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Association of Habitual Preoperative Dietary Fiber Intake With Complications After Colorectal Cancer Surgery

Educational Objective
To identify the value of habitual preoperative dietary fiber intake associated with the risk of complications after surgery for colorectal cancer (CRC).
1 Credit CME
Key Points

Question  Is habitual preoperative dietary fiber intake associated with risk of complications after surgery for colorectal cancer?

Findings  In this cohort study of 1399 patients with colorectal cancer who underwent surgery, higher habitual dietary fiber intake before surgery was associated with a lower risk of any postoperative complications and surgical postoperative complications. Among patients with an anastomosis, dietary fiber intake was not associated with risk of anastomotic leakage.

Meaning  The findings suggest that improving preoperative dietary fiber intake may be considered as a strategy in future prehabilitation programs for patients undergoing surgery for colorectal cancer.


Importance  Postoperative complications are associated with increased morbidity and mortality among patients with colorectal cancer. As a modifiable factor associated with gut health, dietary fiber intake is of interest with regard to the risk of complications after surgery for colorectal cancer.

Objective  To examine the association between preoperative dietary fiber intake and risk of complications after surgery for colorectal cancer.

Design, Setting, and Participants  This cohort study used data from the Colorectal Longitudinal, Observational Study on Nutritional and Lifestyle Factors (COLON) study, which recruited adult patients with colorectal cancer at any stage at diagnosis from 11 hospitals in the Netherlands between August 2010 and December 2017. The present study included patients with stage I to IV colorectal cancer who underwent elective abdominal surgery. Data were analyzed between December 2019 and September 2020.

Exposures  Habitual dietary fiber intake was assessed at diagnosis using a 204-item food frequency questionnaire.

Main Outcomes and Measures  Any complications, surgical complications, and anastomotic leakage occurring during the 30 days after surgery for colorectal cancer. The association between fiber intake and risk of postoperative complications was assessed using logistic regression analyses. Additional analyses stratified by sex, tumor location, and fiber source were performed.

Results  Among the 1399 patients included in the analysis, the median age at inclusion was 66 years (interquartile range, 61-72 years) and 896 (64%) were men. Any complications occurred in 397 patients (28%), and surgical complications occurred in 235 patients (17%). Of 1237 patients with an anastomosis, 67 (5%) experienced anastomotic leakage. Higher dietary fiber intake (per 10 g per day) was associated with a lower risk of any complications (odds ratio [OR], 0.75; 95% CI, 0.62-0.92) and surgical complications (OR, 0.76; 95% CI, 0.60-0.97), whereas no association with anastomotic leakage was found (OR, 0.97; 95% CI, 0.66-1.43). Among women, higher dietary intake was associated with any complications (OR, 0.64; 95% CI, 0.44-0.94), whereas there was no association among men (OR, 0.79; 95% CI, 0.63-1.01). Fiber intake from vegetables (per 1 g per day) was inversely associated with any (OR, 0.90; 95% CI, 0.83-0.99) and surgical (OR, 0.87; 95% CI, 0.78-0.97) complications.

Conclusions and Relevance  In this cohort study, higher habitual dietary fiber intake before surgery was associated with a lower risk of postoperative complications among patients with colorectal cancer. The findings suggest that improving preoperative dietary fiber intake may be considered in future prehabilitation programs for patients undergoing surgery for colorectal cancer.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: March 31, 2021.

Published Online: June 16, 2021. doi:10.1001/jamasurg.2021.2311

Corresponding Author: Dieuwertje E. Kok, PhD, Division of Human Nutrition and Health, Wageningen University & Research, PO Box 17, 6700 AA Wageningen, the Netherlands (dieuwertje.kok@wur.nl).

Author Contributions: Drs Kok and Kampman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kok, Huibregtse, Kruyt, Bac, van Halteren, de Wilt, Kampman.

Acquisition, analysis, or interpretation of data: Kok, Arron, Huibregtse, Kruyt, Kouwenhoven, Wesselink, Winkels, van Zutphen, van Duijnhoven, Kampman.

Drafting of the manuscript: Kok, Arron, Bac, van Halteren.

Critical revision of the manuscript for important intellectual content: Arron, Huibregtse, Kruyt, van Halteren, Kouwenhoven, Wesselink, Winkels, van Zutphen, van Duijnhoven, de Wilt, Kampman.

Statistical analysis: Kok, Arron, Huibregtse, van Duijnhoven.

Obtained funding: Kok, van Duijnhoven, Kampman.

Administrative, technical, or material support: Kruyt, Bac, Wesselink, van Zutphen.

Supervision: Kruyt, Winkels, de Wilt, Kampman.

Conflict of Interest Disclosures: Mrs van Zutphen reported receiving grants from the Dutch Cancer Society outside the submitted work. Dr de Wilt reported receiving grants from the Dutch Cancer Society, the Netherlands Organisation for Health Research and Development, Roche, and Covidien outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grant 016.Veni.188.082 from the Dutch Research Council (Dr Kok). The Colorectal Longitudinal, Observational Study on Nutritional and Lifestyle Factors (COLON) study was supported by Wereld Kanker Onderzoek Fonds and World Cancer Research Fund International; grant 2014/1179 (Dr Kampman) from the World Cancer Research Fund International Regular Grant Programme; grant UW 2013-5927 (Dr van Duijnhoven) from Alpe d’Huzes/Dutch Cancer Society; grant UW 2015-7946 from the Dutch Cancer Society (Dr van Duijnhoven); grants UW2013-6397 and UW2014-6877 from the ERA-NET on Translational Cancer Research, Dutch Cancer Society (Dr Kampman); and The Netherlands Organisation for Health Research and Development.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank all participants, the involved coworkers in the participating hospitals, the COLON investigators at Wageningen University & Research, and all surgeons and other health care professionals who were involved in registering patients in the Dutch Colorectal Audit.

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