Nationwide Prehabilitation Reduces Complications After CRC Surgery : JAMA Surg | May 2026

Introduction

Colorectal Cancer surgery remains associated with substantial postoperative morbidity despite advances in minimally invasive techniques and enhanced recovery pathways. Increasing attention has focused on prehabilitation strategies aimed at optimizing physical fitness, nutritional status and psychological resilience before surgery. However, prior prehabilitation studies have been limited by small sample sizes, selective enrollment and heterogeneous protocols, leaving uncertainty regarding real-world effectiveness at a national scale.

Problem Statement

Whether standardized multimodal prehabilitation improves postoperative outcomes in unselected colorectal cancer populations across diverse healthcare systems has remained unclear. Large implementation-based data evaluating broad clinical applicability have been lacking.

Summary

This nationwide multicenter Dutch cohort study evaluated the real-world impact of a standardized four-week supervised multimodal prehabilitation program among nearly 2,400 patients undergoing elective colorectal cancer resection across 18 hospitals. Patients participating in prehabilitation were propensity-score matched with historical controls to minimize baseline differences in operative and clinical risk factors.

The multimodal program incorporated high-intensity exercise training, nutritional optimization, psychological counseling and targeted management of comorbidities including anemia, frailty and smoking cessation. Importantly, the intervention was implemented broadly across unselected surgical candidates rather than only highly motivated or frail subgroups, enhancing generalizability.

Participation in prehabilitation was associated with significant reductions in overall postoperative complications. Both medical and surgical complications were reduced, with particularly notable decreases in nonsurgical medical morbidity. Hospital stay was shortened by approximately one day, while readmission and intensive care admission rates were also lower in the prehabilitation cohort.

One of the most clinically important observations was that benefit occurred consistently across age groups and ASA classifications. Older patients and those with higher perioperative risk derived similar improvements, suggesting that prehabilitation may improve physiologic reserve irrespective of baseline frailty or comorbidity burden.

Mechanistically, the findings support the concept that improving preoperative functional capacity enhances resilience against surgical stress responses. High-intensity exercise may improve cardiopulmonary reserve and metabolic flexibility, while nutritional optimization likely supports immune competence, wound healing and muscle preservation. Psychological support and smoking cessation may additionally reduce perioperative inflammatory and neuroendocrine stress pathways.

The study is particularly impactful because it demonstrates successful nationwide implementation of a uniform prehabilitation strategy within routine clinical practice rather than highly controlled experimental settings. This suggests that multimodal prehabilitation can be feasibly integrated into standard colorectal cancer care pathways at scale.

Importantly, the observed reduction in complications likely extends beyond simply lowering complication incidence. Enhanced physiologic reserve may also mitigate severity and improve recovery trajectories when complications occur, a concept increasingly recognized as central to perioperative oncology care.

The findings further reinforce the growing paradigm shift from procedure-centered surgery toward patient-centered physiologic optimization. As oncologic surgery becomes increasingly multidisciplinary, prehabilitation may emerge as a core component of perioperative cancer management alongside enhanced recovery protocols and minimally invasive techniques.

Overall, this large nationwide implementation study demonstrates that standardized multimodal prehabilitation is associated with meaningful reductions in postoperative morbidity and healthcare utilization after colorectal cancer surgery across broad patient populations. The results strongly support incorporation of structured prehabilitation programs into routine colorectal surgical oncology practice.