Identifying Patients with Colorectal Cancer Likely to Benefit from a Trimodal Prehabilitation Prior to Surgery

Introduction: While enhanced recovery after surgery (ERAS) programs are widely implemented to reduce postoperative complications of colorectal cancer surgery, evidence for trimodal prehabilitation is inconsistent. We compared prehabilitation+ERAS versus ERAS alone, and explored patient subgroups most likely to benefit from targeted prehabilitation. Methods: A prospective, single-center parallel cohort study was conducted from October 2017 to August 2022. Consecutive adults undergoing elective colorectal surgery received ERAS alone or a 3-6-week trimodal prehabilitation programme (nutritional optimization, aerobic training, psychological preparation), followed by ERAS. Primary outcomes were overall postoperative morbidity at 7 and 30 days. Secondary outcomes included mortality, severe morbidity (Clavien-Dindo ≥ 3), 30-day readmission, and ICU/ward length of stay. Results: Of 344 screened patients, 244 were analyzed (ERAS n = 104; prehabilitation n = 140) with comparable baseline characteristics. Prehabilitation improved 6 min walk distance and incentive spirometry FVC by the time of surgery (p < 0.001 and p = 0.001, respectively), but between-group differences were not sustained at 8 weeks. Overall 7- and 30-day morbidity and mortality, severe morbidity, 30-day readmission, and length of stay did not differ between cohorts. In exploratory subgroup analyses, myosteatosis was associated with higher 7- and 30-day morbidity in the ERAS cohort (7% vs. 28% and 11.6% vs. 40%, respectively), whereas this contrast was not observed under prehabilitation. Among myosteatotic patients, prehabilitation was associated with lower 7-day morbidity (p = 0.045). Frailty was associated with severe morbidity, irrespective of allocation. Discussion: Trimodal prehabilitation improved preoperative functional measures but did not reduce short-term complications overall. CT-defined myosteatosis may help target prehabilitation to higher-risk patients.