QS306 - Refining prehabilitation in elective colorectal surgery – should it be targeted towards only frail and older patients?

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Purpose/Background: Ageing is associated with sarcopenia, which has been found to be a predictor of post-operative complications and mortality following elective colorectal surgery (CRS). With a shift towards an ageing population globally, it is crucial to intervene and correct sarcopenia early. Prehabilitation has been thought to provide pre-operative physical and nutritional support to withstand surgical stress. However, the American Society of Colon and Rectal Surgeons 2022 guidelines provided only weak recommendation for the use of multimodal prehabilitation in patients with multiple co-morbidities or significant deconditioning prior to elective CRS. This study aims to use propensity score matching (PSM) to compare the outcomes of patients who underwent exercise-based prehabilitation versus those who did not to identify if there is a need to revisit our selection criteria for prehabilitation.

Methods/Interventions: This is a retrospective study from July 2010-December 2021 on patients aged ≥75 years, or aged ≥65 years and frail, and/or with Charlson co-morbidity index (CCI) of ≥4 who underwent elective curative CRS. All patients were recruited into our geriatric surgical service (GSS), which consists of a surgeon, geriatrician, anaesthetist, physiotherapist and dietician. Patients who were frail or had CCI ≥4 were selected for exercise-based prehabilitation. Exclusion criteria for prehabilitation were patients who required urgent surgery or refused prehabilitation. The type of prehabilitation (inpatient, day or home-based) was decided jointly between GSS and the patient. A 2:1 PSM was performed, matched based on age, sex, modified Barthel’s index, frailty, ASA ≥3, CCI ≥4 and surgical access.

Results/Outcomes: There were 208 patients (prehabilitation: 148, no prehabilitation: 60) in the unmatched cohort. There were 43.8% who were aged ≥80 years, 63.0% with ASA ≥3 and 31.7% who were frail. There were 43.8% who underwent laparoscopic surgery. Duration of prehabilitation ranged from 2-4 weeks. The overall incidence of major morbidity (Clavien-Dindo grade ≥3A), 30-day and 1-year mortality were 12.0%, 1.9% and 6.7% respectively. The matched cohort had 144 patients (prehabilitation: 96, no prehabilitation: 48). In view of the low incidence of frailty (n=25, 17.4%) following matching, a subgroup analysis was performed in patients who were not frail (n=119): prehabilitation was not an independent predictor of major morbidity, 30-day and 1-year mortality. However, open surgery was an independent predictor of 1-year mortality (near statistical significance) (OR 7.85, 95% CI: 0.95, 65.08, p=0.056).

Conclusion/Discussion: Older patients who were not frail did not benefit from exercise-based prehabilitation in terms of post-operative outcomes after PSM. Open surgery reached near statistical significance in independently predicting 1-year mortality. There is a need to revisit the selection criteria for prehabilitation to maximise its clinical utility given finite resources.