prehabilitation cohort occurred irrespective of age and ASA score. Conclusions and Relevance: Results of this cohort study show that implementation of a uniform multimodal prehabilitation program for unselected patients undergoing colorectal cancer surgery was associated with reduced complication rates and length of hospital stay across all age and ASA score subgroups.