Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial

Min et al. BMC Gastroenterology (2023) 23:127 https://doi.org/10.1186/s12876-023-02755-x BMC Gastroenterology Open Access RESEARCH Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial Jihee Min1,2, Ki-yong An3, Hyuna Park1, Wonhee Cho1, Hye Jeong Jung4, Sang Hui Chu4, Minsoo Cho5, Seung Yoon Yang5, Justin Y. Jeon1,6,7,8* and Nam Kyu Kim5* Abstract Background Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I–III colorectal cancer patients. Methods We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength). Results A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5–7 days) in the exercise group and 6.5 days (IQR 6–7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03). Conclusion Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery. Trial registration The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http:// apps.who.int/trialsearch); Trial number: KCT0003920. *Correspondence: Justin Y. Jeon Nam Kyu Kim Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Min et al. BMC Gastroenterology (2023) 23:127 Page 2 of 9 Keywords Exercise, Colectomy, Colorectal cancer, Post-operative, Length of stay, Patient-perceived readiness for hospital discharge Background Globally, colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death [1]. Surgery is the primary treatment for colorectal cancer. Colorectal cancer surgery is associated with a prolonged hospital stay, postoperative ileus, declined physical function, and possible surgical site infection [2, 3]. Laparoscopic surgery for colorectal cancer is practiced widely with patient benefits, including reduced hospital stay, earlier return of bowel function, better pulmonary function, and reduced morbidity compared to open surgery [4]. After laparoscopic surgery, primary care includes standardized perioperative practices known as an enhanced recovery program [5]. Research has suggested enhanced recovery programs (ERP)s may improve surgical outcomes and prevent complications, decrease hospital length of stay (LOS), reduce healthcare costs, and improve patient satisfaction [5–9]. While early mobilization may reduce LOS [10, 11], evidence of beneficial impacts of early mobilization on surgical outcomes is insufficient for guiding best clinical practices [5, 12–14]. Early mobilization protocols vary across studies [14–18]. For example, one protocol included being out of bed for > 8 h per day on postoperative day 1 [15], while another protocol included sitting on a chair for > 1 h per day with ambulation for > 400 m on postoperative day 1 [16]. Studies have also reported that walking as a postoperative mobilization strategy does not result in a significant reduction in LOS [17, 18]. Our previous work demonstrated patients who received tailored exercise programs, including stretching, strengthening, balance, and walking exercises, had a significantly shorter LOS (7.82 ± 1.07 vs. 9.86 ± 2.66 days) than those who did not [19]. The study had a small sample size and was performed without applying other components of ERP. Knowing that most clinics use some form of ERP, it was imperative to repeat the study with a large sample of participants who received an ERP. Since an ERP encourages a predetermined LOS for different surgeries, it was important also to assess the patient’s perceived readiness for hospital discharge. The primary objective of this randomized controlled trial was to examine the effect of postoperative inpatient exercise on LOS in patients who had undergone laparoscopic colorectal cancer surgery. The secondary objective was to examine the effect of postoperative exercise on patients’ perceived readiness for hospital discharge. Methods Study Design and participants This single-center randomized controlled trial was conducted at the Colorectal Cancer Clinic, a tertiary referral center in Seoul, Korea. We recruited participants between February 5, 2014 and September 23, 2016. Inclusion criteria were (1) stage I-III colon or rectal cancer; (2) 19–70 years of age; (3) American Society of Anesthesiologist grade ≤ 3 at surgery; and (4) the ability to read and understand Korean. Primary exclusion criteria included (1) evidence of recurrent or metastatic disease; (2) postsurgical intensive care unit stay; (3) presence of a stoma after colectomy; and (4) open surgery. All patients who met our inclusion criteria were app (...truncated)