Preoperative prehabilitation within enhanced recovery after surgery for postoperative frailty and functional recovery following laparoscopic colorectal cancer resection

Abstract

BACKGROUND

The incidence of postoperative frailty is elevated among patients undergoing laparoscopic colorectal cancer surgery. However, enhanced recovery after surgery (ERAS)-based preoperative interventions are frequently limited to health education and dietary advice, and adherence to prehabilitation protocols is poor, creating a need for structured and quantifiable perioperative intervention strategies.

AIM

To evaluate the effect of an ERAS-based preoperative prehabilitation management model, delivered through a mobile application, on postoperative frailty and functional recovery in patients undergoing laparoscopic colorectal cancer resection.

METHODS

This was a single-center, two-arm, parallel-group, assessor-blinded, superiority randomized controlled trial with a 1:1 allocation ratio. A total of 182 patients with colorectal cancer admitted to our hospital between October 2023 and October 2025 were enrolled and randomly assigned to a control group and an experimental group (n = 91 each) using a random number table. The control group received conventional ERAS perioperative management, whereas the experimental group received an ERAS-based preoperative prehabilitation management model combining structured exercise training, nutritional support, psychological intervention, and remote monitoring via a mobile application from admission until the day before surgery (≥ 14 days). The prespecified primary outcome was the incidence of postoperative frailty at 6 months after surgery. Secondary outcomes included Fried frailty scores, gastrointestinal recovery, mobility, inflammatory markers, quality of life, and postoperative complications.

RESULTS

All 182 randomized patients completed the study and were analyzed. At 1 month, 3 months, and 6 months postoperatively, Fried scores were lower in the experimental group than in the control group (P < 0.05). The incidence of frailty at 6 months postoperatively was 9.89% (9/91) in the experimental group vs 20.88% (19/91) in the control group [relative risk (RR): 0.47, 95% confidence interval (CI): 0.23-0.99; risk difference (RD): -11.0%, 95%CI: -21.4% to -0.6%]. In the experimental group, the time to return of bowel sounds [mean difference (MD): -4.49 hours, 95%CI: -6.30 to -2.68], time to first flatus (MD: -3.66 hours, 95%CI: -6.23 to -1.09), time to first bowel movement (MD: -3.51 hours, 95%CI: -5.93 to -1.09), time to first oral intake (MD: -4.07 hours, 95%CI: -6.91 to -1.22), and postoperative length of hospital stay (MD: -1.50 days, 95%CI: -2.13 to -0.87) were all shorter than in the control group (P < 0.05). At 1 month and 6 months postoperatively, the experimental group's 6-minute walk test and Berg Balance Scale scores were higher than those of the control group (P < 0.05). At 7 days postoperatively, serum interleukin-6, tumor necrosis factor-α, and interferon-γ levels were lower in the experimental group than in the control group (P < 0.05). At 6 months postoperatively, scores for all dimensions of the Functional Assessment of Cancer Therapy-Colorectal were higher in the experimental group (P < 0.05). The incidence of postoperative complications was 2.20% (2/91) in the experimental group vs 9.89% (9/91) in the control group (RR: 0.22, 95%CI: 0.05-1.00; Fisher's exact P = 0.058; χ² test P = 0.029).

CONCLUSION

In this single-center randomized trial, an ERAS-based preoperative prehabilitation management model was associated with less postoperative frailty, faster gastrointestinal and motor recovery, attenuated inflammatory responses, and better quality of life after laparoscopic colorectal cancer surgery. These findings require confirmation in prospectively registered, multicenter trials with longer follow-up before broader implementation can be recommended.

Key Words: Colorectal neoplasms; Enhanced recovery after surgery; Prehabilitation; Frailty; Laparoscopy; Mobile applications; Randomized controlled trial

Core Tip: This study focuses on patients undergoing laparoscopic colorectal cancer surgery, establishing a preoperative prehabilitation model centered on exercise and facilitated by a mobile application, with conventional enhanced recovery after surgery (ERAS) management serving as the control. The study specifically examines the impact of this model on the incidence of frailty, recovery of gastrointestinal function, physical performance, inflammatory markers, quality of life, and complications at 1 month, 3 months, and 6 months post-surgery. Through multidimensional quantitative interventions and comprehensive remote monitoring, the study aims to clarify the efficacy and mechanisms of the prehabilitation model, with the goal of optimizing ERAS perioperative management, addressing limitations in traditional interventions, and providing an evidence-based foundation for clinical rehabilitation.

