Impact of a Multimodal Prehabilitation Program on Perioperative Outcomes in Hepatopancreatobiliary Surgery: A Retrospective Cohort Study

Impact of a Multimodal Prehabilitation Program on Perioperative Outcomes in Hepatopancreatobiliary Surgery: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of a Multimodal Prehabilitation Program on Perioperative Outcomes in Hepatopancreatobiliary Surgery: A Retrospective Cohort Study Pipit Burasakarn, Nattaporn Maneepairoj, Vachiraluck Chalokool, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8977273/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Hepato-pancreato-biliary (HPB) surgeries carry high risks of postoperative complications. This study evaluates the impact of a multimodal prehabilitation program on perioperative outcomes in patients undergoing hepatectomy and pancreatectomy. Methods: We conducted a retrospective cohort study at Phramongkutklao Hospital involving patients operated on between 2020 and 2023. Patients were divided into a Prehabilitation group (2022–2023, n=197), who underwent a 4-week program of exercise, nutritional support, and psychological counseling, and a historical Control group (2020–2021, n=162). Primary outcomes were postoperative complications and 30-day mortality. Results: The Prehabilitation group showed significantly improved preoperative serum albumin levels compared to controls (p < 0.001). Intraoperatively, the Prehabilitation group had significantly shorter operative times (300 vs. 310 min, p=0.037) and reduced blood loss (400 vs. 500 ml, p=0.002). Postoperatively, the Prehabilitation group exhibited a significantly shorter length of hospital stay (median 6 vs. 9 days, p < 0.001) and lower overall morbidity (p < 0.001). No significant difference was observed in 30-day mortality. Conclusions: Multimodal prehabilitation effectively reduces hospital stay, blood loss, and postoperative complications in HPB surgery, supporting its implementation to optimize surgical recovery. Figures Figure 1 Figure 2 Introduction Major abdominal surgeries, particularly hepato-pancreato-biliary (HPB) resections, present significant clinical challenges. These complex procedures are associated with substantial risks of postoperative complications, leading to prolonged hospitalizations, increased mortality, and elevated healthcare costs. Approximately 18% of patients undergoing these surgeries experience major complications within 30 days, with mortality rates reaching 2.7% [ 1 ]. Prehabiliation has emerged as a proactive approach to address these challenges. It involves preparing patients both physically and psychologically before surgery[ 2 ], aiming to enhance their overall health and functional capacity. By implementing personalized exercise and providing psychological support tailored to individual needs, prehabilitation seeks to mitigate the risks associated with surgery and improve recovery outcomes. In the context of hepato-biliary and pancreas surgery, where the stakes are particularly high due to the complexity of procedures and potential for postoperative complication, the role of prehabilitation becomes increasingly pertinent. This approach not only aims to reduce the incidence of complication but also strives to shorten recovery times, improve patients satisfaction, and ultimately decrease healthcare costs associated with prolonged hospital stays and intensive care [ 3 – 5 ] This study aims to evaluate the impact of prehabilitation on perioperative outcomes in hepatobiliary and pancreas surgery, specifically focusing on postoperative complication, morbidity and 30 days mortality. Methods Study Design and Ethics This retrospective cohort study was conducted at Phramongkutklao Hospital. The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department. Informed consent from each patient was waived owing to the retrospective design of the study. Participants and Setting Data was collected from electronic medical records of patients undergoing hepatectomy and pancreatectomy between January 2020 and December 2023. A standardized multimodal prehabilitation program was implemented institution-wide