Does a multimodal prehabilitation program improve sleep quality and duration in patients undergoing colorectal resection for cancer? Pilot randomized control trial.

Sleep difficulties are a common symptom in cancer patients at different stages of treatment trajectory and may lead to numerous negative consequences for which management is required. This pilot Randomized Controlled Trial (RCT) aims to assess the potential effectiveness of home-based prehabilitation intervention (prehab) on sleep quality and parameters compared to standard care (SOC) in colorectal cancer patients during the preoperative period and up to 8 weeks after the surgery. One hundred two participants (48.3% female, mean age 65 years) scheduled for elective resection of colorectal cancer were randomized to the prehab (n = 50) or the SOC (n = 52) groups. Recruitment and retention rates were 54% and 72%, respectively. Measures were completed at the baseline and preoperative, 4- and 8-week after-surgery follow-ups. Our mixed models' analyses revealed no significant differences between groups observed over time for all subjective and objective sleep parameters. A small positive change was observed in the perceived sleep quality only at the preoperative time point for the prehabilitation group compared to the SOC group, with an effect size d = 0.11 and a confidence interval (CI) between - 2.1 and - 0.1, p = .048. Prehab group patients with high anxiety showed a significant improvement in the rate of change of sleep duration over time compared to the SOC group, with a difference of 110 min between baseline and 8 weeks after surgery (d = 0.51, 95% CI: 92.3 to 127.7, p = .02). Multimodal prehabilitation intervention is feasible in colorectal cancer patients and may improve sleep duration for patients with high anxiety symptoms. Future large-scale RCTs are needed to confirm our results.

The impact of patient activation on the effectiveness of digital health remote post-discharge follow-up and same-day-discharge after elective colorectal surgery.

BACKGROUND: Low patient activation (PA) is associated with worse postoperative outcomes, however, its impact on the effectiveness of digital health interventions is unknown. We sought to determine the impact of PA on the effectiveness of digital health application for remote post-discharge follow-up for patients undergoing elective colectomy. METHODS: Data analysis included a control cohort (CC) of patients undergoing elective colorectal surgery from 10/2017 to 04/2018 without the digital health intervention and a digital application cohort (DAC) that received a smart phone application for remote post-discharge follow-up from 03/2021 to 08/2022, including a subset of same-day discharge (SDD) patients. PA was measured using the Patient Activation Measure (PAM; score 0-100) and categorized into low (< 55.1) and high (≥ 55.1). The PAM was administered 4-6 weeks before surgery in the DAC group and on postoperative day (POD) 1 in the CC group. The main outcome measure was 30-day emergency department (ED) visits. RESULTS: A total of 164 patients were included (89DAC with 50 SDD, 75CC), with no differences in patient characteristics other than more stoma closures in the DAC group. Overall, 77% of patients had high PA level, with no difference between CC and DAC (77% vs. 81%, p = 0.25). There was no difference in ED visits between CC and DAC (19% vs. 18%, p = 0.90). Overall, low PA was associated more ED visits (29% vs 14%, p = 0.04). In the SDD subgroup, low PA patients had more ED visits (38% vs. 7%, p = 0.015). PA level did not affect app usage metrics. On multiple regression, only low PA remained independently associated with ED visits (OR 3.42, 95%CI 1.27, 9.24). CONCLUSION: Low PA remains an important predictor of surgical outcomes after elective colorectal surgery regardless of the use of a digital health application for remote post-discharge follow-up. This suggests that improving PA levels may improve postoperative outcomes.

Predictive Factors for Successful Same-Day Discharge After Minimally Invasive Colectomy and Stoma Reversal.

