Improved preoperative aerobic fitness following a home-based bimodal prehabilitation programme in high-risk patients scheduled for liver or pancreatic resection

Prehabilitation Strategies: Enhancing Surgical Resilience with a Focus on Nutritional Optimization and Multimodal Interventions

Surgery imposes significant physiological and psychological stress, often leading to complications, delayed recovery, and prolonged hospital stays. Prehabilitation, a proactive strategy to optimize patients' resilience before surgery, has emerged as a transformative approach in perioperative care. Nutritional prehabilitation specifically addresses metabolic dysregulation, muscle loss, and immune suppression caused by surgical stress. This review highlights the critical role of nutritional prehabilitation within a multimodal framework, integrating exercise, psychological support, and emerging technologies. Although some evidence supports the effectiveness of prehabilitation in enhancing functional outcomes and improvements in rates of complications and mortality, its implementation faces challenges such as resources, lack of standardized protocols, and variability across healthcare settings, highlighting the need for greater standardization. Physical training as part of prehabilitation also improves mood, fosters patient engagement, and instills a sense of control over the disease process. These psychosocial benefits, alongside enhanced patient-reported outcomes and qualitative measures, reflect the holistic value of prehabilitation. Emerging technologies, such as wearable devices and telemedicine, offer scalable and personalized solutions for delivering prehabilitation, particularly in resource-limited settings. Future research should prioritize refining protocols, exploring long-term outcomes, and addressing the unique needs of high-risk populations. By emphasizing a proactive approach to perioperative care, this review aims to highlight the potential of nutritional prehabilitation as a foundational component of multimodal strategies designed to optimize surgical resilience, empower patients, and transform surgical recovery into a proactive and patient-centered journey.

High-Intensity Interval Training for Cancer Patients: A Review of Key Considerations for Exercise Prescription

BACKGROUND

High-intensity interval training (HIIT) performed before, during, and after cancer treatment can attenuate the adverse effects induced by anti-cancer drugs. A clear presentation and rationale of characteristics of HIIT variables is vital to produce the expected HIIT adaptations in cancer patients. However, there are concerns regarding the HIIT protocols used in the cancer literature.

OBJECTIVES

The aims were to (1) identify the characteristics of HIIT and the formats that have been prescribed, (2) analyze which anchors have been utilized to prescribe effort and pause intensity, (3) examine characteristics of the physical tests used for HIIT prescription, and (4) identify potential adverse events related to HIIT intervention.

METHODS

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, including PubMed, Scopus, and Web of Science databases.

RESULTS

A total of 51 studies were retrieved, and the following results were found: (1) Only 25 studies reported all four essential variables for HIIT prescription [effort intensity (effort duration): pause intensity (pause duration)]. Of these studies, 23 used active pause and employed the following prescription (on average): [84% (116 s): 39% (118 s)] when percentage of maximal aerobic power (MAP) [maximal/peak oxygen uptake ( V O2max/peak)/MAP] was used; [124% (161 s): 55% (142 s)] when percentage of anaerobic threshold (AT) was used; [83% (230 s): 62% (165 s)] when maximal heart rate percentage (%HRmax) was used. From these 23 studies, 12 used V O2max/peak/MAP (one of the most recommended variables for HIIT prescription). Seven studies adopted the HIIT-long format, and in the remaining five studies, the format was unclear. (2) Twenty-four studies used fractions of V O2max/peak or mechanical variables like MAP as anchors for prescribing effort intensity, two studies used AT, 20 studies used fractions of HRmax/heart rate reserve, two studies used rate of perceived exertion (RPE), while one used RPE and % V O2peak concomitantly, and two studies utilized RPE/%HRmax concomitantly. Two studies utilized passive resting, 12 studies used % V O2peak/%MAP for prescribing pause intensity, four studies used AT, seven studies used %HRmax, one study used %HRmax/% V O2peak, and two studies used absolute loads. (3) Ten studies did not report the characteristics of the physical tests employed, two studies used submaximal tests, and 39 studies utilized graded exercise tests. (4) Ten studies did not report if there were adverse events associated with the exercise program, while 34 studies did not report any adverse events.

