Abstract
Pancreatic surgery is associated with significant morbidity. Objectively measured aerobic fitness can predict postoperative outcomes. Similarly, poor insulin sensitivity is associated with postoperative complications. Supervised exercise training can improve cardiorespiratory fitness and insulin sensitivity. Immunonutrition may work synergistically with exercise. The primary objective of this thesis was to investigate the effect of multimodal prehabilitation on aerobic and metabolic fitness, in patients undergoing pancreatic surgery.
In this prospective, non-randomised pilot study, we recruited patients with benign or malignant pathology, listed for pancreatic resection. Subjects underwent a baseline cardiopulmonary exercise test (CPET). Insulin sensitivity was measured using the gold standard technique, the hyperinsulinaemic-euglycaemic clamp. The 4-week intervention comprised: resistance and high intensity interval training (ten sessions) plus daily eicosapentaenoic acid and docosahexaenoic acid (2g), and extra virgin olive oil (30 ml). CPETs and clamps were repeated after four weeks. These were compared with contemporaneous non-randomised controls.
Of 21 recruited patients, 12 out of 12 (prehab) and 6 out of 9 (control) completed the study. Prehabilitation led to an improvement in oxygen uptake at anaerobic threshold (+2.0 (95 per cent CI 0.1 to 4.0) ml kg-1 min-1) and peak exercise (+3.0 (95 per cent CI 0.7 to 5.3) ml kg-1 min-1), compared to controls. Within the prehab group, there were significant improvements in peak power (P = 0.001), oxygen uptake at anaerobic threshold (P = 0.017) and peak exercise (P = 0.002). Aerobic fitness was unchanged amongst controls. Insulin sensitivity did not change in either group.
There is limited work on biological incorporation, in relation to nutritional prehabilitation; a secondary component of this thesis demonstrated a significant increase in serum phospholipid eicosapentaenoic acid and docosahexaenoic acid, after supplementation. Sleep duration and well-being also improved following prehabilitation.
Multimodal prehabilitation can increase aerobic fitness before major pancreatic surgery. This is a novel finding, which could impact postoperative outcomes. Furthermore, this is the first study to measure the metabolic effect of prehabilitation.