Association of Prehabilitation With Postoperative Opioid Use in Colorectal Surgery: An Observational Cohort Study.

INTRODUCTION: Preoperative optimization programs have demonstrated positive effects on perioperative physical function and surgical outcomes. In nonsurgical populations, physical activity and healthy diet may reduce pain and pain medication requirement, but this has not been studied in surgical patients. Our aim was to determine whether a preoperative diet and exercise intervention affects postoperative pain and pain medication use. METHODS: Patients undergoing abdominal colorectal surgery were invited to participate in a web-based patient engagement program. Those enrolling in the first and third time periods received information on the standard perioperative pathway (enhanced recovery after surgery [ERAS]). Those enrolling in the second time period also received reminders on nutrition and exercise (PREHAB + ERAS). The primary outcome was postoperative inpatient opioid use. The secondary outcomes were inpatient postoperative pain scores and nonopioid pain medication use. RESULTS: The ERAS and PREHAB + ERAS groups were similar in demographic and operative characteristics. Subgroup analysis of patients who activated their accounts demonstrated that the two groups had similar average maximum daily pain scores, but the PREHAB + ERAS group (n = 158) used 15.9 fewer oral morphine equivalents per postoperative inpatient day than the ERAS group (n = 92), representing a 30% decrease (53 mg versus 37.1 mg, P = 0.04). The two groups used comparable amounts of acetaminophen, gabapentin, and ketorolac. Generalized linear models demonstrated that PREHAB + ERAS, minimally invasive surgery, and older age were associated with lower inpatient opioid use. CONCLUSIONS: Access to a web-based preoperative diet and exercise program may reduce inpatient opioid use after major elective colorectal surgery. Further studies are necessary to determine whether the degree of adherence to nutrition and physical activity recommendations has a dose-dependent effect on opioid use.

Barriers and Facilitators of Surgical Prehabilitation Adherence from the Patient Perspective: a Mixed Method Study.

BACKGROUND: Adherence to prehabilitation is crucial for optimal benefit, but reasons for low adherence to home-based programs remain unexplored. Our aim was to identify and explore barriers and facilitators to prehabilitation adherence among patients undergoing abdominal surgery. METHODS: Nested in a single-center randomized controlled trial on prehabilitation (Perioperative Optimization With Enhanced Recovery (POWER)), this study had an explanatory sequential design with a connect integration. Patients randomized to the intervention arm were included in the quantitative analysis, and a subset of them was invited for a semi-structured interview. The exposure was the frequency of barriers to physical activity and healthy eating, and the outcome was adherence to those components of prehabilitation. Logistic or linear regression was used as appropriate. RESULTS: Among 133 participants in the intervention arm, 116 (87.2%) completed the initial survey ((56.9% women, median age 61 years old (IQR 49.0; 69.4)). The most frequent barriers to exercise and healthy eating were medical issues (59%) and lack of motivation (31%), respectively. There was no significant association between the barriers to physical activity score and adherence to this component of the program (OR 0.89, 95% CI 0.78-1.02, p=0.09). Higher barriers to healthy eating scores were associated with lower Mediterranean diet scores pre- and post-intervention (coef.: -0.32, 95% CI: -0.49; -0.15, p<0.001; and coef.: -0.27, 95% CI: -0.47; -0.07, p=0.01, respectively). Interviews with 15 participants revealed that participating in prehabilitation was a motivator for healthy eating and exercising through goal setting, time-efficient workouts, and promoting self-efficacy. CONCLUSIONS: We identified key barriers to be addressed and facilitators to be leveraged in future prehabilitation programs. TRIAL REGISTRATION: NCT04504266.