BACKGROUND: Same-day discharge after minimally invasive colorectal surgery is a safe, effective practice in specific patients that can enhance the efficiency of enhanced recovery pathways. OBJECTIVE: To identify predictive factors associated with success or failure of same-day discharge. DESIGN: Prospective cohort study from January 2020 to March 2023. SETTINGS: Tertiary colorectal center. PATIENTS: Adult patients eligible for same-day discharge with remote postdischarge follow-up included those with minimal comorbidities, residing near the hospital, having sufficient home support, and owning a mobile device. INTERVENTIONS: Patients were discharged on the day of surgery upon meeting specific criteria, including adequate pain control, tolerance of oral intake, independent mobility, urination, and the absence of complications. Successful same-day discharge was defined as discharge on the day of surgery without unplanned visits in the first 72 hours. MAIN OUTCOME MEASURES: Factors associated with successful or failed same-day discharge after minimally invasive colorectal surgery. RESULTS: A total of 175 patients (85.3%) were discharged on the day of surgery, with 14 patients (8%) having an unplanned visit within 72 hours. Overall, 161 patients (78.5%) were categorized as same-day discharge success and 44 patients (21.5%) as same-day discharge failure. The same-day discharge failure group had a higher Charlson Comorbidity Index (3.7 vs 2.8, p = 0.03). Mean length of stay (0.8 vs 3.0, p = 0.00), 30-day complications (10% vs 48%, p = 0.00), and readmissions (8% vs 27%, p = 0.00) were higher in the same-day discharge failure group. Regression analysis showed that failed same-day discharge was associated with higher comorbidities (OR 0.79; 95% CI, 0.66-0.95) and prolonged postanesthesia care unit time (OR 0.99; 95% CI, 0.99-0.99). Individuals who received a regional nerve block (OR 4.1; 95% CI, 1.2-14) and those who did not consume postoperative opioids (OR 4.6; 95% CI, 1-21) were more likely to have successful same-day discharge. LIMITATIONS: Single-center study. CONCLUSIONS: Our findings indicate that comorbidities and prolonged postanesthesia care unit stays were associated with same-day discharge failure, whereas regional nerve blocks and minimal postoperative opioids were related to success. These factors may inform future research aiming to enhance colorectal surgery recovery protocols. See Video Abstract . FACTORES PREDICTIVOS PARA UN ALTA EXITOSA EL MISMO DA DESPUS DE UNA COLECTOMA MNIMAMENTE INVASIVA Y REVERSIN DEL ESTOMA: ANTECEDENTES:El alta el mismo día después de una cirugía colorrectal mínimamente invasiva es una práctica segura y eficaz en pacientes específicos que puede mejorar la eficiencia de las vías de recuperación mejoradas.OBJETIVO:Identificar factores predictivos asociados con el éxito o fracaso del alta el mismo día.DISEÑO:Estudio de cohorte prospectivo del 01/2020 al 03/2023.AJUSTES:Centro colorrectal terciario.PACIENTES:Los pacientes adultos elegibles para el alta el mismo día con seguimiento remoto posterior al alta incluyeron aquellos con comorbilidades mínimas, que residían cerca del hospital, tenían suficiente apoyo en el hogar y poseían un dispositivo móvil.INTERVENCIONES:Los pacientes fueron dados de alta el día de la cirugía al cumplir con criterios específicos, incluido un control adecuado del dolor, tolerancia a la ingesta oral, movilidad independiente, micción y ausencia de complicaciones. El alta exitosa el mismo día se definió como el alta el día de la cirugía sin visitas no planificadas en las primeras 72 horas.PRINCIPALES MEDIDAS DE RESULTADO:Factores asociados con el alta exitosa o fallida el mismo día después de una cirugía colorrectal mínimamente invasiva.RESULTADOS:Un total de 175 (85,3%) pacientes fueron dados de alta el día de la cirugía y 14 (8%) pacientes tuvieron una visita no planificada dentro de las 72 horas. En total, 161 (78,5%) pacientes se clasificaron como éxito del alta el mismo día y 44 (21,5%) pacientes como fracaso del alta el mismo día. El grupo de fracaso del alta el mismo día tuvo un índice de comorbilidad de Charlson más alto (3,7, 2,8, p = 0,03). La duración media de la estancia hospitalaria (0,8, 3,0, p = 0,00), las complicaciones a los 30 días (10%, 48%, p = 0,00) y los reingresos (8%, 27%, p = 0,00) fueron mayores en el mismo día grupo de fallo de descarga. El análisis de regresión mostró que el alta fallida el mismo día se asoció con mayores comorbilidades (OR 0,79; IC del 95 %: 0,66; 0,95) y tiempo prolongado en la unidad de cuidados postanestésicos (OR 0,99; IC del 95 %: 0,99; 0,99). Las personas que recibieron un bloqueo nervioso regional (OR 4,1; IC del 95 %: 1,2, 14) y aquellos que no consumieron opioides posoperatorios (OR 4,6, IC del 95 %: 1-21) tuvieron más probabilidades de tener éxito en el mismo día -descarga.LIMITACIONES:Estudio unicéntrico.CONCLUSIONES:Nuestros hallazgos indican que las comorbilidades y las estancias prolongadas en la unidad de cuidados postanestésicos se asociaron con el fracaso del alta el mismo día, mientras que los bloqueos nerviosos regionales y los opioides postoperatorios mínimos se relacionaron con el éxito. Estos factores pueden informar investigaciones futuras destinadas a mejorar los protocolos de recuperación de la cirugía colorrectal. (Traducción-Yesenia Rojas-Khalil ).

