# SCODA: A Low-Cost Prehabilitation Strategy to Improve Outcomes After Cytoreductive Surgery in a Low-Resource Setting

## TL;DR

A low-cost pre-surgery program called SCODA improves outcomes for cancer patients in low-resource settings by focusing on walking, nutrition, and iron supplements.

## Contribution

SCODA is a novel, low-cost prehabilitation strategy that significantly reduces complications and mortality in cytoreductive surgery patients in resource-limited settings.

## Key findings

- SCODA reduced pulmonary complications, major morbidity, transfusions, ICU stays, and 90-day mortality in patients undergoing CRS/HIPEC.
- SCODA participation was an independent protective factor for most outcomes in multivariate analyses.
- The program's low-cost, food-based design makes it feasible for broader implementation in low- and middle-income countries.

## Abstract

Patients undergoing cytoreductive surgery with or without HIPEC face high rates of postoperative complications, especially in low- and middle-income countries where access to costly enhanced recovery programs is limited. To address this challenge, we developed SCODA, a simple and low-cost prehabilitation program based on daily walking, high-protein nutrition using affordable local foods, and routine oral iron supplementation over 90 days before surgery. In this study including 169 patients, SCODA significantly reduced pulmonary complications, major morbidity, transfusion needs, ICU stay, and 90-day mortality compared with standard care. These findings show that an accessible, food-based and activity-centered approach can strengthen perioperative care in resource-constrained settings and may serve as a scalable model for improving outcomes in complex oncologic surgery.

Background: Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) remains the standard of care for peritoneal surface malignancies but carries significant postoperative risks. In low- and middle-income countries (LMICs), the challenge is magnified by limited access to high-cost enhanced recovery programs. The SCODA (Surgical Complication Optimization through Diet and Activity) program was developed as a low-cost prehabilitation intervention to improve outcomes in resource-constrained settings. Methods: This retrospective cohort study included 169 patients undergoing CRS ± HIPEC at a single academic center in Morocco between 2015 and 2023. Patients treated before SCODA implementation (pre-SCODA group, n = 83) were compared to those enrolled in the SCODA program (SCODA group, n = 86). SCODA included oral iron supplementation, a protein-rich food-based diet, and progressive walking sessions over 90 days. Perioperative outcomes, including pulmonary complications, major morbidity (Clavien–Dindo ≥ 3b), transfusions, ICU stay >3 days, and 90-day mortality, were analyzed using univariate and multivariate logistic regression models. Results: The SCODA group had significantly fewer pulmonary complications (2% vs. 13%, p = 0.008), reduced major morbidity (9% vs. 21%, p = 0.031), fewer transfusions (8% vs. 20%, p = 0.024), and shorter ICU stays (median 1.5 vs. 5 days, p < 0.001). Ninety-day mortality was also lower in the SCODA group (5.8% vs. 12.4%, p = 0.046). SCODA participation remained an independent protective factor in multivariate analyses for all endpoints except major complications. Conclusions: The SCODA program is a feasible and effective prehabilitation strategy for improving surgical outcomes after CRS/HIPEC in LMICs. Its low-cost, food-based, and activity-centered design may support broader implementation in resource-limited environments and inform future perioperative care policies in oncology.