Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands.
Department of Surgery, Rijnstate, Arnhem, Netherlands.
Cochrane Database Syst Rev. 2023 May 10;5(5):CD013259. doi: 10.1002/14651858.CD013259.pub3.
Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.
To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.
We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.
We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VOpeak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.
Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.
We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VOpeak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.
AUTHORS' CONCLUSIONS: Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.
手术是治疗结直肠癌的基石。不幸的是，手术本身可能会对患者的健康产生不利影响。“术后加速康复”方案，包括多模式干预，已显著改善了患者的预后。然而，这些方案主要应用于围手术期。多模式术前康复包括多种术前干预措施，旨在提高患者的适应能力，从而改善术后预后。
确定多模式术前康复方案对接受结直肠癌手术的成年患者的功能能力、术后并发症和生活质量的影响。
我们于 2021 年 1 月检索了 CENTRAL、MEDLINE、Embase 和 PsycINFO，并于 2021 年 3 月检索了试验注册库。
我们纳入了非转移性结直肠癌成年患者的随机对照试验（RCT），这些患者计划接受手术，比较了多模式术前康复方案（定义为至少包括两种术前干预措施）与无术前康复的方案。我们关注的主要结局为：功能能力（即 6 分钟步行试验、VOpeak、握力）、术后结局（即并发症、死亡率、住院时间、急诊就诊、再入院）、健康相关生活质量、康复方案的依从性、安全性以及恢复正常活动的能力。
两名作者独立选择研究、提取数据、评估偏倚风险，并使用 GRADE 评估证据的确定性。任何分歧都通过讨论和共识解决。如果可能，我们进行了荟萃分析。
我们纳入了三项 RCT，共纳入了 250 名计划接受择期（主要为腹腔镜）手术的非转移性结直肠癌患者。纳入的试验均在三级护理中心进行，招募的患者时间范围从 17 个月至 45 个月不等。130 名患者参加了为期四周的术前三联康复方案，包括运动、营养干预和焦虑减轻技术。将这些患者的结局与 120 名参加相同但术后方案的患者进行了比较。术后，术前康复可能会改善功能能力，在四周和八周时通过 6 分钟步行试验进行评估（MD 26.02，95%CI -13.81 至 65.85；2 项研究；n = 131；MD 26.58，95%CI -8.88 至 62.04；2 项研究；n = 140）；然而，由于严重的偏倚风险、不准确性和不一致性，证据的确定性非常低和极低。在术前康复后，手术前的功能能力有所提高，平均差异为 24.91 米（95%CI 11.24 至 38.57；3 项研究；n = 225）。证据的确定性为中度，因为严重偏倚风险导致降级。术前康复对并发症数量（RR 0.95，95%CI 0.70 至 1.29；3 项研究；n = 250）、急诊就诊（RR 0.72，95%CI 0.39 至 1.32；3 项研究；n = 250）和再入院（RR 1.20，95%CI 0.54 至 2.65；3 项研究；n = 250）的影响较小或甚至微不足道。由于严重的偏倚风险和不准确性，证据的确定性非常低。对于 VOpeak、握力、住院时间、死亡率、健康相关生活质量、恢复正常活动、方案安全性和依从性率等结局，由于缺失或数据不足，无法进行定量分析。纳入的研究未报告组间健康相关生活质量和住院时间的差异。在纳入的研究中，其他结局的数据未报告或报告不充分。
术前康复可能会改善患者的功能能力，通过 6 分钟步行试验在术前和术后均可进行评估。对于并发症数量、术后急诊就诊和再入院等结局，没有确定明显的效果。证据的确定性从中度到非常低不等，因为严重的偏倚风险、不准确性和不一致性导致降级。此外，本综述仅纳入了三项异质性研究。因此，本综述的结果应谨慎解释。目前正在进行许多相关的 RCT，并将在本综述的未来更新中纳入。