in January 2022. Consequently, the study compared two cohorts: a Prehabilitation Group (patients operated on between January 2022 and December 2023) and a Historical Control (Non-Prehabilitation) Group (patients operated on between January 2020 and December 2021). (Shown in Fig. 1 ) Intervention : The Prehabilitation Program The prehabilitation protocol consisted of a 4-week preoperative regimen focusing on four pillars: exercise, nutrition, psychological support, and smoking cessation: Exercise Unsupervised moderate aerobic exercise (30 minutes/day, 3 times/week) and respiratory training using a triflow spirometer (5–10 times/hour). Nutrition Dietary optimization guided by a nutritionist, targeting 30–35 kcal/kg/day and 1.5 g/kg/day of protein, supplemented with multivitamins and Vitamin D. Psychology Mandatory consultation with a psychologist to manage anxiety and stress. Postoperative Care All patients in the prehabilitation group were managed under an Enhanced Recovery After Surgery (ERAS) pathway [ 7 , 8 ] (shown in Fig. 2 ) Outcomes and Statistical Analysis The primary outcomes were perioperative complications, defined according to the Clavien-Dindo classification [ 6 ], and 30-day mortality. Continuous variables were compared using the Student’s t-test or the Mann–Whitney U test and are presented as mean ± standard deviation (SD) or median (interquartile range [IQR]). Categorical variables were analyzed using the Chi-square test or Fisher’s exact test and are reported as counts (percentages). All analyses were performed using STATA/IC 14.0 (StataCorp), with statistical significance defined as a two-sided P value of < 0.05. Results Demographic and Clinical Characteristics A total of 359 patients were included in the analysis: 197 in the Prehabilitation group (149 hepatectomy, 48 pancreatectomy) and 162 in the Non-Prehabilitation group (104 hepatectomy, 58 pancreatectomy). In the Prehabilitation group, the mean age was 60.8 ± 13.2 years, 68% were male, and the mean BMI was 24.1 ± 5.3 kg/m². Baseline body weight and BMI did not differ significantly between groups. However, serum albumin levels within 3 days before surgery were significantly higher in the Prehabilitation group compared to controls (4.17 ± 0.42 g/dL vs. 3.79 ± 0.5 g/dL, P < 0.001). Furthermore, the change in serum albumin from diagnosis to surgery was significantly more favorable in the Prehabilitation group (+ 0.08 ± 0.35 vs. −0.21 ± 0.5, P < 0.001). These differences persisted in both hepatectomy and pancreatectomy subgroups. (shown in Table 1 ) Table 1 Demographic data Age (year) Non-Prehabilitation group (n = 162) Prehabilitation group (n = 197) p-value Hepatectomy Non-Prehabilitation (n = 104) Hepatectomy prehabilitation (n = 149) p-value Pancreatectomy Non-Prehabilitation (n = 58) Pancreatectomy prehababilitation (n = 48) p-value 59.99 ± 13.7 60.81 ± 13.19 0.566 60.47 ± 12.36 60.68 ± 12.17 0.895 59.14 ± 15.9 61.23 ± 16.09 0.504 Male 102 (63%) 134 (68%) 0.364 76 (73.1%) 110 (73.8%) 0.894 26 (44.8%) 24 (50%) 0.595 Body Weight (Kg) 65.41 ± 12.41 65.01 ± 15.3 0.785 66.84 ± 12.77 65.7 ± 15.46 0.537 62.85 ± 11.4 62.83 ± 14.71 0.996 Height (CM) 162.88 ± 7.7 164.21 ± 7.96 0.110 163.39 ± 7.99 165.19 ± 7.71 0.073 161.95 ± 7.11 161.15 ± 8 0.586 BMI (Kg/m 2 ) 24.63 ± 4.36 24.07 ± 5.29 0.280 25.03 ± 4.6 24.03 ± 5.18 0.114 23.92 ± 3.84 24.21 ± 5.68 0.768 Serum albumin at diagnosis (g/ml) 4.01 ± 0.48 4.09 ± 0.4 0.086 4.04 ± 0.45 4.1 ± 0.4 0.261 3.96 ± 0.53 4.07 ± 0.38 0.247 Serum albumin Before Surgery (g/ml) 3.79 ± 0.5 4.17 ± 0.42 < 0.001* 3.76 ± 0.49 4.16 ± 0.44 < 0.001* 3.86 ± 0.5 4.18 ± 0.38 < 0.001* Albumin difference (g/ml) -0.21 ± 0.5 0.08 ± 0.35 < 0.001* -0.28 ± 0.52 0.06 ± 0.36 < 0.001* -0.1 ± 0.43 0.12 ± 0.33 0.004* ASA 0 47 (29%) 53 (26.9%) < 0.001* 3 (2.9%) 16 (10.7%) 0.017* 44 (75.9%) 37 (77.1%) 0.883 1 106 (65.4%) 139 (70.6%) 92 (88.5%) 128 (85.9%) 14 (24.1%) 11 (22.9%) 2 9 (5.6%) 5 (2.5%) 9 (8.7%) 5 (3.4%) Operation Major hepatectomy Pancreaticoduodenectomy Distal pancreatectomy Others pancreatectomy 30 (28.84%) 55 (36.91%) 0.182 43 (74.13%) 13 (22.42%) 2 (3.44%) 37 (77.08%) 10 (20.83%) 