A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery.

BACKGROUND: Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers. OBJECTIVE: We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery. DESIGN: This is a prospective cohort study with a regression analysis after coarsened exact matching. SETTING: The study was conducted at a single colorectal referral center from May 2019 to September 2020. PATIENTS: A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway. INTERVENTIONS: A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used. MAIN OUTCOME MEASURES: The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability. RESULTS: Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon. LIMITATIONS: We did not account for patient activation or perform a cost-analysis. CONCLUSION: Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 . APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL: ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).

A retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway.

BACKGROUND: There is increasing evidence to support discharge prior to gastrointestinal recovery following colorectal surgery. Furthermore, many patients are discharged early despite being excluded from an ambulatory colectomy pathway. The objective of this study was to determine the outcomes of patients discharged early following laparoscopic colectomy in an enhanced recovery pathway (ERP). METHODS: A retrospective review of all adult patients undergoing elective laparoscopic colectomy at a single university-affiliated colorectal referral center (08/2017-06/2021) was performed. Patients were included if they had undergone elective laparoscopic colectomy or ileostomy closure and excluded if they had been enrolled in an ambulatory colectomy pathway. Patients were then divided into three groups: LOS =1 day, LOS 2-3 days, and LOS 4+ days. The main outcomes were 30-day emergency room (ER) visits and readmissions. Reasons for inpatient stay per post-operative day (POD) were also recorded. RESULTS: A total of 497 patients were included [LOS1 n = 63 (13%), LOS2-3 n = 284 (57%), and LOS4+ n = 150 (30%)]. There were no differences in patient characteristics, diagnosis, or procedure between the groups. Patients were discharged with gastrointestinal recovery (GI-3) in 54% LOS1 vs. 98% LOS2-3 vs. 100% LOS4+ (p<0.001). Shorter procedure duration, transversus abdominus plane block, and lower opioid requirements were associated with shorter LOS (p<0.001). The absence of flatus was the most common reason to keep patients hospitalized: 61% on POD1, 21% on POD2, and 8% on POD3 (p<0.001). There were no differences in 30-day emergency visits, or readmission between the groups. In the LOS1 group, there were no differences in outcomes between patients with full return of bowel function at discharge compared to those without. CONCLUSION: Discharge on POD1 was not associated with increased emergency department use, complications, or readmissions. Importantly, full return of bowel function at discharge did not affect outcomes. There may be potential to expand eligibility criteria for ambulatory colectomy protocol.

Predictors of pre- and post-treatment bowel dysfunction severity in patients with rectal cancer.

BACKGROUND: Treatment of rectal cancer is frequently associated with low anterior resection syndrome. However, data concerning the contribution rectal tumors have on pretreatment bowel-dysfunction is scarce. We sought to evaluate the impact of the untreated rectal cancer on bowel-dysfunction and the relationship of pretreatment and post-treatment function. METHODS: A prospective database of adults with rectal cancer at a single university-affiliated colorectal referral center from August 2018 to March 2022 was queried. Bowel-dysfunction was measured using the low anterior resection syndrome score questionnaire (categorized as no, minor, or major low anterior resection syndrome) which was provided to patients at their primary visit, and after treatment. Patients were included if they underwent rectal cancer treatment and had pre- and post-treatment low anterior resection syndrome measurements. Observed low anterior resection syndrome scores were compared to normative low anterior resection syndrome data for age and sex-specific distributions from published data. Multiple multinomial regression compared pre- and post-treatment low anterior resection syndrome scores. RESULTS: Overall, 121 patients were included with mean age 62.0 years (standard deviation 12.3), 74% male, and mean tumor height 8.7 cm (standard deviation 5.72). The proportion of pretreatment observed low anterior resection syndrome were 48% no low anterior resection syndrome, 28% minor, and 24% major. Male and older patients were more likely to have worse than predicted low anterior resection syndrome categories (P < .05). On average, low anterior resection syndrome category did not change after treatment (P = .618) and pretreatment low anterior resection syndrome category was a significant independent predictor of post-treatment category (P = .037). CONCLUSION: Pretreatment bowel-dysfunction in rectal cancer patients is common and significantly worse than predicted for older and male patients. Importantly, pretreatment bowel-dysfunction predicted postoperative function. These results may better inform the shared decision-making process.

