Personalized community-based prehabilitation for a high-risk surgical patient opting for pylorus-preserving pancreaticoduodenectomy: a case report

Abstract

Introduction: Prehabilitation aims for an optimal physical functioning level before, during, and after hospitalization for major surgery. The purpose of this case report was to illustrate the care pathway of a high-risk patient who opted for pylorus-preserving pancreaticoduodenectomy, including preparation for this procedure by participating in a community-based exercise prehabilitation program. The report describes patient examination, evaluation in decision-making for surgery, the prehabilitation program, and outcomes within the context of the Hypothesis-Oriented Algorithm for Clinicians II. Case Description: The patient was a 75-year-old woman with a history of several comorbidities and a polypoid mass in the descending segment of the duodenum. Based on the preoperative assessment, the level of physical functioning was expected to be insufficient to cope adequately with the stress of hospitalization and surgery. Intervention: A 4-week prehabilitation program, including aerobic, resistance, and functional task training in a community-based physical therapy practice. Outcomes: Prehabilitation had a beneficial impact on improving functional mobility preoperatively (timed up-and-go test score improved from 19.4 to 10.0 s, five times sit-to-stand test score improved from 30.1 to 10.1 s, and two-minute walk test distance improved from 55.0 to 107.0 m). Surgery and postoperative recovery proceeded without complications. She achieved independent physical functioning on postoperative day 6 and was discharged home on postoperative day 12. Conclusion: Preoperative risk-assessment can support clinical decision-making in a high-risk patient opting for major abdominal surgery. Furthermore, a remarkable improvement in physical functioning can be achieved by community-based prehabilitation in a high-risk surgical patient.

Enhanced recovery after surgery programmes in older patients undergoing hepatopancreatobiliary surgery: what benefits might prehabilitation have?

“…Postoperative length of hospital stay tended to be shorter in the prehabilitation group compared to the usual care group (mean ± SD of 8 ± 8 versus 13 ± 20 days; P ¼ 0.078) [76]. Likewise, the case study of van Beijsterveld et al [77] reported that four weeks of supervised community-based prehabilitation (aerobic, resistance, and functional exercises) in a high-risk 75-year-old patient opting for pylorus-preserving pancreaticoduodenectomy improved preoperative physical fitness and resulted in an uncomplicated postoperative course. The preoperative period thus provides a window of opportunity for older patients undergoing elective HPB surgery, especially for those classified as high-risk patients, to decrease the risk of adverse postoperative outcomes by optimizing reserve capacity before surgery.…”

Making functional assessment functional

“…However, average patients are not easy to find. To offer the best care for individual patients within their specific context based on the evidence available, the HOAC II can be helpful to make informed choices as shown in a recent case study of van Beijsterveld et al [73]. Thereby, this hurdle of treating "average patients" can also be tackled with a relatively new research design; N of 1.…”