Abstract
Background: Enhanced recovery after surgery (ERAS) principles are well established, but there is a lack of data on the long-term impact after pancreaticoduodenectomy (PD). This study aimed to quantify nutritional impact, muscle loss and physical activity levels to support the design of a multi-modal post-surgical rehabilitation programme alongside ERAS. Methods: Thirty-five patients [46% pancreatic ductal adenocarcinoma (PDAC)] due to undergo PD in a tertiary centre were recruited to this feasibility prospective observational cohort study. Patient demographics, nutritional status, dietary intake, muscle mass, physical activity levels, surgical and oncological outcomes and survival were collected over a 24-month period. Results: Pre-operative screening demonstrated malnutrition in 63%, new-onset diabetes in 19%, and iron deficiency in 22%. Nutritional status and physical activity levels declined post-operatively; only one patient was able to achieve >60% of their nutritional requirements with food alone on discharge, all other patients required input from a specialist dietitian. Most (71%) were discharged on oral nutritional supplements (ONS), and 13% on enteral nutrition (EN). Reduced oral intake at 1 month after surgery was associated with dose reduction in adjuvant chemotherapy in PDAC (P=0.03). Nutritional and functional assessment markers returned to baseline 3 months post-operatively. There was an increasing incidence of sarcopenic obesity in the post-operative setting (P=0.01), despite a stabilisation in body weight. Physical activity was <2,500 steps per day in most cases, and appeared to be over-reported using questionnaires. Conclusions: Nutritional recovery remains poor after PD, and individualised nutritional intervention did not meet the recommendations of the ERAS guidelines, representing an area for clinical improvement. This study highlights the diversity of nutritional interventions required, and further work should consider multi-modal nutritional support using ONS, escalating to enteral nutritional interventions as required, alongside prospectively measured physical activity. Step counters were well tolerated and could support both assessment of physical activity and targeted intervention. Body weight alone is not adequate for nutritional assessment-body composition analysis should be included in trial design, and ultrasound requires further interrogation. Multi-centre randomised controlled trials are now required to determine the impact of multimodal individualised rehabilitation programmes after PD on long-term outcomes, including uptake of adjuvant chemotherapy and return to activities of daily living.