Implementation of the Pre-operative Rehabilitation Recovery Protocol and Its Effect on the Quality of Recovery After Colorectal Surgeries
Colorectal cancer and other benign diseases are the primary causes of colorectal surgery worldwide. The surgical wound of the intestine and peri-operative stress often result in pain and delayed recovery of gastrointestinal (GI) function. Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve patients’ prognosis, satisfaction, and shorten hospital stays compared to conventional care. ERAS facilitates minimally invasive surgery, mitigates surgery-related stress, provides nutritional support, and employs multimodal analgesia, contributing to superior outcomes. Despite these advancements, post-operative gastrointestinal dysfunction (POGD) remains a common morbidity, leading to prolonged hospital stays. To address this, a novel enhanced recovery protocol based on pre-operative rehabilitation was implemented, and its effects were explored in this study.
The study aimed to minimize the side effects of peri-operative surgical stress and accelerate patients’ recovery of GI function and quality of life after colorectal surgeries. A prospective randomized controlled clinical trial was conducted from January 2018 to September 2019 at the First Affiliated Hospital of Chongqing Medical University. Patients scheduled for elective colorectal surgeries were randomly allocated to either the standardized enhanced recovery after surgery (S-ERAS) group or the enhanced recovery after surgery based on pre-operative rehabilitation (PR-ERAS) group. The PR-ERAS group received formatted rehabilitation exercises pre-operatively in addition to the standard ERAS strategies.
The primary outcome was the quality of GI recovery measured using the I-FEED scoring system. Secondary outcomes included quality of life scores, strength of handgrip, and the incidence of adverse events up to 30 days post-operatively. A total of 240 patients were screened, and 213 eligible patients were enrolled, with 104 in the S-ERAS group and 109 in the PR-ERAS group.
The results showed that the percentage of normal recovery graded by I-FEED scoring was higher in the PR-ERAS group (79.0% vs. 64.3%, P < 0.050). The subscores of life ability and physical well-being at 72 hours post-operatively were significantly improved in the PR-ERAS group using the quality of recovery score (QOR-40) questionnaire (P < 0.050). The strength of handgrip post-operatively was also improved in the PR-ERAS group (P 0.050).
The study concluded that peri-operative rehabilitation exercise might be another beneficial factor for early recovery of GI function and quality of life after colorectal surgery. The findings suggest that newer, more surgery-specific rehabilitation recovery protocols merit further exploration for these patients.
The pre-operative rehabilitation exercise program in the PR-ERAS group included strengthening of the upper and lower extremities, thoracic and abdominal breathing exercises, and exercise of abdominal muscles. Patients were encouraged to perform these exercises twice daily, with 10 to 15 repetitions of each movement. The intensity of exercise was individualized based on patients’ tolerance, and compliance was monitored daily by a rehabilitation therapist.
The I-FEED scoring system classified the early recovery of GI function into three grades: normal (score 0-2), post-operative gastrointestinal intolerance (POGI, score 3-5), and post-operative gastrointestinal dysfunction (POGD, score ≥6). The PR-ERAS group showed a higher percentage of normal recovery and a lower incidence of POGI compared to the S-ERAS group. However, no significant difference was observed in the incidence of POGD between the two groups.
Quality of life was assessed using the QOR-40 questionnaire, which provided a total score and subscores in five dimensions: patient support, comfort, emotions, life ability, and physical well-being. At 72 hours post-operatively, the PR-ERAS group showed significant improvements in life ability and physical well-being subscores compared to the S-ERAS group. No significant differences were observed in the other dimensions at 30 days post-operatively.
Handgrip strength was measured using a hydraulic dynamometer. The PR-ERAS group demonstrated stronger handgrip strength post-operatively compared to the S-ERAS group. This improvement in muscle strength may contribute to better functional recovery and quality of life after surgery.
The incidence of major post-operative complications, including bowel-related and non-bowel-related adverse events, was similar in both groups up to 30 days post-operatively. The total length of hospital stay was also comparable between the two groups, with no significant difference observed.
The study’s findings suggest that pre-operative rehabilitation exercise can accelerate the early recovery of GI function and improve the quality of life after colorectal surgery. The exercise program, which included dynamic, isometric, and resistance exercises, may pre-condition the mesenteric flow to surgical stress, reduce the risk of impaired anastomotic blood supply, and promote subsequent healing. Additionally, the exercise program improved patients’ cardiorespiratory function and muscle strength, contributing to better functional recovery.
However, the study had some limitations. It did not quantify changes in mesenteric flow or measure serum markers of colon inflammation. The strength of other core muscles, such as respiratory and abdominal muscles, was not investigated. Tumor grading and pre-operative chemotherapy, which could be confounding factors, were not evaluated. The effectiveness and safety of the prehabilitation-based enhanced recovery protocol in open colorectal surgery remain to be assessed.
In conclusion, the pre-operative rehabilitation recovery protocol helped accelerate early recovery of GI function and improve the quality of life after colorectal surgery. The findings highlight the potential benefits of incorporating pre-operative rehabilitation exercises into the ERAS protocol. Further research is warranted to design and explore optimal rehabilitation recovery protocols for improving patients’ short-term and long-term recovery after colorectal surgery.
doi.org/10.1097/CM9.0000000000001709
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