December’s Paper of the Month’ aimed to assess associations between modifiable preoperative lifestyle factors and postoperative complications in patients undergoing elective surgery for colorectal cancer.

The Association Between Modifiable Lifestyle Factors and Postoperative Complications of Elective Surgery in Patients with Colorectal Cancer
doi: 10.1097/DCR.0000000000001976
Diseases of the Colon & Rectum: November 2021 – Volume 64 – Issue 11 – p 1342-1353

What is known about this subject?

The use of ‘prehabilitation’ is gaining traction as a means to preoperatively increase a patient’s functional capacity before elective colorectal cancer surgery. The aim of this intervention is to reduce postoperative morbidity and accelerate postsurgical recovery. Through prehabilitation, modifiable risk factors for an individual patient are addressed. These factors may include smoking status, nutrition, alcohol consumption and physical exercise.


Retrospective analysis of data from a prospectively maintained database. The study was undertaken as part of the Colorectal cancer: Longitudinal, Observational study on Nutritional and lifestyle factors that influence colorectal tumour recurrence, survival and quality of life” (COLON) study


Patients with newly diagnosed colorectal cancer undergoing elective surgery at 11 Dutch hospitals from August 2010 and December 2018

Those who had a history of previous CRC, other bowel resection, chronic IBD, a hereditary CRC syndrome, dementia, undergoing transanal surgery or hyperthermic intraperitoneal chemotherapy were excluded.

Methods and outcomes

Patients completed self-administered questionnaires shortly after diagnosis regarding their smoking status, alcohol consumption, BMI and physical activity.

Data on postoperative outcomes were collected from the Dutch Colorectal Audit.

The authors used multivariable logistic regression to identify which preoperative lifestyle factors were associated with postoperative complications.

Primary outcome

Occurrence of postoperative complications after elective CRC surgery. Complications were recorded up to 30 days (pre-2018) or 90 days (post-2018).

Secondary outcome

The secondary outcome was length of stay.


  • 1564 patients were studied (68.9% colon cancer, 31.1% rectal cancer)
  • 87.2% were classified as ASA I or II
  • 446 patients (28.5%) experienced 1 or more postoperative complication.
  • Complication increased length of stay (12 vs 5 days, p < 0.001)
  • Current smoking (vs never smoking) was associated with postoperative complications (OR, 1.62; 95% CI, 1.02–2.56; p = 0.04)
  • BMI, alcohol consumption, and physical activity were not independently associated with postoperative complications in general
  • Among ASA class III to IV physical activity >1000 min/wk was independently associated with a reduced risk of postoperative complications (OR, 0.17; 95% CI, 0.03–0.87; p = 0.04) compared with <150 min/wk

Implications for colorectal practice?

This paper highlights the effect of smoking status on the risk of postoperative complication in elective CRC surgery. This finding serves to reinforce the need to encourage smoking cessation among newly diagnosed CRC patient. Interestingly, despite the authors hypothesis other factors such as increasing BMI and alcohol consumption showed no association.

The study was observational and did not measure the effect of modifying these named risk factors on patient outcome. It must also be acknowledged that risk factors were self-reported by patients and are reliant on the accuracy of this.

Given the results, it would be interesting to measure the effect of preoperative smoking cessation in this cohort, particularly when factoring the pressures of cancer waiting targets.