INTRODUCTION

Colorectal cancer is a highly prevalent malignant tumor of the digestive tract, with age-standardized incidence and mortality rates as high as 26.7 per 100000 and 13.7 per 100000, respectively[1]. Laparoscopic radical resection is the mainstream treatment; however, postoperative frailty, gastrointestinal dysfunction, and reduced mobility are common and can substantially delay recovery and impair quality of life[2]. Enhanced recovery after surgery (ERAS), which optimizes perioperative processes, attenuates surgical stress, and promotes early recovery, is a key component of contemporary perioperative care[2,3]. The ERAS protocol has been shown to shorten hospital stays, reduce complication rates, and lower readmission rates after elective colorectal cancer surgery[4], to attenuate postoperative stress responses and perioperative complications in elderly patients[5], and to reduce the need for indwelling urinary catheters in elective colectomy[6].

Nevertheless, the preoperative component of ERAS is often limited to basic health education and dietary guidance. Structured, quantified exercise-based prehabilitation is rarely implemented, and conventional in-person delivery is hampered by poor compliance, insufficient supervision, and limited individualization[7,8]. Several randomized trials and systematic reviews have examined prehabilitation before colorectal surgery, but most programs relied on supervised, hospital-based or community-based sessions of short duration, and few incorporated real-time remote monitoring with quantified, tiered exercise prescription across the entire home-to-hospital period. Evidence is particularly limited regarding the effect of such programs on postoperative frailty as a patient-centered outcome. Whether a mobile application-supported model can deliver individualized, quantified preoperative rehabilitation while maintaining standardization and adherence therefore remains unclear.

Against this background, the present study developed an ERAS-based preoperative prehabilitation management model centered on quantified exercise training and supported by a mobile application. We hypothesized that, compared with conventional ERAS management, this model would reduce the incidence of postoperative frailty at 6 months after laparoscopic colorectal cancer resection and improve functional recovery. The aim was to refine the ERAS perioperative intervention system and to provide evidence for perioperative rehabilitation management in this patient population.

MATERIALS AND METHODS

General information

This was a single-center, two-arm, parallel-group, assessor-blinded, superiority randomized controlled trial with a 1:1 allocation ratio, conducted at Nanfang Hospital (Guangzhou, Guangdong Province, China) between October 2023 and October 2025. This study has not yet been registered with clinical trials. The study protocol and any amendments were registered and are available from the corresponding author upon reasonable request. The manuscript was prepared with reference to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement. The study protocol was reviewed and approved by the Medical Ethics Committee of Nanfang Hospital, No. 2023067. All participants provided written informed consent before enrollment, and the study was conducted in accordance with the principles of the Declaration of Helsinki[9].

Patients with colorectal cancer admitted to our hospital between October 2023 and October 2025 were screened for eligibility. Inclusion criteria were: (1) Meeting the diagnostic criteria for colorectal cancer as outlined in the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for colon cancer[10] and scheduled for laparoscopic radical resection; (2) Age ≥ 18 years; (3) American Society of Anesthesiologists physical status class I-III; (4) Capable of using a smartphone and able to cooperate with remote intervention via the application and daily check-ins; and (5) Alert and able to communicate normally. Exclusion criteria were: (1) Distant metastases from malignant tumors or primary malignant tumors at other sites; (2) Coexisting coagulation disorders; (3) Severe systemic infectious diseases; (4) Limb dysfunction caused by bone and joint diseases, stroke, or neuromuscular diseases; (5) Coexisting psychiatric or psychological disorders; (6) Receipt of preoperative adjuvant chemoradiotherapy; and (7) Presence of frailty before surgery. Withdrawal criteria were: (1) Conversion to open surgery; (2) Occurrence of serious adverse events during surgery; (3) Loss to follow-up or voluntary withdrawal for any reason; and (4) Missing observational data.

The allocation sequence was generated by an independent statistician who was not involved in recruitment or outcome assessment, using a random number table with a 1:1 allocation ratio and a block size of 4. Allocation was concealed using sequentially numbered, opaque, sealed envelopes. A designated nurse who was not involved in outcome assessment enrolled participants and assigned them to groups in the order of enrollment.

Because of the nature of the intervention, participants could not be blinded to group allocation. Outcome assessors performing the Fried Frailty Phenotype, 6-minute walk test (6MWT), and Berg Balance Scale (BBS) evaluations, as well as data collectors and the statistician, remained blinded to group assignment throughout the study. Assessors received standardized training before the study, and inter-rater reliability was confirmed (intraclass correlation coefficient > 0.90). Any unblinding events were recorded and reported to the principal investigator and documented in the trial file.