CONCLUSIONS

Only 50% of the studies provided all the necessary variables for accurate HIIT prescription, raising concerns about the replicability, comprehension, and effective application of HIIT in cancer patients. Most of the studies that reported all variables appeared to have employed the HIIT-long format. Only a few studies used more individualized anchors (e.g., AT) to prescribe HIIT-long format for cancer patients, which is considered a very heterogeneous population.

Nationwide implementation of the international multidisciplinary best-practice for locally advanced pancreatic cancer (PREOPANC-4): study protocol

BACKGROUND

The introduction of (m)FOLFIRINOX and gemcitabine-nab-paclitaxel has changed the perspective for patients with locally advanced pancreatic cancer (LAPC). Consequently, in experienced centres 23% of patients with LAPC undergo a resection with 5-year overall survival (OS) rates of up to 25%. In the Netherlands, the nationwide resection rate for LAPC remains low at 8%. The PREOPANC-4 program aims for a nationwide implementation of the international multidisciplinary best-practice to improve patient outcome.

METHODS

Nationwide program implementing the international multidisciplinary best-practice for LAPC. In the training phase, multidisciplinary and surgical webinars are given by 4 international experts, leading to a clinical protocol, followed by surgical off-site and on-site proctoring sessions. In the implementation phase, the clinical protocol will be implemented in all centres, including a nationwide expert panel (2022-2024). Healthcare professionals will be trained in shared decision-making. Consecutive patients diagnosed with pathology-proven LAPC (i.e., arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion [DPCG criteria]) are eligible. Primary outcomes are median and 5-year OS from diagnosis, resection rate, in-hospital/30-day mortality and major morbidity (i.e., Clavien-Dindo grade ≥ IIIa), and radical resection (R0) rate. Secondary outcomes include quality of life, functioning, side effects, and patients' healthcare satisfaction in all included patients. Outcomes will be compared with patients with borderline resectable pancreatic cancer (BRPC) treated with neoadjuvant FOLFIRINOX in the PREOPANC-2 trial (EudraCT: 2017-002036-17) and a historical cohort of patients with LAPC from the PACAP registry (NCT03513705). The existing prospective LAPC Registry and PACAP PROMs (NCT03513705) will be used for data collection. In qualitative interviews, treatment preferences, values, and experiences of LAPC patients, their relatives, and healthcare professionals will be assessed for the development of shared decision-making supportive tools. It is hypothesized that the program will double the nationwide LAPC resection rate to 16% with major morbidity < 50% and mortality ≤ 5%, and OS following resection similar to that observed in patients with BRPC.

DISCUSSION

The PREOPANC-4 program aims to safely implement the international multidisciplinary best-practice for LAPC leading to benchmark outcomes for both short-term morbidity, mortality, and OS.

TRIAL REGISTRATION

PREOPANC-4 program was registered at ClinicalTrials.gov (NCT05524090) on September 1, 2022.

Personalized nutrition after discharge for pancreatic surgery: A study protocol

Background: Pancreatic cancer has an increasing incidence and prevalence trend. Its prognosis is negatively affected by poor/altered nutritional status. Therefore, nutritional interventions play a critical/pivotal role at any stage. Despite being included in the prehabilitation items of Enhanced Recovery After Surgery (ERAS) protocols for pancreatic surgery, nutritional recommendations concerning early post-discharge period are lacking. Aim: To assess the acceptability and feasibility of a personalized and standardized food plan for patients following pancreatic surgery. A secondary aim is to determine if adherence to a personalized food plan is linked to improved postoperative outcomes. Methods: A prospective monocentric cohort study will be performed, including 180 patients undergoing pancreatic surgery. Body composition, nutritional, muscular, and hydro-electrolyte status will be assessed with bio-impedance analysis (BIA). Patients will receive a personalized nutritional plan after discharge for the following 45 days. Summary: Detailed nutritional indications have been formulated with broad consensus for the pre-operative (prehabilitation) and postoperative period. No previous study has specifically formulated or validated a nutritional intervention focused on the early post-discharge period. The results of this study might contribute to paving the way for future research and to broaden nutritional recommendations within the ERAS protocol.

Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review

OBJECTIVE

Providing an overview of the clinimetric properties of the steep ramp test (SRT)-a short-term maximal exercise test-to assess cardiorespiratory fitness (CRF), describing its underlying physiological responses, and summarizing its applications in current clinical and research practice.

DATA SOURCES

MEDLINE (through PubMed), CINAHL Complete, Cochrane Library, EMBASE, and PsycINFO were searched for studies published up to July 2023, using keywords for SRT and CRF.

STUDY SELECTION

Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch.

DATA EXTRACTION

Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated.

DATA SYNTHESIS

In total, 370 studies were found, of which 39 were included in this study. In several healthy and patient populations, correlation coefficients between the work rate at peak exercise (WRpeak) attained at the SRT and oxygen uptake at peak exercise during cardiopulmonary exercise testing (CPET) ranged from .771-.958 (criterion validity). Repeated measurements showed intraclass correlation coefficients ranging from .908-.996 for WRpeak attained with the first and second SRT (test-retest reliability). Physiological parameters, like heart rate and minute ventilation at peak exercise, indicated that the SRT puts a lower burden on the cardiopulmonary system compared to CPET. The SRT is mostly used to assess CRF, among others as part of preoperative risk assessment, and to personalize interval training intensity.

CONCLUSIONS

The SRT is a practical short-term maximal exercise test that is valid for CRF assessment and to monitor changes in CRF over time in various healthy and patient populations. Its clinimetric properties and potential applications make the SRT of interest for a widespread implementation of CRF assessment in clinical and research practice and for personalizing training intensity and monitoring longitudinal changes in CRF.

Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery-A Narrative Review

Malnutrition plays a crucial role as a risk factor in patients undergoing major abdominal surgery. To mitigate the risk of complications, nutritional prehabilitation has been recommended for malnourished patients and those at severe metabolic risk. Various approaches have been devised, ranging from traditional short-term conditioning lasting 7-14 days to longer periods integrated into a comprehensive multimodal prehabilitation program. However, a significant challenge is the considerable heterogeneity of nutritional interventions, leading to a lack of clear, synthesizable evidence for specific dietary recommendations. This narrative review aims to outline the concept of nutritional prehabilitation, offers practical recommendations for clinical implementation, and also highlights the barriers and facilitators involved.

'Effects of a home-based bimodal lifestyle intervention in frail patients with end-stage liver disease awaiting orthotopic liver transplantation': study protocol of a non-randomised clinical trial

INTRODUCTION

Patients with end-stage liver disease awaiting orthotopic liver transplantation (OLT) are generally classified as frail due to disease-related malnutrition and a progressive decline in musculoskeletal and aerobic fitness, which is associated with poor pre-OLT, peri-OLT and post-OLT outcomes. However, frailty in these patients may be reversable with adequate exercise and nutritional interventions.

METHODS AND ANALYSIS

Non-randomised clinical trial evaluating the effect of a home-based bimodal lifestyle programme in unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min listed for OLT at the University Medical Center Groningen (UMCG). The programme is patient tailored and comprises high-intensity interval and endurance training, and functional exercises three times per week, combined with nutritional support. Patients will go through two training periods, each lasting 6 weeks.The primary outcome of this study is the impact of the programme on patients' aerobic fitness after the first study period. Secondary outcomes include aerobic capacity after the second study period, changes in sarcopenia, anthropometry, functional mobility, perceived quality of life and fatigue, incidence of hepatic encephalopathy and microbiome composition. Moreover, number and reasons of intercurrent hospitalisations during the study and postoperative outcomes up to 12 months post OLT will be recorded. Finally, feasibility of the programme will be assessed by monitoring the participation rate and reasons for non-participation, number and severity of adverse events, and dropout rate and reasons for dropout.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee of the UMCG (registration number NL83612.042.23, August 2023) and is registered in the Clinicaltrials.gov register (NCT05853484). Good Clinical Practice guidelines and the principles of the Declaration of Helsinki will be applied. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05853484.

Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review

Gastrointestinal (GI) cancers constitute over 25% of global cancer cases annually, with hepato-pancreato-biliary (HPB) cancers presenting particularly poor prognosis and challenging surgical treatments. While advancements in clinical care have improved post-operative outcomes over time, surgery for HPB cancers remains associated with high morbidity and mortality rates. Patients with HPB cancer are often older, diagnosed at later stages, and have a higher prevalence of co-morbid conditions, leading to reduced life expectancy, suboptimal post-operative recovery, and increased recurrence risk. Exercise and nutrition interventions have emerged as safe non-pharmacological strategies to enhance clinical outcomes among cancer survivors, but their potential in the pre-operative period for patients with HPB cancer remains underexplored. This narrative review evaluates existing evidence on exercise and nutritional interventions during pre-operative prehabilitation for HPB cancer populations, focusing on clinically relevant post-operative outcomes related to frailty and malnutrition. We conducted a literature search in PubMed and Google Scholar databases to identify studies utilizing a prehabilitation intervention in HPB cancer populations with exercise and nutritional components. The currently available evidence suggests that incorporating exercise and nutrition into prehabilitation programs offers a critical opportunity to enhance post-operative outcomes, mitigate the risk of comorbidities, and support overall survivorship among HPB cancer populations. This review underscores the need for further research to optimize the timing, duration, and components of pre-operative prehabilitation programs, emphasizing patient-centered, multidisciplinary approaches in this evolving field.

Cardiac and intramuscular adaptations following short-term exercise prehabilitation in unfit patients scheduled to undergo hepatic or pancreatic surgery: study protocol of a multinuclear MRI study

INTRODUCTION

Short-term exercise prehabilitation programmes have demonstrated promising results in improving aerobic capacity of unfit patients prior to major abdominal surgery. However, little is known about the cardiac and skeletal muscle adaptations explaining the improvement in aerobic capacity following short-term exercise prehabilitation.

METHODS AND ANALYSIS

In this single-centre study with a pretest-post-test design, 12 unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min, who are scheduled to undergo hepatopancreatobiliary surgery at the University Medical Center Groningen (UMCG), the Netherlands, will be recruited. As part of standard care, unfit patients are advised to participate in a home-based exercise prehabilitation programme, comprising high-intensity interval training and functional exercises three times per week, combined with nutritional support, during a 4-week period. Pre-intervention and post-intervention, patients will complete a cardiopulmonary exercise test. Next to this, study participants will perform additional in-vivo exercise cardiac magnetic resonance (MR) imaging and phosphorus 31-MR spectroscopy of the quadriceps femoris muscle before and after the intervention to assess the effect on respectively cardiac and skeletal muscle function.

ETHICS AND DISSEMINATION

This study was approved in May 2023 by the Medical Research Ethics Committee of the UMCG (registration number NL83611.042.23, March 2023) and is registered in the ClinicalTrials.gov register. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05772819.

Personalized multimodal prehabilitation reduces cardiopulmonary complications after pancreatoduodenectomy: results of a propensity score matching analysis

BACKGROUND

The purpose of prehabilitation is to improve postoperative outcomes by increasing patients' resilience against the stress of surgery. This study investigates the effect of personalized multimodal prehabilitation on patients undergoing pancreatoduodenectomy.

METHODS

Included patients were screened for six modifiable risk factors: (1) low physical fitness, (2) malnutrition, (3) low mental resilience, (4) anemia and hyperglycemia, (5) frailty, and (6) substance abuse. Interventions were performed as needed. Using 1:1 propensity score matching (PSM), patients were compared to a historical cohort.

RESULTS

From 120 patients, 77 (64.2%) performed a cardiopulmonary exercise test to assess their physical fitness and provide them with a preoperative training advice. Furthermore, 88 (73.3%) patients received nutritional support, 15 (12.5%) mental support, 17 (14.2%) iron supplementation to correct for iron deficiency, 18 (15%) regulation support for hyperglycemia, 14 (11.7%) a comprehensive geriatric assessment, and 19 (15.8%) substance abuse support. Of all patients, 63% required ≥2 prehabilitation interventions. Fewer cardiopulmonary complications were observed in the prehabilitation cohort (9.2% versus 23.3%; p = 0.002). In surgical outcomes and length of stay no differences were observed.

