Prehabilitation in HBP surgery

Abstract

-9]. Irrespective of the assessment tool used, a number of studies have indicated that frailty is associated with surgical outcomes and survival [5-13]. Therefore, it is considered that frail patients may be possible candidates for prehabilitation.Effect of prehabilitationPrehabilitation is strongly endorsed in the ERAS® recommendation [14]. However, the effect of prehabilitation in patients with HBP cancer is still unclear. In a randomized controlled study that analyzed the impact of prehabilitation on postoperative outcomes in patients undergoing pancreaticoduodenectomy (PD), prehabilitation did not reduce postoperative complications. However, delayed gastric emptying was reduced [15]. Perlmutter et al. [16] also reported that prehabilitation did not affect hospital stay, complications, and 90-day readmission rates after PD. In another RCT, however, Barberan-Garcia et al. [17] reported that prehabilitation enhanced postoperative outcomes in high-risk candidates for elective major abdominal surgery. Katsourakis et al. [18] carried out a RCT which evaluated the impact of prehabilitation on quality of life (QoL) in patients who underwent pancreatic resection. They reported that exercise improved QoL after pancreatectomy. In a large-scale retrospective study, Yamaue et al. [19] reported that prehabilitation might reduce postoperative pulmonary complications and shorten postoperative hospital stay after PD. Fard-Aghaie et al. [20] demonstrated enhanced liver regeneration after ALPPS by means of physical prehabilitation in an animal experiment. Lin et al. [21] reported the feasibility of prehabilitataion in improving the Liver Frailty Index, functional capacity, and survival in liver transplantation candidates. Because of the heterogeneity of the studies, the results of meta-analyses are inconclusive [22-25]. On the one hand, a meta-analysis by Dagorno et al. [22], with regard to HBP surgery, reported that prehabilitation had no effect on length of stay (LOS) or the rate of postoperative complications. On the other hand, Lambert et al. [24] reported a shortened LOS associated with prehabilitation. Bundred et al. [23] reported improvement in LOS, DGE, muscle mass, and functioning following prehabilitation, but no effect on postoperative outcomes. Daniels et al. [26] reported decreased postoperative complications in multimodal prehabilitation, but not in “exercise only” prehabilitation. Despite the divergency of the above results, many studies have, nevertheless, demonstrated the possible benefits of prehabilitation suggesting that such a program may improve surgical outcomes, survival, and QoL [21,27].How to do “prehabilitation”?An international research consortium on prehabilitation created a “best practice” approach for multimodal prehabilitation for colorectal cancer surgery in 2016. This four-pillar program consists of high-intensity interval training on endurance and strength; nutritional support with protein and vitamin supplementation; mental support; and a smoking cessation program [28]. This program has been adopted in many clinical studies, as well as in response to subsidiary requests for patients with diseases other than colorectal cancer. Hence prehabilitation should be multimodal, and physical exercise should be individualized according to the functional capacity of the patient.Closing remarksFrailty is an important risk factor for patients with HBP cancer, and a frailty assessment should be considered in older patients before a planned surgery. The waiting period for surgery is an optimal time for physical and psychological conditioning to improve the functional capacity of patients. There are evidences that improvement in functional capacity may be related to improvement in surgical outcome and survival. The “marginal gain” obtained from prehabilitation may, therefore, induce a significant improvement in outcomes when aggregated with other strategies.