Comparative effectiveness of preoperative prehabilitation modalities for postoperative recovery in colorectal cancer: A systematic review and network meta-analysis.

BACKGROUND

Preoperative prehabilitation has been increasingly incorporated into perioperative care for colorectal cancer (CRC), yet the comparative effectiveness of different prehabilitation modalities remains unclear. This study aimed to compare the relative effects of major preoperative prehabilitation models on postoperative recovery in patients who undergo surgery for CRC.

METHODS

A systematic review and network meta-analysis (NMA) were conducted by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to March 31, 2026. Randomized controlled trials enrolling adults with CRC scheduled for elective curative surgery were eligible if they evaluated structured preoperative prehabilitation and reported at least 1 relevant postoperative outcome. Interventions were classified as exercise-only prehabilitation (EX), nutrition-only prehabilitation (NU), combined exercise plus nutrition prehabilitation (EX+NU), multimodal prehabilitation combining exercise, nutrition, and psychological support (EX+NU+PSY), or usual care (UC). The primary outcome was postoperative 6-minute walk distance (6MWD). Secondary outcomes included length of hospital stay (LOS), readmission within 30 days, adverse events (AEs), serious AEs (SAEs), quality of life (QoL), anxiety, and depression. Pairwise meta-analyzes were first performed to evaluate the overall effect of prehabilitation vs UC, followed by NMA to compare the relative effects of different prehabilitation modalities. Continuous outcomes were summarized as standardized mean differences (SMDs) with 95% CIs, and dichotomous outcomes were summarized as odds ratios (ORs) with 95% CIs.

RESULTS

A total of 22 randomized controlled trials involving 1545 patients were included. In the pairwise meta-analysis, preoperative prehabilitation significantly improved postoperative 6MWD compared with UC (SMD, 0.18; 95% CI, 0.05-0.31; I²= 5.0%). In the NMA, EX+NU+PSY ranked the highest for 6MWD and was superior to UC (SMD, 0.24; 95% CI, 0.02-0.46). No significant overall effects were observed for LOS (SMD, -0.06; 95% CI, -0.28 to 0.16), readmission within 30 days (OR, 0.94; 95% CI, 0.53-1.67), AE (OR, 0.85; 95% CI, 0.67 to 1.06), or SAE (OR, 0.89; 95% CI, 0.53-1.51). Evidence regarding QoL, anxiety, and depression was limited.

CONCLUSION

In patients undergoing surgery for CRC, the most consistent benefit of preoperative prehabilitation was improved postoperative functional recovery, with EX+NU+PSY showing the most favorable effect on 6MWD. The current evidence does not support consistent benefits for LOS, readmission, or postoperative complications across prehabilitation modalities.