E408: Prehabilitation and Textbook Oncologic Outcome in Pancreatic Cancer Surgery

Preoperative Rehabilitation (prehab) is a strategy used to improve a patient’s physiology prior to undergoing major surgery. Our prehab bundle includes consultations to nutrition, palliative care, and physical therapy. Recent data suggests prehab may preserve patient physical fitness, reduce hospital length of stay and costs of care (PMID 35788874). We sought to identify associations between prehab completion and textbook oncologic outcomes in patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). 

Methods:

A retrospective chart review identified patients who underwent pancreaticoduodenectomy for PDAC at a high-volume academic center between 2018-2023. The primary outcomes were adherence to the prehab bundle and rate of textbook oncologic outcome (TOO). TOO, as applicable, was defined as a margin negative resection, adequate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of neoadjuvant or adjuvant chemotherapy (PMID 32124437). Secondary outcomes included changes in nutritional status, as measured by albumin, prealbumin and BMI. 

Results:

72 patients underwent pancreaticoduodenectomy, of which 27 had clinical stage 1-3 PDAC. Overall median length of stay was 7 days (IQR: 7-10 days). Despite routine referrals at the time of surgical consultation, adherence to the prehab bundle was poor: 6/72 (8%) met with all 3 consultation services, while 23/72 (29%) met with 2+ consultation services. Median prehab duration (initial consultation to surgery) was 135 days. 

Textbook oncologic outcomes were achieved in 24 patients (33%) and were not associated with completion of the prehab bundle. Failure to achieve TOO was due most frequently due to prolonged length of stay in 33 patient (69%) and 30-day readmission in 16 patients (33%). PDAC patients for whom TOO were achieved had lower BMI at diagnosis (23.9 vs 29.2, p=0.047), at surgery (24.2 vs 28.6, p=0.029) and postoperatively (21.9 vs 26.6, p=0.019) as compared to those who did not. However, there were no significant changes in prehab adherence rates. 

Conclusions:

Nutritional status and BMI correlate with TOO in PDAC patients undergoing pancreaticoduodenectomy. Further study is needed to elucidate the impact of prehabilitation on oncologic outcomes, evaluate the efficacy of individual prehabilitation bundles, and understand factors influencing patient adherence to the prehabilitation bundles.