Intensive perioperative rehabilitation improves surgical outcomes after pancreaticoduodenectomy
- 211 Downloads
Although the mortality rate for pancreaticoduodenectomy (PD) has decreased to around 2.8–5% in high-volume centers, postoperative complications are still common in 30–50% of cases. Preoperative exercise, called “prehabilitation,” has been recently reported to reduce the frequency of complications after surgery. This study aims to evaluate the impact of the intensive perioperative rehabilitation on improvement of surgical outcomes for patients undergoing PD.
Between 2003 and 2014, 576 consecutive patients underwent PD in Wakayama Medical University Hospital. Of these, 331 patients received perioperative rehabilitation combined with prehabilitation and postoperative rehabilitation between 2009 and 2014. Previously, 245 patients underwent PD without perioperative rehabilitation between 2003 and 2008. We compared surgical outcomes between the patients undergoing PD with and without perioperative rehabilitation to evaluate the efficacy of our rehabilitation program.
The frequency of pulmonary complications was significantly lower in patients undergoing PD with perioperative rehabilitation than those without (0.9% vs. 4.3%, P = 0.011). There were no significant differences in other complication or mortality rates. Length of hospital stay was also shorter in patients receiving perioperative rehabilitation than that of those not receiving it (16 vs. 24 days, P < 0.001).
Intensive perioperative rehabilitation might reduce postoperative pulmonary complications and shorten postoperative hospital stay after PD. Therefore, we suggest that perioperative rehabilitation should be included as part of enhanced recovery after surgery for patients undergoing PD, although further large-scale studies are necessary to confirm our results.
KeywordsPerioperative rehabilitation Prehabilitation Pancreaticoduodenectomy Postoperative complication ERAS
We would like to thank the Clinical Research Center, Wakayama Medical University, for proofreading and editing the manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This study was approved by WMUH Institutional Review Board (No. 1805) with waived informed consent.
- 1.Kawai M, Tani M, Terasawa H, Ina S, Hirono S, Nishioka R, Miyazawa M, Uchiyama K, Yamaue H (2006) Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 244:1–7CrossRefGoogle Scholar
- 2.Partelli S, Crippa S, Castagnani R, Ruffo G, Marmorale C, Franconi AM, de Angelis C, Falconi M (2016) Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients. HPB(Oxford) 18:153–158Google Scholar
- 3.Addeo P, Delpero JR, Paye F, Oussoultzoglou E, Fuchshuber PR, Sauvanet A, Sa Cunha A, le Treut YP, Adham M, Mabrut JY, Chiche L, Bachellier P, French Surgical Association (AFC) (2014) Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association. HPB (Oxford) 16:46–55CrossRefGoogle Scholar
- 4.Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hubert C, Janssens M, Closset J, Belgian Section of Hepatobiliary and Pancreatic Surgery (2013) Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. The Lancet Oncology 14:655–662CrossRefGoogle Scholar
- 5.Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM (2015) Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB(Oxford) 17:1040–1048Google Scholar
- 7.Roberts KJ, Sutcliffe RP, Marudanayagam R, Hodson J, Isaac J, Muiesan P, Navarro A, Patel K, Jah A, Napetti S, Adair A, Lazaridis S, Prachalias A, Shingler G, al-Sarireh B, Storey R, Smith AM, Shah N, Fusai G, Ahmed J, Hilal MA, Mirza DF (2015) Scoring system to predict pancreatic fistula after pancreaticoduodenectomy: a UK multicenter study. Ann Surg 261:1191–1197CrossRefGoogle Scholar
- 11.Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH, Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care, European Society for Clinical Nutrition and Metabolism (ESPEN), International Association for Surgical Metabolism and Nutrition (IASMEN) (2013) Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg 37:240–258CrossRefGoogle Scholar
- 18.PEJv A, MSc MPRL et al (2014) Comparison of two preoperative inspiratory muscle training programs to prevent pulmonary complications in patients undergoing esophagectomy: a randomized controlled pilot study. Ann Surg Oncol 21:2353–2360Google Scholar
- 20.Onerup A, Angenete E, Bock D, Börjesson M, Fagevik Olsén M, Grybäck Gillheimer E, Skullman S, Thörn SE, Haglind E, Nilsson H (2017) The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomised controlled trial. Trials 18:212CrossRefGoogle Scholar
- 22.Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, Uchiyama K, Yamaue H (2011) Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy. Ann Surg 253:495–501CrossRefGoogle Scholar
- 24.Hirono S, Kawai M, Tani M, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H (2014) Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes. Langenbeck’s Arch Surg 399:461–471CrossRefGoogle Scholar
- 26.Hirono S, Kawai M, Okada KI, Miyazawa M, Kitahata Y, Hayami S, Ueno M, Yamaue H (2018) Modified Blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy: randomized controlled trial. Ann Surg:1. https://doi.org/10.1097/SLA.0000000000002802
- 27.Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (ISGPS) (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591CrossRefGoogle Scholar
- 28.Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142(5):761–768CrossRefGoogle Scholar
- 42.WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. World Health Organization technical report series 854.;1995Google Scholar