CONCLUSION

Our prehabilitation program is effective in detecting risk factors in patients; most patients required multiple interventions. Consequently, a reduction in cardiopulmonary complications was observed.

Preoperative screening and prehabilitation strategies prior to ileocolic resection in patients with Crohn's disease are not incorporated in routine care

PURPOSE

Recently, recommendations on perioperative care have been published to optimize postoperative outcomes in preoperative patients with inflammatory bowel disease. This study evaluated the current use of preoperative screening and prehabilitation strategies (PS) prior to elective ileocolic resection (ICR) in patients with Crohn's disease (CD).

METHODS

Patients with CD who underwent an elective ICR were identified from a Dutch prospective cohort study. Primary endpoint was to evaluate to what extent IBD-relevant PS were applied in patients with CD prior to ICR according to the current recommendations.

RESULTS

In total, 109 CD patients were included. Screening of nutritional status was performed in 56% of the patients and revealed malnutrition in 46% of these patients. Of the malnourished patients, 46% was referred to a dietitian. Active smoking and alcohol consumption were reported in 20% and 28%; none of these patients were referred for a cessation program. A preoperative anemia was diagnosed in 61%, and ferritin levels were assessed in 26% of these patients. Iron therapy was started in 25% of the patients with an iron deficiency anemia. Exposure to corticosteroids at time of ICR was reported in 29% and weaned off in 3%. Consultation of a dietitian, psychologist, and physiotherapist was reported in 36%, 7%, and 3%. Physical fitness was assessed in none of the patients.

CONCLUSION

PS are not routinely applied and not individually tailored in the preoperative setting prior to elective ICR in patients with CD. Prior to implementation, future research on the costs and effectiveness of PS on postoperative outcomes and quality of life is necessary.

Supervised Home-Based Exercise Prehabilitation in Unfit Patients Scheduled for Pancreatic Surgery: Protocol for a Multicenter Feasibility Study

BACKGROUND

Morbidity rates in pancreatic surgery are high, and frail patients with low aerobic capacity are especially at risk of complications and require prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes.

OBJECTIVE

In this study, we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale.

METHODS

In this multicenter study, adult patients scheduled for elective pancreatic surgery with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min or a VO2 at peak exercise ≤18 mL/kg/min will be recruited. A total of 30 patients will be included in the 4-week, home-based, partly supervised exercise prehabilitation program. The program comprises 25-minute high-intensity interval training on an advanced cycle ergometer 3 times a week. Training intensity will be based on steep ramp test performance (ie, a short-term maximal exercise test on a cycle ergometer), aiming to improve aerobic capacity. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. A steep ramp test will be repeated weekly, and training intensity will be adjusted accordingly. Next to assessing the feasibility (participation rate, reasons for nonparticipation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this program, individual patients' responses to prehabilitation on aerobic capacity, functional mobility, body composition, quality of life, and immune system factors will be evaluated.

RESULTS

Recruitment for this study began in January 2022 and is expected to be completed in the summer of 2023.

CONCLUSIONS

Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05496777; https://classic.clinicaltrials.gov/ct2/show/NCT05496777.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46526.

European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

EffectiveNess of a multimodal preHAbilitation program in patieNts with bladder canCEr undergoing radical cystectomy: protocol of the ENHANCE multicentre randomised controlled trial

INTRODUCTION

Radical cystectomy (RC) is the standard treatment for patients with non-metastatic muscle-invasive bladder cancer, as well as for patients with therapy refractory high-risk non-muscle invasive bladder cancer. However, 50-65% of patients undergoing RC experience perioperative complications. The risk, severity and impact of these complications is associated with a patient's preoperative cardiorespiratory fitness, nutritional and smoking status and presence of anxiety and depression. There is emerging evidence supporting multimodal prehabilitation as a strategy to reduce the risk of complications and improve functional recovery after major cancer surgery. However, for bladder cancer the evidence is still limited. The aim of this study is to investigate the superiority of a multimodal prehabilitation programme versus standard-of-care in terms of reducing perioperative complications in patients with bladder cancer undergoing RC.