Tolerating clear fluids diet on postoperative day 0 predicts early recovery of gastrointestinal function after laparoscopic colectomy.

INTRODUCTION: A high proportion of colorectal surgery patients within an enhanced recovery pathway (ERP) do not experience complications but remain hospitalized mainly waiting for gastrointestinal (GI) recovery. Accurate identification of these patients may allow discharge prior to the return of GI function. Therefore, the objective of this study is to determine if tolerating clear fluid (CF) on postoperative day (POD) 0 was associated with uncomplicated return of GI function after laparoscopic colorectal surgery. METHODS: Pooled data from three prospective studies from a single specialist colorectal referral center were analyzed (2013-2019). The present study included adult patients that underwent elective laparoscopic colectomy without stoma. Postoperative GI symptoms were collected daily in all three datasets. The main exposure variable, whether CF diet was tolerated on POD0, was defined as patients drinking at least 300 mL of CF without any nausea, anti-emetics, or vomiting (CF+ vs CF-). The main outcome measure was time to GI-3 (tolerating solid diet and passage of gas or stools). RESULTS: A total of 221 patients were included in this study, including 69% CF+ and 31% CF-. The groups were similar in age, gender, and comorbidities, but the CF- patients were more likely to have surgery for inflammatory bowel disease. CF+ patients had faster time to GI-3 (mean 1.6d (SD 0.7) vs. 2.3d (SD 1.5), p < 0.001). The CF+ group also experienced fewer complications (19% vs. 35%, p = 0.009), shorter mean LOS (mean 3.6d (SD 2.9) vs. 6.2d (SD 9.4), p = 0.002), and were more likely to be discharged by the target LOS (66% vs. 50%, p = 0.024). CONCLUSION: Toleration of CF on POD0 was associated with faster return of GI function, fewer complications, and shorter LOS. This may be used as a criteria for potential discharge prior to full return of GI function after laparoscopic colectomy within an ERP.

Periodontal disease as a risk factor for sporadic colorectal cancer: results from COLDENT study.

Colorectal cancer remains the top leading cancer worldwide. Accumulating evidence suggests periodontal pathogens are involved in colorectal carcinogenesis, indicating the need for high-quality epidemiological evidence linking periodontal disease (PD) and colorectal cancer (CRC). Thus, we conducted the first population-based case-control study that was specifically designed to investigate the association between compromised oral health and sporadic CRC. A total of 348 incident cases of colon or rectal cancer, and 310 age and sex frequency-matched controls, from the Montreal island and Laval population participated in the study. Data were collected on PD and on several CRC risk factors using validated questionnaires. A life-course approach was used to document long-term history regarding lifestyle factors. Multivariable unconditional logistic regression analysis was used to estimate the rate ratio (RR) quantifying the association between CRC and PD. Results showed that the rate of new diagnosis of CRC in persons with a positive history of PD was 1.45 times higher than in those with a negative history of PD adjusting for age, sex, BMI, education, income, diabetes, family history of CRC, regular use of non-steroidal anti-inflammatory drugs, lifetime cumulative smoking, lifetime consumption of red meats, processed meats, and alcoholic drinks, and lifetime total physical activity score (adjusted RR = 1.45; 95% CI 1.04-2.01; p = 0.026). Our results support the hypothesis of an association between PD and sporadic CRC risk.

Trajectory of gastrointestinal function after laparoscopic colorectal surgery within an enhanced recovery pathway.

