Effect of multidisciplinary prehabilitation-rehabilitation on outcomes after colorectal surgery in elderly patients

Objective. To determine the effect of the start-to-finish programme by comparing outcomes of elderly patients who underwent colorectal surgery before and after introduction of the programme. Methods: Data of consecutive patients aged ≥75 years who underwent major colorectal surgery (open, minimally invasive, elective, or emergency) between February 2007 and November 2015 at our institution were collected prospectively. Postoperative outcomes of patients were compared before and after the July 2013 introduction of the start-to-finish programme. Patients were risk-stratified for decision on whether prehabilitation was required, based on frailty syndrome, weighted Charlson Comorbidity Index, and ambulatory status. Frailty was defined as presentation of three or more of the following criteria: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. Outcome measures included discharge destination, functional decline in terms of a loss of ≥10 points in the Barthel Index at postoperative week 6, length of hospital stay, postoperative complication in terms of a Clavien-Dindo score of ≥3, and 30-day mortality. Results: A total of 121 geriatric patients were recruited and followed up for a mean duration of 36 months. Of whom, 49 (40.1%) were recruited after the introduction of start-to-finish programme in July 2013. 34 (28.1%) of the 121 patients were determined to be frail. In multivariate analysis, frailty was the only predictor of discharge destination (odds ratio [OR]=6.067, p=0.001). Patients with a Clavien-Dindo score of ≥3 were more likely to have functional decline at postoperative week 6 (OR=83.926, p=0.003). The start-to-finish programme (OR=0.067, p=0.023) and elective surgery (OR=0.091, p=0.024) were associated with maintenance of functional. Frailty was associated with discharge to facilities other than home (OR=6.067, p=0.001) and a steeper decline on longer-term follow-up. Conclusion: The start-to-finish programme had a positive effect on reducing functional decline after colorectal surgery. Frail patients and patients with major complications require special attention to mitigate the steep functional decline.