METHODS AND ANALYSIS

This multicentre, open label, prospective, randomised controlled trial, will include 154 patients with bladder cancer undergoing RC. Patients are recruited from eight hospitals in The Netherlands and will be randomly (1:1) allocated to the intervention group receiving a structured multimodal prehabilitation programme of approximately 3-6 weeks, or to the control group receiving standard-of-care. The primary outcome is the proportion of patients who develop one or more grade ≥2 complications (according to the Clavien-Dindo classification) within 90 days of surgery. Secondary outcomes include cardiorespiratory fitness, length of hospital stay, health-related quality of life, tumour tissue biomarkers of hypoxia, immune cell infiltration and cost-effectiveness. Data collection will take place at baseline, before surgery and 4 and 12 weeks after surgery.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Medical Ethics Committee NedMec (Amsterdam, The Netherlands) under reference number 22-595/NL78792.031.22. Results of the study will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05480735.

External Validation of a Risk Model for Severe Complications following Pancreatoduodenectomy Based on Three Preoperative Variables

BACKGROUND

Pancreatoduodenectomy (PD) is the only cure for periampullary and pancreatic cancer. It has morbidity rates of 40-60%, with severe complications in 30%. Prediction models to predict complications are crucial. A risk model for severe complications was developed by Schroder et al. based on BMI, ASA classification and Hounsfield Units of the pancreatic body on the preoperative CT scan. These variables were independent predictors for severe complications upon internal validation. Our aim was to externally validate this model using an independent cohort of patients.

METHODS

A retrospective analysis was performed on 318 patients who underwent PD at our institution from 2013 to 2021. The outcome of interest was severe complications Clavien-Dindo ≥ IIIa. Model calibration, discrimination and performance were assessed.

RESULTS

A total of 308 patients were included. Patients with incomplete data were excluded. A total of 89 (28.9%) patients had severe complications. The externally validated model achieved: C-index = 0.67 (95% CI: 0.60-0.73), regression coefficient = 0.37, intercept = 0.13, Brier score = 0.25.

CONCLUSIONS

The performance ability, discriminative power, and calibration of this model were acceptable. Our risk calculator can help surgeons identify high-risk patients for post-operative complications to improve shared decision-making and tailor perioperative management.

Thickness of Biceps and Quadriceps Femoris Muscle Measured Using Point-of-Care Ultrasound as a Representation of Total Skeletal Muscle Mass

Generalized loss of muscle mass is associated with increased morbidity and mortality in patients with cancer. The gold standard to measure muscle mass is by using computed tomography (CT). However, the aim of this prospective observational cohort study was to determine whether point-of-care ultrasound (POCUS) could be an easy-to-use, bedside measurement alternative to evaluate muscle status. Patients scheduled for major abdominal cancer surgery with a recent preoperative CT scan available were included. POCUS was used to measure the muscle thickness of mm. biceps brachii, mm. recti femoris, and mm. vasti intermedius 1 day prior to surgery. The total skeletal muscle index (SMI) was derived from patients’ abdominal CT scan at the third lumbar level. Muscle force of the upper and lower extremities was measured using a handheld dynamometer. A total of 165 patients were included (55% male; 65 ± 12 years). All POCUS measurements of muscle thickness had a statistically significant correlation with CT-derived SMI (r ≥ 0.48; p < 0.001). The strongest correlation between POCUS muscle measurements and SMI was observed when all POCUS muscle groups were added together (r = 0.73; p < 0.001). Muscle strength had a stronger correlation with POCUS-measured muscle thickness than with CT-derived SMI. To conclude, this study indicated a strong correlation between combined muscle thickness measurements performed by POCUS- and CT-derived SMI and measurements of muscle strength. These results suggest that handheld ultrasound is a valid tool for the assessment of skeletal muscle status.