Preoperative optimisation for colorectal cancer

In this episode of PodMD, specialist colorectal surgeon Dr Suat Chin Ng will be discussing the topic of preoperative optimisation and prehabilitation for colorectal patients, including a brief overview about these areas, why they are important, which group of patients would benefit the most, the role a GP plays in the process and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Suat Chin Ng

    Dr. Suat Chin Ng is a specialist colorectal surgeon treating patients in the Eastern suburbs of Melbourne.

    Dr Suat Chin Ng is one of the few female colorectal surgeons in Melbourne who is a member of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and member of the Section of Colorectal Surgery of the Royal Australasian College of Surgeons (RACS). She attained her General Surgical Fellowship of the RACS in 2018 and completed a Masters degree in Colorectal Surgery.

    Today, we’ll be discussing the topic of preoperative optimisation for colorectal cancer

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Suat Chin, thanks for talking with us on PodMD today.

    Suat Chin: Thank you for having me.

    Question 1
    The topic of today’s discussion is preoperative optimisation and prehabilitation for colorectal patients. Suat Chin, can you describe for our listeners what this is?

    Suat Chin: Optimization refers to the assessment and intervention that’s used in preoperative phase to improve surgical recovery and outcomes, whereas the concept of rehabilitation is a relatively new development, you can pretty much see it as an extension of the standard preoperative optimization. It’s essentially an intervention that capitalises on the waiting period before surgery, with pre-OP strategies designed to optimise the patient’s condition to enhance surgical recovery.

    Question 2
    Why is this important?

    Suat Chin: Well, prehabilitation strategies basically aims to reduce surgical morbidity. It also speeds up recovery and reduces the length of stay of patients post major colorectal surgery. It does so via mechanisms aiming to reduce pre OPS stresses as well as to maintain the physiological function of patients.

    Question 3
    Which group of patients would benefit from pre-op optimisation + prehabilitation?

    Suat Chin: Unfortunately, the time sensitive nature of emergency colorectal surgery does not lend itself to extensive pre-op optimization. So really, the patients most likely to benefit from pre OP optimization are elective patients who are undergoing colonic resection will often have multiple medical comorbidities. Those whom we consider as high-risk patients where they would also tend to have malnutrition and ,anaemia due to reasons of their underlying malignancy, chronic flare up from their inflammatory bowel disease or complicated diverticulitis with recurrent infections.

    And another obvious group of patients to target are those with advanced colorectal malignancies, who require a period of neural driven therapy, and these patients would have a decent waiting period before surgeries perform, giving us an opportunity to instil intervention. Last but not least, the elderly group of patients, and in this specific group of patients usually are tailored, supervised programme in the home of the patient, may be required such that GP referral to allied health would be necessary to increase their compliance.

    Question 4
    What role does the GP play in this process?

    Suat Chin: I think the GP actually plays an important role here because preoperative optimization can often be initiated by the GP in the community quite early in the pace when they see patients with potential malignancies, with recurrent attacks from their diverticulitis or known inflammatory bowel disease. The assessment and intervention classically, can be divided into 3 areas.

    Firstly, performing risk assessment and medical optimization, I feel that this is probably what the GP would do routinely anyway, preoperative risk assessment is intuitive and it’s very important. Patients with medical comorbidities should have their existing disease optimised as the outcomes have been shown to be worse in those with unchecked comorbidity. Particularly those with diabetes, anaemia, hypertension and congestive heart failure. Importantly, advice should be given to stop smoking and alcohol, ideally immediately, but I know that this is not easy. Patients often find it very difficult, but we should still persist in advising them to stop. At least four weeks preoperatively, especially if the GP’s predict that the patients are likely to need surgery at some stage.

    Secondly, screening for malnutrition, there are several screening tools out there that are validated for use. Such as the malnutrition universal screening tool, MUST for short. Nutritional risk screening tool, NRS for short, and sometimes preoperative albumin can be used as an adjunct. Once malnutrition is identified, the GP can commence Antero supplementation such as Fortisip or Ensure and referral to dietitian can be made in conjunction. These supplements are actually quite easy to prescribe and has the best effect when start at 5 to 10 days preoperatively. You must know that there’s actually a lot of evidence showing reduction, particularly in infectious complications, including anastomotic leak once malnutrition is corrected.

    Lastly, anaemia. Aneamia is very common in colorectal cancer, inflammatory bowel disease and patients with recurrent infections. So you should really be corrected when identified. We know that allogenic red cell transfusion is associated with adverse clinical outcomes, including potential recurrences in colorectal cancer. Thus it should be avoided when it’s feasible. Nowadays we have the newer preparation of iron infusion, for example Ferrinject. It’s usually given over dosage of 1 gramme and have an extremely low risk of adverse events and is effective in restoring the iron levels in the colorectal cohort as well as improving their anemia.