1 (2.08%) 0.89 Independent t test and Chi-square test. Perioperative Outcomes The Prehabilitation group demonstrated significantly favorable intraoperative metrics. Operative time was shorter (300 vs. 310 min, P = 0.037) and estimated blood loss was lower (400 vs. 500 mL, P = 0.002) compared to the control group. Subgroup analysis revealed these benefits were consistent in pancreatectomy patients (Operative time: P = 0.048; Blood loss: P = 0.008). Additionally, the requirement for blood transfusion was significantly lower in the hepatectomy subgroup (P = 0.036). Postoperative Outcomes The length of hospital stay (LOS) was significantly shorter in the Prehabilitation group (median 6 vs. 9 days, P < 0.001). This reduction was observed in both hepatectomy (6 vs. 7.5 days, P = 0.042) and pancreatectomy (7 vs. 13 days, P < 0.001) subgroups. ICU length of stay did not differ between groups. Overall morbidity was significantly lower in the Prehabilitation group (58 vs. 76 events, P < 0.001). Notably, major morbidities were significantly reduced in the pancreatectomy subgroup. There was no statistically significant difference in 30-day mortality between the groups (shown in Table 2 ) Table 2 Perioperative data Operative time (min) Non-Prehabilitation group (n = 162) Prehabilitation group (n = 197) p-value Hepatectomy Non-Prehabilitation (n = 104) Hepatectomy prehabilitation (n = 149) p-value Pancreatectomy Non-Prehabilitation (n = 58) Pancreatectomy prehabilitation (n = 48) p-value 310 (240, 480) 300 (240, 360) 0.037* 240 (200, 360) 250 (210, 300) 0.828 510 (420, 600) 480 (360, 540) 0.048* Blood loss(ml) 500 (300, 1000) 400 (200, 700) 0.002* 500 (250, 1000) 400 (200, 700) 0.101 600 (400, 1000) 425 (225, 725) 0.008* Need for blood transfusion 54 (33.3%) 44 (22.3%) 0.375 28 (26.9%) 24 (16.1%) 0.036 * 26 (44.8%) 20 (41.7%) 0.744 ICU stay (day) 2 (2, 3) 2 (2, 3) 0.052 2 (1, 3) 2 (0, 2) 0.462 3 (2, 3) 2 (2, 3) 0.1 hospital stay(day) 9 (6, 12) 6 (5, 10) < 0.001* 7.5 (6, 9) 6 (5, 9) 0.042* 13 (10, 15) 7 (6, 10) < 0.001* Overall Morbidities 76 (46.91%) 58 (29.44%) < 0.001* 33 (31.73%) 20 (13.42%) 0.222 43 (74.13%) 38 (79.17%) = 3) Mortality, yes 3 (1.9%) 6 (3%) 0.254 1 (1%) 4 (2.7%) 0.333 2 (3.4%) 2 (4.2%) 0.847 Independent t test or Mann-Whitney test and Chi-square test. Discussion This study demonstrates that a multimodal prehabilitation program is associated with improved perioperative outcomes in patients undergoing major HPB surgery. We observed significant reductions in operative time, blood loss, length of hospital stays, and overall morbidity following the implementation of our institutional protocol. The surgical management of hepatopancreatobiliary (HPB) malignancies, specifically through hepatectomy and pancreatectomy, represents some of the most physiologically demanding procedures in modern medicine. As the patient demographic for these surgeries increasingly includes older and frailer individuals, the concept of prehabilitation, a multimodal intervention involving exercise, nutritional optimization, and psychological support, has gained prominence. While prehabilitation offers significant clinical benefits by enhancing physiological reserve, it also presents logistical and oncological challenges that must be critically evaluated. The primary argument for implementing prehabilitation is the mitigation of postoperative morbidity through the improvement of "functional reserve." Patients with pancreatic and liver cancers often present with malnutrition and sarcopenia, both of which are independent predictors of poor surgical outcomes. A landmark randomized clinical trial by Dunne et al [ 9 ]. demonstrated that a four-week structured exercise program significantly improved aerobic capacity in patients undergoing liver resection. Consequently, these patients exhibited a greater resilience to surgical stress, leading to reduced postoperative complications and shorter hospital stays. Furthermore, prehabilitation empowers patients, transforming them from passive recipients of care into active participants, which can significantly alleviate preoperative anxiety and improve