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Comment & Response
June 17, 2020

Prehabilitation vs Postoperative Rehabilitation for Frail Patients

Author Affiliations
  • 1Department of Anesthesia, McGill University, Montreal, Quebec, Canada
  • 2Department of Surgery, McGill University, Montreal, Quebec, Canada
JAMA Surg. Published online June 17, 2020. doi:10.1001/jamasurg.2020.1816

In Reply We appreciate the opportunity to reply to the comments regarding our article1 on prehabilitation for frail patients undergoing colorectal cancer resection. These comments reflect a growing and enthusiastic interest in improving the quality of surgical care using prehabilitation.

Despite semantic differences in the description of study aims between our protocol and the article published in JAMA Surgery,1 our trial was clearly intended to be a confirmatory superiority trial and was powered as such. The effect size used for power calculation was based on a study2 from the developers of the Comprehensive Complication Index supporting that trials measuring Comprehensive Complication Index should target a between-group differences of 10 points because this reflects a meaningful difference of 1 grade in the Clavien-Dindo classification.2 The literature does not support that this effect size is overoptimistic or unrealistic. As with any single-center trial, our results are only generalizable to contexts of care that are similar to our study setting. We would like to reiterate that the enhanced recovery pathway and high prevalence of laparoscopic surgery at our center may have contributed to attenuating surgical stress, thus minimizing the effect of prehabilitation on postoperative outcomes. To increase generalizability of findings, we agree that a multicenter randomized trial with a clustered design is an interesting venue for future prehabilitation research. We do not agree that the quality control of our trial was questionable owing to patients’ potential cognitive decline because we excluded patients with neurological and mental comorbidities that could impair exercise and fitness assessments.

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