    Question 5
    What is the rationale for preoperative optimisation and prehabilitation?

    Suat Chin: Basic science underpinning the approach to modernise perioperative care was established in the early 20th century. I think it was probably in 1930s that Sir Cuthbertson described the ebb in a flow metabolic response to trauma of surgery where the hyper metabolic state is initiated during surgery in an attempt to maintain homeostasis and ensure recovery, although initially beneficial, after a prolonged inflammatory catabolic response would ultimately increase the clinical complications, delay patient recovery and increase mortality. The idea of attenuating the body’s response to surgical trauma has therefore attracted surgical research for a century or so, and the development and implementation of ERAS since I think early 1990s has helped patients reduce physiological stress and expedite recovery. Therefore, becoming an established component of corrective surgery.

    Now, while compliance with the US has resulted in reduced complications, there remains a significant functional burden. I know of a large study, it reported that up to approximately 40% of patients who have undergone colorectal cancer surgery despite having gone through ERAS were found not to have functionally recovered to their baseline een after two months. So the awareness of this problem has caused a conceptual shift from attempting to restore function postoperatively as you would expect to see in our rehab facilities at current, towards a more preventative type of strategy and such strategies have the potential to result in faster recovery of things, physical function and a reduction in postoperative complications, length of stay and direct and indirect healthcare cost.

    Question 6
    What are the prehabilitation components?

    Suat Chin: There are again 3 components to rehabilitation as this is an extension of preoperative optimization. You may find that some of these may overlap.

    Firstly exercise. Exercise delivers a physiological stressor to the tissue that causes an adaptive response in the patient, which improves their ability for the patient then to withstand the upcoming surgery, improve cardiorespiratory fitness also increases their capacity for meeting the additional oxygen requirement placed upon them usually by the colorectal cancer itself or the neural juvenile adjuvant therapies themselves. So advice to exercise preoperatively, can be provided by the GP. We generally recommend approximately 150 minutes per week, probably every second day or so, up to 50 to 75% maximal predicted heart rate. Half an hour per session, combining aerobic resistance and flexible training. But of course, if we’re talking about an elderly comorbid patient, the intensity and the duration of the exercise may need to be modified. Sometimes even simpler advice such as 20 to 30 minutes of walk a day should suffice in certain patients, as the good old saying goes, doing something is better than nothing.

    Secondly, nutritional support. Other than using the nutritional assessment tools previously mentioned, the practical prompt for nutritional intervention is when the patient loses approximately more than 10% of their total body weight, dietitian referral by the GP and commencement of oral nutritional supplements is very important to reduce post operative morbidity and mortality.

    Thirdly, psychological support. I feel that the importance of education in counselling preoperatively are often understated, be it in the Community or in a hospital setting. It’s important to note that psychological support has been shown in randomised controlled trials and in Cochrane analysis to have positive impact on length of stay and postoperative outcomes.

    So what can we do about this? A few things can be initiated by the GP in the community for this, but firstly I’d like to share that a statistic there’s probably worth noting, preoperative psychiatric diagnosis are reported to be present in approximately 15% of patients with colorectal cancer and are associated with worse postoperative outcome. So I feel that mental health diagnosis should be addressed if possible prior to surgery. Education on the disease and psychological support in the form of providing skills to reduce patient anxiety and improve coping mechanisms in the time leading up to surgery are all important techniques. Sometimes early referral to psychologists or psychiatrists may be necessary.

    Question 7
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Suat Chin: There has been a growing body of evidence investigating prehabilitation in the context of abdominal surgery, and in particular in colorectal surgery. The most recent systematic reviews on prehabilitation in major abdominal surgery and in abdominal cancer surgery in particular has found a significant reduction in postoperative lung complications, morbidity and length of stay, as well as an improvement in the preoperative function respect. In terms of ongoing trials, there’s a large international, multicentre, randomised controlled trial at current that is evaluating multimodal prehabilitation within an ERAS programme for patients undergoing colorectal surgery. Their results are very much anticipated by the colorectal craft group in Australia and New Zealand.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on preoperative optimisation for patients needing major colorectal surgery?

    Suat Chin: Three take home messages. Let’s see.

    I think firstly, preoperative optimization can start at the community with GPs focusing on optimising patient comorbidities, screening and commence simple intervention for malnutrition and anaemia, especially in colorectal patients with malignancies, inflammatory bowel disease and complex diverticulitis with recurrent and infection.

    Secondly, Prehabilitation is an extension in the field of preoperative optimization. The three components involve exercise, nutrition, and psychological support. All of which may require a further referral to our allied health counterparts, namely the physiotherapist, dietician and psychologist.

    And finally, the target group of patients for preoperative optimization and prehabilitation are the elderly, the high risk patients and the patients needing neuro driven therapy.

    Thanks for your time and the insights you’ve provided.

    Suat Chin: Thank you so much for everyone’s time

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.