Surgical methods

All operations were performed by the same surgical team. For colonic lesions, complete mesocolic excision was performed; for rectal lesions, total mesorectal excision was adopted. A standardized surgical protocol was implemented to minimize procedural bias. All patients underwent general anesthesia with endotracheal intubation. After positioning, a pneumoperitoneum of 12-14 mmHg was established and maintained. Trocars were inserted using the standard five-port technique, and radical surgery was performed after routine laparoscopic exploration to rule out widespread metastatic disease. The Toldt’s space and pelvic floor space were dissected precisely, with mesenteric fascial integrity maintained and the no-touch principle strictly followed. Mesenteric vessels were ligated and transected at their origins, dissection 2 lymph node dissection was performed, and safe resection margins were controlled. A laparoscopic cutting and sealing device was used to transect the affected bowel segment, and the specimen was removed through a 3-5 cm auxiliary incision. Gastrointestinal reconstruction was performed according to abdominal conditions, bowel perfusion, and tension, with routine intraoperative air leak testing. In rare cases in which the low-lying rectum could not be preserved, combined abdominoperineal radical resection with permanent colostomy was performed. At the end of the procedure, the abdominal or pelvic cavity was irrigated; after routine placement of a drainage tube, the incision was closed in layers. Postoperative analgesia and anti-infective therapy were administered routinely.

Control group

Patients received standard ERAS perioperative management without systematic or quantified preoperative exercise-based prehabilitation interventions. Preoperative care included routine health education, dietary guidance, and basic psychological counseling, along with adherence to preoperative fasting and fluid restriction protocols. During surgery, the ERAS principles of minimally invasive techniques, thermal preservation, and restricted fluid administration were followed. Postoperatively, patients received standard nursing care, including early oral intake, routine ambulation, pain management, and complication prevention; however, there were no standardized exercise training programs or remote monitoring interventions.

Experimental group

In addition to standard ERAS perioperative management, patients received a preoperative prehabilitation management model centered on quantified exercise training and supported by a mobile application. The intervention period extended from admission and diagnosis to the day before surgery and lasted no fewer than 14 days, covering the entire cycle from home to hospitalization. A multidisciplinary team of surgeons, physical therapists, specialized nurses, and dietitians delivered the program. A custom-developed gastrointestinal surgery prehabilitation application was used for protocol delivery, quantified training, remote monitoring, data recording, and dynamic adjustment. The core intervention was structured, quantified exercise training, supplemented by nutritional and psychological interventions.

Functional modules of the prehabilitation application

The application is customized to the perioperative characteristics of patients with colorectal cancer. It omits generic nursing education functions and focuses on the quantification and management of exercise training. Its core modules are: (1) Personalized program delivery: Rehabilitation therapists enter baseline data [age, body mass index (BMI), baseline physical fitness, cardiopulmonary function, and frailty scores], and the system automatically matches patients with tiered exercise programs (low-intensity and moderate-intensity aerobic and resistance training packages), with daily tasks delivered at scheduled times; (2) Standardized video instruction: Built-in standardized training videos cover diaphragmatic breathing, pursed-lip breathing, ankle pump exercises, straight-leg raises, wall squats, resistance band exercises, and upper-body strength training, ensuring consistent movement form; (3) Check-in and quantitative monitoring: After each session, patients submit a check-in, and the application records exercise duration, sets, and completion rate, and integrates heart rate and step tracking with alerts for overexertion or insufficient exercise, generating daily and weekly training reports; (4) Remote interaction and adjustment: Patients report training questions or discomfort, and rehabilitation therapists provide daily online consultation and dynamically adjust exercise intensity and duration according to tolerance; and (5) Follow-up data recording: Built-in scales record Fried scores, 6-minute walk distance, grip strength, and activities of daily living scores at each time point, with automatically generated trend charts. An example of the application interface is shown in Figure 1.

Figure 1 Pre-rehabilitation application user interface. A: Example of the main interface module of the pre-rehabilitation application (app); B: Example of the training data monitoring interface of the pre-rehabilitation app; C: Example of the online question and answer interface of the pre-rehabilitation app.

Core quantified exercise program

All training content was delivered via scheduled application push notifications, video guidance, and check-in monitoring. Sessions were conducted one to two times daily, each lasting 40-60 minutes, on no fewer than 5 days per week.