BACKGROUND: Early identification of colorectal surgery patients predicted to have uneventful gastrointestinal recovery may allow for early discharge. Our objective was to identify trajectories of gastrointestinal recovery within a colorectal surgery enhanced recovery pathway. METHODS: Data from 2 prospective studies enrolling adult patients undergoing elective laparoscopic colorectal resection at a specialist colorectal referral center were analyzed (2013-2019). All patients were managed according to a mature enhanced recovery pathway with a 3-day target length of stay. Postoperative gastrointestinal symptoms were collected daily and expressed using the validated I-FEED score. Latent-class growth curve (trajectory) analysis was used to identify different I-FEED trajectories over the first 3 postoperative days. RESULTS: A total of 192 patients were analyzed. Trajectory analysis identified 3 distinct trajectories: trajectory 1 had no gastrointestinal symptoms (41%); trajectory 2 had mild early symptoms with improvement over time (48%); and trajectory 3 had gastrointestinal symptoms that significantly worsened between postoperative days 1 and 2 (11%). I-FEED score ≤1 on postoperative day 1 predicted trajectory 1. Trajectory 1 had the best clinical outcomes, whereas trajectory 3 had the worst. CONCLUSION: I-FEED trajectory over postoperative days 1-3 was associated with clinical outcomes and may be used to predict gastrointestinal recovery. Findings from this study may inform clinical decision making regarding early hospital discharge within colorectal enhanced recovery pathways.

Enhanced Recovery 2.0 - Same Day Discharge With Mobile App Follow-up After Minimally Invasive Colorectal Surgery.

OBJECTIVE: To investigate the feasibility of SDD protocol with postdischarge follow-up using a mobile phone app in patients undergoing elective minimally-invasive colectomy. SUMMARY OF BACKGROUND DATA: Discharge before gastrointestinal recovery and use of mobile health technology for remote follow-up may allow for SDD after minimally-invasive colectomy within an ERP. METHODS: Adult patients undergoing elective laparoscopic colectomy or loop ileostomy reversal from February 2020 to November 2020 were screened for eligibility. Patients were eligible if they lived within a 30-minute drive from the hospital, had an adequate support system at home, and owned a smart phone. Patients were discharged from the recovery room on the day of surgery based on set criteria with postdischarge remote follow-up using a mobile application. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within the first 3 days. 30-day complications, ED visits, and readmissions were compared to a non-SDD historical cohort (May 2019-March 2020) also remotely followed-up using the same mobile phone app (standard ERP group). RESULTS: A total of 48 patients were recruited to SDD, of which 77% were discharged on the day of surgery without subsequent ED visit in the first 72 hours. There were 11 patients that could not be discharged, including 7 for failure of discharge criteria and 4 for intraoperative complications/concerns. Overall 30-day complications in the SDD group (17%) was similar to the standard ERP group (15%, P = 0.813). ED visits (SDD10% vs standard ERP8%, P = 0.664) and readmissions (6% vs 4%, P = 0.681) were also similar. CONCLUSIONS AND RELEVANCE: Findings from this study support the feasibility of a SDD protocol in select patients undergoing minimally-invasive colorectal resection. SDD colectomy protocols may represent the next evolution of ERP and postoperative recovery.

Impact of Facilitation of Early Mobilization on Postoperative Pulmonary Outcomes After Colorectal Surgery: A Randomized Controlled Trial.

OBJECTIVE: To estimate the extent to which staff-directed facilitation of early mobilization impacts recovery of pulmonary function and 30-day postoperative pulmonary complications (PPCs) after colorectal surgery. SUMMARY BACKGROUND DATA: Early mobilization after surgery is believed to improve pulmonary function and prevent PPCs; however, adherence is low. The value of allocating resources (eg, staff time) to increase early mobilization is unknown. METHODS: This study involved the analysis of a priori secondary outcomes of a pragmatic, observer-blind, randomized trial. Consecutive patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity, forced expiratory volume in 1 second (FEV1), and peak cough flow were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. RESULTS: Ninety-nine patients (57% male, 80% laparoscopic, median age 63, and predicted FEV1 97%) were included in the intention-to-treat analysis (usual care 49, facilitated mobilization 50). There was no between-group difference in recovery of forced vital capacity [adjusted difference in slopes 0.002 L/d (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/d (-0.01 to 0.01)] or peak cough flow [-0.002 L/min/d (-0.02 to 0.02)]. Thirty-day PPCs were also not different between groups [adjusted odds ratio 0.67 (0.23-1.99)]. CONCLUSIONS: In this randomized controlled trial, staff-directed facilitation of early mobilization did not improve postoperative pulmonary function or reduce PPCs within an enhanced recovery pathway for colorectal surgery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02131844.

