A. Sender Liberman

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer.

Background:The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods:A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results:Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. −21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion:Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

Nutrition Adequacy in Enhanced Recovery After Surgery: A Single Academic Center Experience

BACKGROUND A prospective observational study was initiated to determine the prevalence of nutrition risk before surgery and assess nutrition adequacy of food choices after elective colorectal surgery. MATERIALS AND METHODS Patient-Generated Subjective Global Assessment was used to screen all preoperative clinic patients (n = 70) scheduled for elective colorectal surgery. Adequacy of dietary intake (n = 40) was determined for the first 3 postoperative days by estimating total energy and protein intake from leftover food at each meal based on standard hospital portions with food composition tables. Food access questionnaire provided a rationale for observed food intake. All patients received Enhanced Recovery After Surgery (ERAS) and room service system care. RESULTS Before surgery, 63% of patients were considered well-nourished, 29% suspected or moderately undernourished, and 8% severely undernourished. Fifty-one percent of patients scored > 4 on the Patient-Generated Subjective Global Assessment, indicating requirement for dietary intervention or symptom management. On average, 77% ± 27%, 63% ± 28%, and 92% ± 39% of energy requirements were met on postoperative days 1, 2, and 3, respectively; conversely, 55% ± 24%, 43% ± 16%, and 45% ± 12% of protein requirements were met. Most common reasons for missed meals included loss of appetite and feelings of fatigue or worry. Preoperative nutrition risk tended to result in a greater 30-day hospital readmission rate compared to well-nourished patients (P = .07). CONCLUSIONS A third of patients scheduled for elective colorectal surgery were at nutrition risk. An acceptable intake of dietary protein was not achieved during the first 3 days of hospitalization. Preoperative nutrition education, as part of Enhanced Recovery Programs, may be useful to optimize nutrition status before surgery to mitigate clinical consequences associated with undernutrition and empower patients to make adequate food choices for recovery. NCT 01727570.

Laparoscopic Re-exploration for Colorectal Surgery Complications

Minimally invasive surgery is the standard practice for many elective colorectal cases. Emergency laparoscopic colon surgery is gaining momentum and has been found to be safe and technically feasible [1]. A systematic review demonstrated earlier return of gastrointestinal function, shorter length of hospital stay, fewer complications, and lower mortality rates in those undergoing laparoscopic compared to open colectomy [2]. With advanced minimally invasive surgery expertise, management of surgical complications following colorectal surgery, such as anastomotic leak, rectal stump blowout, and small bowel volvulus, can be approached laparoscopically. The patient’s hemodynamic function should be able to tolerate the physiologic effects of CO2 pneumoperitoneum [3, 4]. Patients with abdominal compartment syndrome, poor lung compliance, bradyarrhythmias, or hemodynamic instability will not tolerate the increased intra-abdominal pressure, decreased functional residual capacity of the lung, or vagal stimulation induced by stretching of the peritoneum on insufflation that are associated with laparoscopy [4, 5]. The purpose of this chapter is to highlight the clinical and technical aspects of laparoscopic management of the common complications following colorectal surgery.