Aerobic endurance training (20-30 minutes per session): Brisk walking on flat ground, slow stair climbing, and rhythmic breathing exercises, with dual monitoring of step count and heart rate to maintain exercise intensity within the target heart rate range of 100-120 beats/minute.

Full-body resistance training (20-30 minutes per session): Upper-body resistance band chest expansions, fist-clenching exercises, and light weight lifts (1-2 kg); core abdominal contractions and gluteal lifts; and lower-body straight-leg raises, wall squats, and weighted toe raises; each set comprised 10-15 repetitions with 1 minute of rest between sets, for a total of three sets.

Pulmonary function training: Diaphragmatic pursed-lip breathing with a breathing trainer (inhale 4 seconds, hold 2 seconds, exhale 6 seconds), 10 minutes daily.

Training quality control: A daily completion rate of ≥ 90% was considered satisfactory; rehabilitation therapists reviewed the data daily and provided online reminders and one-on-one correction for patients who did not complete the exercises or whose form was incorrect.

Adjunctive interventions

Nutritional support: Based on Nutritional Risk Screening 2002 results, the application provided personalized dietary plans guiding patients toward a high-protein, high-vitamin diet with quantified supplementation of high-quality protein and calories.

Psychological intervention: Brief relaxation exercises and mindfulness breathing audio were offered to alleviate preoperative anxiety and stress.

Outcomes

Primary outcome: The prespecified primary outcome was the incidence of postoperative frailty at 6 months after surgery. Frailty was assessed with the Fried Frailty Phenotype[11], administered at 1 month, 3 months, and 6 months postoperatively. The phenotype comprises five components: Unintentional weight loss, weakness (grip strength), self-reported exhaustion, slow walking speed, and low physical activity; each component is scored 0 or 1, for a total score of 0-5[12]. A score of 0 indicates no frailty, 1-2 indicates pre-frailty, and ≥ 3 indicates frailty. Weight loss was defined as an unintentional loss of ≥ 4.5 kg (or ≥ 5% of body weight) in the preceding year in this study, unintentional weight loss of ≥ 5% of body weight within 1 year before surgery was used as the cutoff; grip strength was measured with a hand-held dynamometer measured with a Jamar hydraulic hand dynamometer with the patient seated and the elbow flexed at 90°, taking the best of three trials; weakness was defined using the Fried cutoffs (men: ≤ 29 Lb/13.1 kg for BMI ≤ 24, ≤ 30 Lb/13.6 kg for BMI 24.1-28, ≤ 32 Lb/14.5 kg for BMI > 28; women: ≤ 17 Lb/7.7 kg for BMI ≤ 29, ≤ 21 Lb/9.5 kg for BMI > 29); walking speed was assessed as the time to walk a fixed distance at the usual pace 15 ft (4.57 m) at the usual pace; slowness was defined as a walking time of ≥ 7 seconds for height ≤ 173 cm (men) or ≤ 159 cm (women), and ≥ 6 seconds for taller individuals; and physical activity was evaluated with the Minnesota Leisure Time Activities questionnaire, with the lowest quintile of energy expenditure (men < 383 kcal/week; women < 270 kcal/week) classified as low physical activity.

Secondary outcomes

Gastrointestinal recovery: From the time of transfer to the ward postoperatively, the time to return of bowel sounds, time to first flatus, time to first bowel movement, time to first oral intake, and postoperative length of hospital stay were recorded.

Mobility: The 6MWT and the BBS[13] were administered on the day before surgery, and at 1 month and 6 months postoperatively. The 6MWT was conducted on an open, obstacle-free path within the hospital grounds under the guidance of the same nurse; the distance walked in 6 minutes was recorded, with the nurse accompanying the patient throughout without interfering with the walking rhythm; a longer distance indicates greater exercise tolerance. The BBS consists of 14 balance-related items, each scored 0-4, for a total of 0-56; a higher score indicates better balance.

Inflammatory markers: On postoperative days 1 and 7, 3 mL of fasting blood was collected from the antecubital vein. After centrifugation (radius 10 cm, 4 ^°C, 1500 × g, 10 minutes), the serum supernatant was analyzed using a fully automated biochemical analyzer (Atellica CH 930; Siemens Healthcare Diagnostics Inc.) to measure C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and interferon-γ (IFN-γ).

