Preoperative interventions boost outcomes after liver resection

Prehabilitation programmes (PPs) appear to improve outcomes in patients undergoing elective liver resection (LR), according to a recent Singapore study.

“This is the first study reporting the effect of prehabilitation on clinical, quality of life (QoL) and cost outcomes in patients undergoing elective LR,” researchers said. “PP reduced length of stay, morbidity, social issues and improves social well-being at no additional cost to [the] patient.”

Of the 104 patients enrolled, 70 (median age, 68 years; 74 percent male) underwent prehabilitation while the remaining 34 (median age, 66 years; 73.5 percent male) were set as controls. Participants were assessed for outcomes such as length of stay, morbidity, mortality, functional capacity and QoL. Most of the participants were indicated for LR due to hepatocellular carcinoma (62.5 percent). [J Surg Res 2020;251:119-125]

Intraoperatively, the duration of the procedure (median, 235 vs 252 minutes; p=0.61) and blood loss (500 vs 400 mL; p=0.61) were both comparable in the PP and control groups.

However, researchers detected a significantly higher overall rate of complication in those who underwent LR without prehabilitation (52.9 percent vs 30 percent; p=0.02). This was driven by large differences in rates of pulmonary complications (23.5 percent vs 18.6 percent), cardiac dysfunction (14.7 percent vs 4.3 percent) and postoperative ileus (11.8 percent vs 7.1 percent).

Smaller discrepancies were observed for other complications, such intra-abdominal collection, electrolyte imbalance, anastomotic/bile leaks, bleeding and superficial surgical site infections. On the other hand, controls reported lower rates of urinary tract infections and liver failures.

Notably, none of the participants who underwent prehabilitation before resection reported social issues, as opposed to three (8.8 percent) in the control group (p=0.03).

Prehabilitation conferred no additional significant benefit on other postoperative outcome measures: length of stay (6 vs 8.5 days; p=0.21), 90-day mortality rate (1 percent vs 1 percent; p=0.54) and readmission rate (4 percent vs 3 percent; p=0.55) and overall QoL.

“Our study showed that multidisciplinary PP helped to identify issues earlier and resolve them even before surgery,” the researchers said, pointing to scores in the social/family domains of the Functional Assessment of Cancer Therapy-Hepatobiliary survey, which were significantly better in the PP group (p<0.0001).

“Positive postoperative behaviour of patients in prehabilitation group was also observed by case managers and physiotherapists. They witnessed patients to be more cooperative and willing to participate in early mobilization and pulmonary exercises,” they added. “PP helped patients with cancer change their traditional belief that patients were better to rest in bed after major surgery.”

In the present study, the research team enrolled patients undergoing elective LR for HCC at a university-affiliated hospital in Singapore. Prehabilitation was voluntary and involved a multidisciplinary programme combining nutritional, psychological and behavioural interventions, along with exercise, delivered prior to the procedure.

“An ideal PP should be customized to individual needs, directly supervised within community by the multidisciplinary team and continued throughout the patients’ journey,” the researchers said.

“In our opinion, such programme shall not be possible without adequate resource allocation and success of such initiatives should be measured from patient- and clinician-centric views,” they added.