Variability in the Application and Principles of Prehabilitation and Enhanced Recovery (VAPPER Survey) Among Colorectal Surgery Units: A National Multicentre Survey

Abstract

Background: Prehabilitation has become an essential component of perioperative care in colorectal surgery, aiming to improve postoperative outcomes through multimodal interventions. However, its real-world implementation remains heterogeneous. This study aimed to evaluate the degree of implementation and variability of prehabilitation programs across colorectal surgery units in Spain. Methods: A national multicenter cross-sectional survey (VAPPER Survey) was conducted among colorectal surgery units. The questionnaire included 83 items addressing organizational structure, nutritional assessment, frailty screening, and multidisciplinary collaboration. Data were analyzed descriptively and expressed as frequencies and percentages. Results: A total of 104 hospitals participated. Prehabilitation programs were present in 79% (n = 82) of centers, while 21% (n = 22) reported no program. Nutritional screening was not performed in 21% (n = 22) of hospitals. Among those performing screening, MUST was the most frequently used tool (68%, n = 56), although considerable variability existed. Systematic use of GLIM criteria was reported in only 24% (n = 20), whereas 35% (n = 28) did not use GLIM and 41% (n = 34) applied it selectively. Frailty screening in patients ≥70 years was absent in 54% (n = 44) of centers, and geriatric involvement was limited and non-standardized. Conclusions: Prehabilitation is widely implemented in Spain but remains highly heterogeneous across all dimensions. The most relevant deficits are concentrated in systematic nutritional assessment, malnutrition diagnosis using standardized criteria, geriatric integration, and psychological support. Standardization of protocols, strengthening of multidisciplinary teams, and enhanced training in perioperative nutrition are priorities for optimizing outcomes in colorectal surgery.