Quality of life: Assessed with the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) questionnaire[14] on the day before surgery and 6 months postoperatively. The questionnaire comprises five dimensions: Physical well-being (PWB, 7 items), social/family well-being (SFWB, 7 items), emotional well-being (EWB, 6 items), functional well-being (FWB, 7 items), and colorectal cancer-specific concerns (CCS, 9 items). Except for the last two items of the CCS, each item is scored 0-4, for a total of 0-136; higher scores indicate better quality of life.

Postoperative complications: All complications occurring within 30 days after surgery were recorded, including anastomotic fistula, intestinal obstruction, nausea and vomiting, and diarrhea. Complications were graded according to the Clavien-Dindo classification.

Sample size

The sample size was estimated using PASS 21.0 software. Based on a preliminary pilot study involving non-study participants, the incidence of frailty at 6 months postoperatively was assumed to be 25% in the control group and 9% in the experimental group. With a two-sided significance level of α = 0.05, test power of 1-β = 0.80, and a 1:1 allocation ratio, the required sample size per group was calculated to be 73 patients per group; allowing for a 20% attrition rate, 91 patients per group (182 in total) were enrolled. Allowing for an attrition rate of 20%, 91 patients per group (182 in total) were enrolled.

Statistical analysis

Data were analyzed using SPSS 27.0 (IBM Corp., Armonk, NY, United States). All analyses were performed on the intention-to-treat (ITT) population, defined as all randomized participants analyzed according to their assigned group; a per-protocol (PP) analysis excluding major protocol deviations (conversion to open surgery, violation of inclusion or exclusion criteria, or completion of < 80% of the scheduled training sessions) was performed as a sensitivity analysis, and a safety analysis included all participants who received any part of the assigned intervention. The normality of continuous variables was assessed with the Kolmogorov-Smirnov test. Normally distributed continuous data are presented as mean ± SD. For outcomes measured repeatedly (Fried scores, 6MWT, BBS scores, inflammatory markers, and FACT-C scores), between-group differences were analyzed using linear mixed-effects models (or generalized estimating equations for non-normal data) with group, time, and the group × time interaction as fixed effects and patient as a random effect; between-group comparisons at single time points were adjusted for multiple comparisons using the Bonferroni method. For single-time-point continuous outcomes, independent-samples t-tests were used between groups and paired t-tests within groups. Categorical data are expressed as n (%). Between-group comparisons of categorical variables were performed with the χ² test; when the expected count in any cell was < 1 or the expected count in more than 20% of cells was < 5, Fisher's exact test was used. Treatment effects are reported with 95% confidence intervals (CIs), mean differences (MDs) for continuous outcomes, and relative risks (RRs) and risk differences (RDs) for binary outcomes. Missing data were handled by the mixed-effects model under the missing-at-random assumption, and a complete-case sensitivity analysis was performed in this study, no missing outcome data occurred because all randomized participants completed the scheduled follow-up assessments. A two-sided P value < 0.05 was considered statistically significant. Because of the number of secondary outcomes, the results for secondary outcomes should be interpreted as exploratory.

RESULTS

Participant flow

A total of 182 patients were enrolled and randomized to the control group (n = 91) and the experimental group (n = 91). All randomized patients received the assigned intervention and completed all follow-up assessments, with no exclusions after randomization for conversion to open surgery, serious adverse events, loss to follow-up, or missing data; therefore, the ITT, PP, and safety populations each comprised 182 patients (91 per group). No unblinding of outcome assessors was reported a total of 182 patients were assessed for eligibility, all of whom met the inclusion criteria and consented to randomization; no exclusions occurred after randomization.

Baseline characteristics

The baseline characteristics of the two groups are summarized in Table 1. The groups were similar with respect to sex, age, BMI, comorbidities, American Society of Anesthesologists classification, tumor location, and tumor stage, supporting the comparability of the groups; no between-group baseline P values are reported, in line with current recommendations for randomized trials.

Table 1 Baseline characteristics of the two groups, n (%)/mean ± SD.