Patients' preferences for sphincter preservation versus abdominoperineal resection for low rectal cancer.

BACKGROUND: Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer. METHODS: Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection. RESULTS: A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients. CONCLUSION: An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis.

Effect of two different pre-operative exercise training regimens before colorectal surgery on functional capacity: A randomised controlled trial.

BACKGROUND: Multimodal prehabilitation, including exercise training, nutritional therapy and anxiety reduction, has been shown to attenuate functional decline associated with surgery. Due to the growing interest in functional status as a targeted surgical outcome, a better understanding of the optimal prescription of exercise is critical. OBJECTIVE: The objective is to compare peri-operative functional trajectory in response to two different exercise training protocols within a 4-week, supervised, multimodal prehabilitation programme. DESIGN: This was a single blinded, single centre, randomised controlled study. Participants performed four assessments: at baseline, after prehabilitation (just before surgery), and at 1 and 2 months after surgery. PATIENTS: Adult patients scheduled for elective resection of nonmetastatic colorectal cancer were included provided there were no absolute contraindications to exercise nor poor language comprehension. INTERVENTION: Patients followed either high-intensity interval training (HIIT), or moderate intensity continuous training (MICT), as part of a 4-week multimodal prehabilitation programme. Both groups followed the same supervised resistance training, nutritional therapy and anxiety reduction interventions. All patients followed standardised peri-operative management. MAIN OUTCOME MEASURE: Changes in oxygen consumption at anaerobic threshold, measured with sequential cardio-pulmonary exercise testing, were assessed and compared between groups. RESULTS: Forty two patients were included in the primary analysis (HIIT n = 21 vs. MICT n = 21), with mean ±â€ŠSD age 64.5 ±â€Š11.2 years and 62% were men. At 2 months after surgery, 13/21 (62%) in HIIT and 11/21 (52%) in MICT attended the study visits. Both protocols significantly enhanced pre-operative functional capacity, with no difference between groups: mean (95% confidence interval) oxygen consumption at anaerobic threshold 1.97 (0.75 to 3.19) ml kg min in HIIT vs. 1.71 (0.56 to 2.85) in MICT, P = 0.753. At 2 months after surgery, the HIIT group showed a higher improvement in physical fitness: 2.36 (0.378 to 4.34) ml kg min, P = 0.021. No adverse events occurred during the intervention. CONCLUSION: Both MICT and HIIT enhanced pre-operative functional capacity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03361150.

Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial.

Importance: Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes. Objective: To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation. Design, Setting, and Participants: This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019. Interventions: Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway. Main Outcomes and Measures: The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures. Results: Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups. Conclusions and Relevance: In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively. Trial Registration: ClinicalTrials.gov identifier: NCT02502760.

The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients.

INTRODUCTION: Treatment delay may have detrimental effects on cancer outcomes. The impact of longer delays on colorectal cancer outcomes remains poorly described. The objective of this study was to determine the effect of delays to curative-intent surgical resection on survival in colorectal cancer patients. METHODS: All adult patients undergoing elective resection of primary non-metastatic colorectal adenocarcinoma from January 2009 to December 2014 were reviewed. Treatment delays were defined as the time from tissue diagnosis to definitive surgery, categorized as < 4, 4 to < 8, and ≥ 8 weeks. Primary outcomes were 5-year disease-free (DFS) and overall survival (OS). Statistical analysis included Kaplan-Meier curves and Cox regression models. RESULTS: A total of 408 patients were included (83.2% colon;15.8% rectal) with a mean follow-up of 58.4 months (SD29.9). Fourteen percent (14.0%) of patients underwent resection < 4 weeks, 40.0% 4 to < 8 weeks, and 46.1% ≥ 8 weeks. More rectal cancer patients had treatment delay ≥ 8 weeks compared with colonic tumors (69.8% vs. 41.4%, p < 0.001). Cumulative 5-year DFS and OS were similar between groups (p = 0.558; p = 0.572). After adjusting for confounders, surgical delays were not independently associated with DFS and OS. CONCLUSIONS: Treatment delays > 4 weeks were not associated with worse oncologic outcomes. Delaying surgery to optimize patients can safely be considered without compromising survival.

