Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have?

Abstract

Due to an aging population and the related growing number of less physically fit patients with multiple comorbidities, adequate perioperative care is a new and rapidly developing clinical science that is becoming increasingly important. This narrative review focuses on enhanced recovery after surgery (ERAS®) programmes and the growing interest in prehabilitation programmes to improve patient-and treatment-related outcomes in older patients undergoing hepatopancreatobiliary (HPB) surgery. Future steps required in the further development of optimal perioperative care in HPB surgery are also discussed. Multidisciplinary preoperative risk assessment in multiple domains should be performed to identify, discuss, and reduce risks for optimal outcomes, or to consider alternative treatment options. Prehabilitation should focus on high-risk patients based on evidence-based cutoff values and should aim for (partly) supervised multimodal prehabilitation tailored to the individual patient's risk factors. The program should be executed in the living context of these high-risk patients to improve the participation rate and adherence, as well as to involve the patient's informal support system. Developing tailored (multimodal) prehabilitation programmes for the right patients, in the right context, and using the right outcome measures is important to demonstrate its potential to further improve patient-and treatment-related outcomes following HPB surgery.

A prospective cohort study evaluating screening and assessment of six modifiable risk factors in HPB cancer patients and compliance to recommended prehabilitation interventions

“…A recently published article argued that multimodal prehabilitation should include exercise, nutrition and psychosocial care (Kamarajah et al 2020 ). The authors consider it a lost opportunity not to include the other known risk factors and suggest that each patient should be screened for the six risk factors as discussed in the present study, which also corresponds to the recommendation of Bongers and colleagues (Bongers et al 2020 ). In addition, our results showed that 53 of the 77 HPB patients (68.8%) needed at least one intervention, and patients with a low literacy had on average significant more risk factors than patients with a normal health literacy.…”

“…Although the evidence to support this practice is not yet conclusive, it is mounting rapidly. Although prehabilitation does not harm anyone, it has been suggested that a prehabilitation programme is most beneficial for high-risk patients (Barberan-Garcia et al 2019 ; Berkel et al 2018 ; Barberan-Garcia et al 2018 ; Bongers et al 2020 ).…”

“…It has been shown that this practice often results in subjective and unreliable data (Wijeysundera et al 2018 ). Furthermore, to reduce perioperative risk, attention should be paid not only to patients’ physical fitness, but also to other modifiable risk factors including malnutrition, iron-deficiency anaemia, frailty, substance use and low psychological resilience (Scheede-Bergdahl et al 2019 ; Bongers et al 2020 ; Carli et al 2017 ; Carli and Ferreira 2018 ).…”

The effect of prehabilitation on postoperative complications and postoperative hospital stay in hepatopancreatobiliary surgery a systematic review

“…They believe that an outcome measure in which the impact of a complication is also considered (use of resources, length of hospital stay) better describes this 'resilience' , and should be used to investigate potential benefits from prehabilitation. 9,39,41 As opposed to postoperative complications, results of this review did show more consistent results regarding length of hospital stay, favoring the prehabilitation group. 42 Finally, most studies have small patient groups, and lack a power analysis.…”

“…Thereby, monitoring of training progress was not reported in any study, which is important to motivate responders, timely identify nonresponders, and make necessary personalized program adjustments. 39 Included studies generally did not focus on high-risk patients. 7,9,38 Some studies even excluded some of them due to the inability to perform the proposed physical exercise training program.…”