Item	Control group (n = 91)	Experimental group (n = 91)	χ2/t	P value
Gender			0.200	0.655
Male	49 (53.85)	52 (57.14)
Female	42 (46.15)	39 (42.86)
Age (years)	62.10 ± 10.33	61.49 ± 7.83	0.445	0.657
BMI (kg/m²)	22.22 ± 2.61	22.28 ± 2.25	0.156	0.876
Underlying conditions
Hypertension	12 (13.19)	13 (14.29)	0.046	0.830
Diabetes	9 (9.89)	11 (12.09)	0.225	0.635
Hyperlipidemia	10 (10.99)	9 (9.89)	0.059	0.808
ASA classification			0.122	0.941
I	26 (28.57)	24 (26.37)
II	50 (54.95)	51 (56.04)
III	15 (16.48)	16 (17.58)
Tumor type			0.088	0.766
Colon cancer	40 (43.96)	43 (47.25)
Rectal cancer	51 (56.04)	48 (52.75)
Tumor stage			0.088	0.767
II	45 (49.45)	43 (47.25)
III	46 (50.55)	48 (52.75)

Between-group P values are not reported for baseline variables in randomized trials. BMI: Body mass index; ASA: American Society of Anesthesiologists.

Postoperative frailty

At 1 month, 3 months, and 6 months postoperatively, Fried scores in the experimental group were lower than those in the control group (P < 0.05; Figure 2A). The incidence of frailty at 1 month, 3 months, and 6 months postoperatively was 36.26% (33/91), 25.27% (23/91), and 20.88% (19/91) in the control group and 20.88% (19/91), 16.48% (15/91), and 9.89% (9/91) in the experimental group, respectively. At 1 month postoperatively, the frailty incidence was lower in the experimental group (RR: 0.58, 95%CI: 0.35-0.93; RD: -15.4%, 95%CI: -28.3% to -2.4%; χ² = 5.277, P = 0.022; Fisher's exact P = 0.032). At 6 months postoperatively, the frailty incidence was lower in the experimental group (RR: 0.47, 95%CI: 0.23-0.99; RD: -11.0%, 95%CI: -21.4% to -0.6%; χ² = 4.221, P = 0.040; Fisher's exact P = 0.063). At 3 months postoperatively, the difference was not statistically significant (RR: 0.65, 95%CI: 0.36-1.17; P > 0.05). The corresponding number needed to treat at 6 months was approximately 10. Fried scores at each time point are shown in Figure 2A, and the frailty data are summarized in Figure 2.

Figure 2 Comparison of Fried Frailty Scores and incidence of Frailty. A: Bar chart of Fried scores for both groups; B: Sankey diagram of frailty incidence rates for both groups.

Gastrointestinal recovery

In the experimental group, the time to return of bowel sounds, time to first flatus, time to first bowel movement, time to first oral intake, and postoperative hospital stay were all shorter than in the control group (P < 0.05) (Table 2).

Table 2 Comparison of gastrointestinal function recovery among patients, mean ± SD.

Item	Control group (n = 91)	Experimental group (n = 91)	MD (95%CI)	P value
Time to return of bowel sounds (hours)	20.35 ± 6.75	15.86 ± 5.67	-4.49 (-6.30 to -2.68)	< 0.001
Time to first flatus (hours)	34.43 ± 9.16	30.77 ± 8.52	-3.66 (-6.23 to -1.09)	0.006
Time to first bowel movement (hours)	39.56 ± 8.35	36.05 ± 8.28	-3.51 (-5.93 to -1.09)	0.005
Time to first oral feeding (hours)	48.88 ± 9.81	44.81 ± 9.77	-4.07 (-6.91 to -1.22)	0.006
Postoperative hospital stay (days)	7.40 ± 2.19	5.90 ± 2.15	-1.50 (-2.13 to -0.87)	< 0.001

MD: Mean difference; CI: Confidence interval.

Comparison of patients’ motor function

One day pre-operation, there was no statistically significant difference in 6MWT and BBS scores between the two groups (P > 0.05). At one month and six months post-surgery, the experimental group’s 6MWT and BBS scores were both higher than those of the control group (P < 0.05) (Figure 3).

Figure 3 Comparison of patients’ motor function. A: Bar chart of 6-minute walk test scores for both groups; B: Bar chart of Berg Balance Scale scores for both groups. 6MWT: 6-minute walk test; BBS: Berg Balance Scale.

Comparison of inflammatory markers

One day pre-operation, there were no statistically significant differences in CRP, IL-6, TNF-α, and IFN-γ between the two groups (P > 0.05). Seven days postoperatively, IL-6, TNF-α, and IFN-γ levels in the experimental group were lower than those in the control group (P < 0.05) (Figure 4).

