Preoperative Optimisation of Modifiable Risk Factors in Surgery of the Pancreas

Background In the past, little attention has been given in the daily practice to the patient's condition before an operation. Recent studies have shown the benefit of preoperative optimisation programs. However, these studies consisted only of smaller studies and were mainly performed in patients who underwent colorectal surgery. Although promising, unfortunately, strong evidence to support the contribution of prehabilitation to optimize the functional outcome after surgery is still lacking and consequently it is not included in the Dutch basic health insurance package.

Objective To investigate whether implementation of a best practice program for preoperative optimisation of patients with a focus on screening, assessment, and intervention of 8 potentially (partly) modifiable risk factors (low (aerobic) fitness level, malnutrition, low psychological resilience, comorbidities (iron deficiency (anaemia), impaired glucose control and frailty), and intoxications (alcohol and smoking behaviour)) will improve the time to functional recovery.

Study design A nationwide stepped-wedge cluster randomized trial. In this design all participating centres will cross over from current practice to the best practice program, in a randomised order. At the end of the study, all centres will have implemented the best practice program.

Study population 13 centres performing major pancreatic surgery in the Netherlands collaborating within the Dutch Pancreatic Cancer Group (DPCG).

Intervention Preoperative screening of all patients scheduled for pancreatic resection on (aerobic) fitness level, malnutrition risk, psychological resilience, haemoglobin, iron and HbA1c concentration, frailty, and alcohol and smoking behaviour. All patients are provided with a patient-tailored, multimodal prehabilitation program, in which these potentially (partly) modifiable factors are preoperatively addressed. This program is based on findings in previous screening and prehabilitation programs, a national inventory of current preoperative care protocols and expert opinion. Consensus upon this program was reached with pancreatic surgeons from all centres of the DPCG. The final program was critically reviewed by the advisory committee of internationally respected experts in the field of prehabilitation and pancreatology.

Comparison Preoperative care according to current practice.

• Comprehensive Complication Index (CCI) [Срок оценки: 30 days postoperative]
• Length of hospital stay [Срок оценки: On average 2 weeks postoperative]
• Readmissions [Срок оценки: 30 days after discharge of primary admission]
• Postoperative complications [Срок оценки: During primary admission, on average 14 weeks postoperative]
• Incremental cost-effectiveness ratio (ICER) [Срок оценки: 1 year postoperative]
• Evaluation of health status [Срок оценки: At baseline, 3 months and 12 months postoperative]
• Evaluation of quality of life for cancer patients [Срок оценки: At baseline, 3 months and 12 months postoperative]