June's paper of the month looks at the effect of short-term exercise on recovery after colorectal cancer surgery.


What is known about the subject?
There has been increasing interest in the role of preoperative physical activity and prehabilitation in enhancing postoperative recovery and functional outcomes from major colorectal surgery. Prehabilitation is based on a structured exercise program preoperatively aiming to improve cardiovascular, respiratory, and muscular conditioning. Preoperative physical inactivity and functional capacity have been associated with postoperative recovery after colorectal cancer surgery. [1-4] Although there are international guidelines regarding prehabilitation before colorectal surgery, these recommendations are based on weak quality of evidence. [5] To date, evidence for an effect of prehabilitation in patients undergoing elective colorectal surgery on postoperative outcomes is uncertain.


What the study adds?
This was a randomized, parallel, open-label trial in six university or regional hospitals in Sweden. Patients older than 20 years undergoing elective colorectal cancer surgery were included in the study. Participants were randomized in two groups: one group with a physical activity intervention (involving aerobic activity and inspiratory muscle training 2 weeks preoperatively and 4 weeks after surgery) and a group receiving usual care. The primary outcome measure (based on intention-to-treat) was self-assessed physical recovery 4 weeks after surgery.

Participants in the intervention and control groups were balanced in terms of demographic factors, treatments, and tumour stage. After exclusions, 668 participants (317 participants in the interventional group and 351 in the control group) were included in the primary analysis. There was no effect from the intervention on the primary outcome measure (adjusted odds ratio 0.84, 95% confidence interval 0.62–1.15) with 13% of participants in the interventional group and 15% of participants in the control group feeling fully recovered physically. There were no reported adverse events. Furthermore, no differences were reported between the groups for incidence or type of complications at 30 or 90 days postoperatively, length of hospital stay or re-admissions within 90  days postoperatively.


Implications for colorectal practice
There was no effect from a physical activity intervention before and after colorectal cancer surgery on short-term self-assessed physical recovery. The results from this study call for reconsiderations regarding current recommendations for preoperative physical activity interventions.



  1. Onerup A, Angenete E, Bonfre P, et al.. Self-assessed preoperative level of habitual physical activity predicted postoperative complications after colorectal cancer surgery: a prospective observational cohort study. Eur J Surg Oncol 2019; 45:2045–2051
  2. Onerup A, Bock D, Borjesson M, et al.. Is preoperative physical activity related to post-surgery recovery?-a cohort study of colorectal cancer patients. Int J Colorectal Dis 2016; 31:1131–1140
  3. West MA, Asher R, Browning M, et al.. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016; 103:744–752
  4. Wilson RJT, Yates DRA, Walkington JP, et al.. Ventilatory inefficiency adversely affects outcomes and longer-term survival after planned colorectal cancer surgery. Br J Anaesth 2019; 123:238–245
  5. Gustafsson UO, Scott MJ, Hubner M, et al.. Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS((R))) society recommendations: 2018. World J Surg 2019; 43:659–695


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