Figure 4 Comparison of inflammatory markers in patients. A: Bar chart of C-reactive protein levels in both groups; B: Bar chart of interleukin-6 levels in both groups; C: Bar chart of tumor necrosis factor-α levels in both groups; D: Bar chart of interferon-γ levels in both groups. CRP: C-reactive protein; IL-6: Interleukin-6; TNF-α: Tumor necrosis factor-α; IFN-γ: Interferon-γ.

Comparison of patients’ quality of life

One day pre-operation, there were no statistically significant differences in PWB, SFWB, EWB, FWB, CCS, and FACT-C scores between the two groups (P > 0.05). Six months after surgery, the experimental group’s PWB, SFWB, EWB, FWB, CCS, and FACT-C scores were all higher than those of the control group (P < 0.05) (Figure 5).

Figure 5 Comparison of patients’ quality of life. A: Bar chart of physical well-being scores for both groups; B: Bar chart of social/family well-being scores for both groups; C: Bar chart of emotional well-being scores for both groups; D: Bar chart of functional well-being scores for both groups; E: Bar chart of colorectal cancer-specific concerns scores for both groups; F: Bar chart of Functional Assessment of Cancer Therapy-Colorectal scores for both groups. PWB: Physical well-being; SFWB: Social/family well-being; EWB: Emotional well-being; FWB: Functional well-being; CCS: Colorectal cancer-specific concerns; FACT-C: Functional Assessment of Cancer Therapy-Colorectal.

Comparison of postoperative complication rates

In this study, 11 patients developed postoperative complications, with an overall incidence of 6.04% (11/182). One patient developed an anastomotic fistula; following anastomotic repair, routine correction of electrolyte and acid-base imbalances, and continuous negative pressure drainage, symptoms such as lower abdominal tenderness and fever were significantly alleviated. Two patients developed intestinal obstruction. After administration of prokinetic agents, fasting, and gastrointestinal decompression, symptoms of abdominal distension and pain were significantly resolved. Four patients experienced nausea and vomiting. Three underwent continuous gastrointestinal decompression, and one was administered an oral 5-HT receptor antagonist; symptoms resolved within 1 day of intervention. Four patients developed diarrhea; three cases were functional diarrhea, and symptoms resolved after dietary adjustments and oral probiotics; one case was infectious diarrhea. Following stool bacterial culture and antibiotic susceptibility testing, antimicrobial therapy with antibiotics sensitive to the pathogen was administered, and symptoms resolved within 3 days. The incidence of postoperative complications in the experimental group was lower than that in the control group (P < 0.05) in Table 3.

Table 3 Comparison of postoperative complication rates.

Item	Control group (n = 91)	Experimental group (n = 91)	χ2	P value
Anastomotic fistula	1 (1.10)	0 (0.00)
Intestinal obstruction	2 (2.20)	0 (0.00)
Nausea and vomiting	3 (3.30)	1 (1.10)
Diarrhea	3 (3.30)	1 (1.10)
Total complications	9 (9.89)	2 (2.20)	4.741	0.029

DISCUSSION

Patients undergoing laparoscopic colorectal cancer surgery vary considerably in preoperative physical fitness, adherence to home-based interventions is difficult to monitor, and outcomes such as frailty and physical function require long-term follow-up. In this single-center randomized trial, an ERAS-based preoperative prehabilitation model combining tiered and quantified exercise, nutritional support, psychological intervention, and remote monitoring via a mobile application was associated with a lower incidence of postoperative frailty at 1 month and 6 months, faster gastrointestinal recovery, better mobility, lower postoperative IL-6, TNF-α, and IFN-γ levels, higher quality-of-life scores at 6 months, and fewer postoperative complications than conventional ERAS management alone.

Compared with conventional digital tools that provide generic education or simple activity tracking, the application in this study incorporated automated stratification of exercise programs according to baseline physical fitness, cardiopulmonary function, and frailty scores; dynamic adjustment of training load according to daily check-in data and heart rate monitoring; and integrated recording of Fried scores, 6MWT, grip strength, and activities of daily living within a single platform. These functions were intended to address poor compliance, insufficient supervision, and lack of individualization that limit conventional prehabilitation[15]. Because adherence and application usage data were not reported in this manuscript, the degree to which these functions were actually used cannot be verified here.

