Maximizing Prehabilitation’s Potential Before Pancreatic Surgery

A pilot prehabilitation program intended to boost pancreatic cancer patients’ strength before resection surgery and improve their postoperative outcomes did not produce those expected benefits, Cleveland Clinic researchers report in a new study.

Patients’ stamina levels remained largely unchanged after completing the program, and patients with varying presurgical levels of frailty showed no difference in complication rates or other postsurgical outcome measures, the study found.

A longer prehabilitation regimen with multiple types of intervention and a heightened focus on patient participation may help achieve better results, the researchers say. Their findings highlight the challenges inherent in improving the resilience of severely ill patients so they can better tolerate and recover from intense medical treatments.

“Our study underscores the need for further research and a more comprehensive prehabilitation program,” says the report’s lead author, Matthew Walsh, MD, a gastrointestinal surgeon and Chair of the Digestive Disease & Surgery Institute’s Department of General Surgery.

The case for prehabilitation

Patients with major illnesses such as pancreatic cancer often experience fatigue, pain and nutritional deficiencies that can affect their recovery. Recently there has been growing interest in prehabilitation, which focuses on optimizing a patient’s health by increasing strength and reducing frailty prior to undergoing a serious medical procedure. The length and constituents of an ideal prehabilitation program to maximize benefits have yet to be determined.

To better understand the potential of this approach and its impact on patient outcomes, Dr. Walsh and colleagues initiated a pilot program for patients undergoing pancreatic resection.

“Once we decide a patient requires surgery, there isn’t a system in place to help them improve their physical health before they undergo the procedure,” he notes. “Therefore, we implemented a prehabilitation regimen to explore the potential implications for patient recovery and postoperative outcomes.”

The researchers hypothesized that patients who completed prehabilitation would improve their baseline strength and those with significant baseline frailty would show greater improvements than those who weren’t as frail.

Program details

Adult patients who were scheduled for a pancreatic resection — either partial or total pancreatectomy — between April 2019 and February 2021 at Cleveland Clinic were enrolled in the prehabilitation program. The study included four stages: preintervention assessment, the prehabilitation regimen, postintervention assessment and postoperative follow-up.

Prior to initiating the prehabilitation regimen, the baseline physical status of each patient was assessed using three validated measures: the 6-minute walk test, grip strength, and the chair-stand test. The researchers calculated patients’ preintervention frailty using the Modified Johns Hopkins Frailty score.

The patients then completed their prehabilitation regimen at home until the day of their surgery. The program’s daily goals included 7,500 steps, 30 grip strength exercises and 100 chair-stand exercises. Patients were provided an activity tracker and a logbook to record their progress. Given the importance of nutrition, the researchers encouraged patients to incorporate a health drink into their routine, but that was not required, according to Dr. Walsh.

For the postintervention assessment, the three baseline frailty measures were repeated immediately before patients underwent surgery. After resection, the researchers evaluated postoperative outcomes. These included hospital duration of stay, complications and 90-day readmission rates.

Results and key takeaways

A total of 32 patients with a median age of 69 years completed the prehabilitation program and postintervention assessment and were included in the data analysis. The majority were men (62.5%) and the median duration of participation was 21.5 days.

The researchers observed a negative correlation between increasing frailty score and the baseline 6-minute walk and chair-stand tests, according to Dr. Walsh. “As a patient’s frailty score increased, the distance walked and the number of chair stands completed decreased,” he says. “This underscores the connection between frailty and a patient’s physical status.”

After completing the prehabilitation program, patients’ grip strengths and the number of chair-stands they could complete showed no change from their baseline preintervention values; the mean distance that patients could cover during the 6-minute walk test decreased at the end of the prehabilitation program In terms of postoperative outcomes, Dr. Walsh and colleagues observed no difference in hospital duration of stay, complications, or 90-day readmission rates among patients with low, intermediate and high baseline frailty scores.

The lack of improvement in patients’ baseline strengths after prehabilitation, although unexpected, is not unprecedented; the researchers noted a similar outcome in a study of patients who underwent prehabilitation prior to gastrointestinal cancer resection. Both regimens were four weeks or less in duration. Prehabilitation programs lasting months have produced demonstrable strength improvements.

The relatively short 21-day regimen evaluated by Dr. Walsh and colleagues “likely explains why our cohort did not show significant improvements … and our regimen may be more impactful in patients undergoing neoadjuvant therapy where the duration of conditioning occurs over months.”

The negative correlation between frailty scores and baseline 6-minute walk and chair-stand results shows that clinicians only need to perform one of those assessments, not both, when determining patients’ physical status, saving time and inconvenience.

The researchers acknowledged there were limitations to the study, including the small sample size and a lack of comprehensive nutritional and psychosocial interventions. Future studies, they noted, will include these components for a more holistic approach.

“Overall, this study is a proof-of-concept that shows you can test a patient’s physical status and correlate it with frailty,” Dr. Walsh notes. “It also demonstrates that providing exercises to patients does not necessarily mean they will complete them as required. More consistent guidance and active encouragement is critical. Our study underscores the need for further study and a more comprehensive prehabilitation program.”

What’s next?

While these findings do not definitively show the impact of prehabilitation on postoperative outcomes, there are lessons to be learned and next steps to consider, according to Dr. Walsh, whose team has received a grant to continue their work in this area. Activities will include randomized research evaluating a more extensive exercise program, with physical therapy as well as nutrition.

“Although our study did not show an objective improvement on outcomes, patients did find the program beneficial,” Dr. Walsh says. “They felt like they were more in control of their health and appreciated the ability to participate in their own care in a positive way.

“We aren’t the first to have trouble showing the benefit of these programs, which is interesting and not a negative study,” he concludes. “There is value to it, whether you can quantify it or not; so, I believe that the field of prehabilitation will continue to grow and there is potentially a lot of impact to be had down the line.”