A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial.

BACKGROUND: Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. METHODS: This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. RESULTS: In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52-66%) in the intervention group and 62% (95% CI 56-68%) in the control group [Adjusted mean difference 2.4% (95% CI - 5 to 10%) p = 0.53]. CONCLUSIONS: In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.

Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer.

BACKGROUND: High-quality surgery is essential for optimal oncologic outcomes in rectal cancer, but total mesorectal excision (TME) can be difficult for mid- and low rectal cancers. Preoperative identification of patients at risk for difficult TME may change the operative approach. The objective of this study was to determine if MRI pelvimetry can predict poor-quality surgery in patients undergoing laparoscopic low anterior resection (LAR) for mid- and low rectal cancer. METHODS: All patients undergoing laparoscopic LAR for rectal cancer ≤ 9 cm from the anal verge at a single tertiary care referral center from 2011 to 2017 were retrospectively reviewed. Pelvic dimensions were measured from preoperative staging MRI on sagittal and axial views. Pelvimetry variables were all dichotomized based on median values. Exploratory factor analysis then identified the most relevant variables for regression analysis. The primary outcome was poor-quality resection, defined as an incomplete mesorectal grade, or involved circumferential (CRM) or distal (DRM) resection margins. RESULTS: There were 92 patients included in this study, of which 70% were male, the mean BMI was 26.0 kg/m2, and the mean tumor height was 6.6 cm. Preoperative (chemo)radiotherapy was administered in 70%, and the pathologic T-stage was T3/T4 in 41%. The overall incidence of poor-quality resection was 17%, including 13% incomplete TME, 7% involved CRM, and 1% involved DRM. Factor analysis identified S1-pubic symphysis and the angle between S1 and S5-bottom of symphysis (angle ABD) as relevant variables. After adjusting for pathologic T-stage, BMI, and tumor height, a S1-S5-bottom of symphysis angle > 74.3° (OR 6.19, 95% CI 1.18-32.37) independently predicted poor-quality resection. CONCLUSIONS: MRI pelvimetry can identify patients at risk for a poor-quality resection after laparoscopic proctectomy for mid- and low rectal cancer. These patients may benefit from the selective use of more advanced access methods to improve surgical resection quality.

Intracorporeal versus extracorporeal anastomosis for right colectomy does not affect gastrointestinal recovery within an enhanced recovery after surgery program.

INTRODUCTION: Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program. METHODS: Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery. RESULTS: A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2-4] vs. 3 [IQR 3-5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71-1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)). CONCLUSION: In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

Cost-Effectiveness of Extended Thromboprophylaxis in Patients Undergoing Colorectal Surgery from a Canadian Health Care System Perspective.