Postoperative frailty is a common complication among colorectal cancer patients and is closely associated with muscle loss, inflammatory stress, and reduced cardiopulmonary function[16]. This study demonstrates that the Fried frailty scores and incidence rates in the experimental group were significantly lower than those in the control group at 1 month, 3 months, and 6 months postoperatively. Additionally, the experimental group exhibited faster gastrointestinal recovery and stronger physical performance, which is directly attributable to the structured exercise intervention within the preoperative pre-rehabilitation management model. Aerobic training can enhance cardiopulmonary reserve, improve oxygen metabolism, and reduce postoperative oxidative stress[17,18]; resistance training stimulates muscle protein synthesis, reduces preoperative muscle loss, and enhances limb and core muscle strength, thereby reducing the risk of frailty at its source[19]. This is consistent with the findings of Li et al[20], which confirmed that preoperative resistance-based prehabilitation can improve muscle mass and reduce the incidence of postoperative frailty in elderly patients undergoing abdominal surgery. Gastrointestinal dysfunction is a core complication following laparoscopic colorectal cancer surgery; surgical trauma, anesthetic suppression, and bed rest can delay gastrointestinal motility. The benefits observed in the experimental group may be partly explained by improved gastrointestinal blood circulation, enhanced gastrointestinal smooth muscle contractility, and better regulation of gut microbiota, as preoperative exercise training may promote these physiological changes[21]. Additionally, pulmonary function training improves ventilation and reduces the risk of abdominal distension. It should be noted that these mechanisms are biologically plausible and supported by previous literature, but this study did not directly measure these pathways; therefore, they should be considered potential explanations rather than proven findings. These findings are consistent with Zhang et al[22], who reported that preoperative prehabilitation can shorten the time to gastrointestinal recovery and reduce postoperative hospital stays in patients undergoing abdominal surgery. Furthermore, mobile apps can overcome spatial and temporal limitations, enabling standardized training, remote supervision, quantitative data tracking, and individualized dynamic adjustments, thereby effectively addressing issues such as improper movement execution, lack of supervision, delayed feedback, and poor compliance in traditional prehabilitation[23].

Surgical trauma triggers an inflammatory response, and excessive inflammation can promote muscle breakdown and frailty. In this study, IL-6, TNF-α, and IFN-γ levels at 7 days postoperatively were lower in the experimental group, suggesting attenuation of the postoperative inflammatory response. Regular exercise can modulate immune cell activity and reduce the release of pro-inflammatory mediators[24,25], which offers a plausible explanation, although this trial did not measure immune cell populations or mechanistic pathways directly. Quality-of-life scores were also higher in the experimental group at 6 months, plausibly reflecting better physical function, nutritional status, and EWB, together with faster gastrointestinal recovery and fewer complications[26]. The incidence of postoperative complications was 2.20% vs 9.89% (RR: 0.22, 95%CI: 0.05-1.00); although the χ² test reached significance (P = 0.029), Fisher's exact test did not (P = 0.058), and this result should therefore be regarded as preliminary.

Several limitations temper the interpretation of these findings. First, this was a single-center trial, and regional and case-mix differences may limit generalizability. Second, the follow-up was limited to 6 months, and the long-term effect of the model on frailty and survival was not assessed. Third, adherence rates, application usage, and patient satisfaction with the digital platform were not reported, which limits judgments about feasibility and replicability. Fourth, participants could not be blinded, and although outcome assessors were blinded, the details of allocation concealment require documentation against trial records. Fifth, this was a multimodal intervention combining exercise, nutrition, psychology, and remote monitoring, so the observed effects cannot be attributed to exercise alone or to the application alone. Sixth, the number of secondary outcomes was large and no multiplicity adjustment was prespecified, so secondary findings are exploratory. Finally, the ethical approval number (2023067) requires verification against the approval date and the recruitment window, and the prospective registration record should be made available to readers. Future multicenter, prospectively registered trials with longer follow-up, prespecified analysis plans, and full reporting of adherence and implementation outcomes are needed to confirm these results and to assess cost-effectiveness and digital equity before the model can be recommended for widespread implementation.

CONCLUSION

In this single-center, assessor-blinded randomized trial, an ERAS-based preoperative prehabilitation management model was associated with reduced postoperative frailty, faster gastrointestinal and motor recovery, attenuated postoperative inflammation, fewer complications, and better quality of life after laparoscopic colorectal cancer surgery. These findings should be regarded as preliminary until confirmed in prospectively registered, multicenter trials with longer follow-up and complete reporting of adherence and implementation outcomes. The model may hold promise for perioperative rehabilitation management in colorectal cancer patients and warrants further evaluation before broader clinical application.

ACKNOWLEDGEMENTS

Thank you to the nursing staff and statistical support personnel who participated in the data collection.