BACKGROUND: There is increasing evidence to support extended thromboprophylaxis after colorectal surgery to minimize the incidence of postdischarge venous thromboembolic events. However, the absolute number of events is small, and extended thromboprophylaxis requires significant resources from the health care system. OBJECTIVE: This study aimed to determine the cost-effectiveness of extended thromboprophylaxis in patients undergoing colorectal surgery for malignancy or IBD. DESIGN: An individualized patient microsimulation model (1,000,000 patients; 1-month cycle length) comparing extended thromboprophylaxis (28-day course of enoxaparin) to standard management (inpatient administration only) after colorectal surgery was constructed. SETTINGS: The sources for this study were The American College of Surgeons National Surgical Quality Improvement Project Participant User File and literature searches. OUTCOMES: Costs (Canadian dollars), quality-adjusted life-years, and venous thromboembolism-related deaths prevented over a 1-year time horizon starting with hospital discharge were determined. The results were stratified by malignancy or IBD. RESULTS: In patients with malignancy, extended prophylaxis was associated with higher costs (+113$; 95% CI, 102-123), but increased quality-adjusted life-years (+0.05; 95% CI, 0.04-0.06), resulting in an incremental cost-effectiveness ratio of 2473$/quality-adjusted life-year. For IBD, extended prophylaxis also had higher costs (+116$; 95% CI, 109-123), more quality-adjusted life-years (+0.05; 95% CI, 0.04-0.06), and an incremental cost-effectiveness ratio of 2475$/quality-adjusted life-year. Extended prophylaxis prevented 16 (95% CI, 4-27) venous thromboembolism-related deaths per 100,000 patients and 22 (95% CI, 6-38) for malignancy and IBD. There was a 99.7% probability of cost-effectiveness at a willingness-to-pay threshold of 50,000$/quality-adjusted life-year. To account for statistical uncertainty around variables, sensitivity analysis was performed and found that extended prophylaxis is associated with lower overall costs when the incidence of postdischarge venous thromboembolic events reaches 1.8%. LIMITATIONS: Significant differences in health care systems may affect the generalizability of our results. CONCLUSIONS: Despite the rarity of venous thromboembolic events, extended thromboprophylaxis is a cost-effective strategy. See Video Abstract at http://links.lww.com/DCR/A976. COSTO-EFECTIVIDAD DE LA TROMBOPROFILAXIS EXTENDIDA EN PACIENTES SOMETIDOS A CIRUGÍA COLORRECTAL DESDE UNA PERSPECTIVA DEL SISTEMA DE SALUD CANADIENSE:: Cada vez hay más pruebas que apoyen la tromboprofilaxis extendida después de la cirugía colorrectal para minimizar la incidencia de eventos tromboembólicos venosos después del alta hospitalaria. Sin embargo, el número absoluto de eventos es pequeño y la tromboprofilaxis extendida requiere recursos significativos del sistema médico.Determinar la rentabilidad (relación costo-efectividad) de la tromboprofilaxis extendida en pacientes sometidos a cirugía colorrectal por neoplasia maligna o enfermedad inflamatoria intestinal.Un modelo de microsimulación de paciente individualizado (1,000,000 de pacientes; ciclo de 1 mes) que compara la tromboprofilaxis extendida (curso de enoxaparina de 28 días) con el tratamiento estándar (solo para pacientes hospitalizados) después de la cirugía colorrectal.Archivo de usuario participante del Proyecto de Mejoramiento de la Calidad Quirúrgica del Colegio Nacional de Cirujanos Americanos (ACS-NSQIP) y búsquedas bibliográficas.Costos (en dólares Canadienses), años de vida ajustados por la calidad y muertes relacionadas con el tromboembolismo venoso prevenidas en un horizonte temporal de 1 año a partir del alta hospitalaria. Los resultados fueron estratificados por malignidad o enfermedad inflamatoria intestinal.En pacientes con neoplasias malignas, la profilaxis extendida se asoció con costos más altos (+113 $; IC del 95%, 102-123), pero con un aumento de la calidad de vida ajustada por años de vida (+0.05; IC del 95%, 0.04-0.06), lo que resultó en un incremento de relación costo-efectividad de 2473 $/año de vida ajustado por calidad. Para la enfermedad inflamatoria intestinal, la profilaxis extendida también tuvo costos más altos (+116 $; 95% IC, 109-123), más años de vida ajustados por calidad (+0.05; 95% IC, 0.04-0.06) y una relación costo-efectividad incremental de 2475 $/año de vida ajustado por calidad. La profilaxis prolongada evitó 16 (95% IC, 4-27) muertes relacionadas con tromboembolismo venoso por cada 100,000 pacientes y 22 (95% IC, 6-38) por malignidad y enfermedad inflamatoria intestinal, respectivamente. Hubo un 99.7% de probabilidad de costo-efectividad en un límite de disposición a pagar de 50,000 $/año de vida ajustado por calidad. Para tener en cuenta la incertidumbre estadística en torno a los variables, se realizó un análisis de sensibilidad y se encontró que la profilaxis extendida se asocia con menores costos generales cuando la incidencia de eventos tromboembólicos venosos después del alta hospitalaria alcanza 1.8%.Las diferencias significativas en los sistemas de salud pueden afectar la generalización de nuestros resultados.A pesar de la escasez de eventos tromboembólicos venosos, la tromboprofilaxis extendida es una estrategia rentable. Vea el video del resumen en http://links.lww.com/DCR/A976.