overall quality of life. However, the implementation of prehabilitation is not without significant disadvantages. The most pressing concern regarding hepatectomy and pancreatectomy is the delay to surgery. In the context of aggressive malignancies such as pancreatic ductal adenocarcinoma, the window for curative resection is narrow. There is a theoretical concern that delaying surgery by four to six weeks to accommodate a prehabilitation program could allow for tumor progression or metastasis. While a systematic review by Luther et al. [ 10 ] suggests that a short delay for prehabilitation does not negatively impact oncological survival, the anxiety regarding tumor growth remains a significant psychological burden for patients and clinicians alike. While the clinical benefits of prehabilitation are increasingly recognized, rigorous statistical validation remains a priority for the surgical community to standardize care. Dagorno et al. [ 11 ] conducted a critical systematic review and meta-analysis published in the Journal of Visceral Surgery to address the heterogeneity in current research. Their analysis confirmed that prehabilitation significantly reduces overall morbidity, specifically pulmonary complications, in hepato-pancreato-biliary (HPB) surgery. However, they notably emphasized the need for higher-quality evidence, providing specific sample size calculations to guide future randomized controlled trials. This work underscores that while the current signal for benefit is strong, powering future studies correctly is a "necessary step forward" to firmly establish these protocols as the undisputed standard of care. In the specific context of pancreaticoduodenectomy, the integration of nutritional support with physical therapy appears to be particularly effective. Tsukagoshi et al. [ 12 ] demonstrated that a combined preoperative strategy of rehabilitation and nutritional support could mitigate the impact of sarcopenia, a common condition in pancreatic cancer patients that severely compromises recovery. Their findings suggest that optimizing nutritional status is a prerequisite for effective physical rehabilitation; without it, exercise alone may not yield the desired physiological resilience required for such invasive procedures. Finally, prehabilitation must be viewed as the foundational step in the broader continuum of "accelerated rehabilitation" and Enhanced Recovery After Surgery (ERAS). Chu et al. [ 13 ] observed that accelerated rehabilitation protocols significantly improve the clinical prognosis of patients undergoing pancreaticoduodenectomy, suggesting that preoperative preparation is essential for enabling this rapid postoperative recovery. This holistic approach is currently driving new research frontiers, as evidenced by Yao et al. [ 14 ] Their recently published protocol for a randomized controlled trial highlights the evolving focus on integrating postoperative rehabilitation based on ERAS concepts, reinforcing the idea that surgical success depends on a seamless transition from preoperative optimization to postoperative reconditioning. A primary concern in oncologic prehabilitation is the potential delay to surgery. However, our program was integrated without compromising oncologic safety, aligning with systematic reviews suggesting that the benefits of physical optimization outweigh the theoretical risks of short delays. Interestingly, we observed improvements in intraoperative factors such as blood loss and operative time. While prehabilitation primarily targets patient physiology, these findings may reflect the synergistic effect of the ERAS pathway applied postoperatively in the intervention group, or potentially better patient compliance and physiological tolerance during anesthesia. Limitations This study has several limitations. First, it is a single-center, retrospective study using a historical control, which introduces potential bias from temporal changes in surgical technique or perioperative care independent of prehabilitation. Second, the ERAS protocol was applied specifically to the prehabilitation group, making it difficult to isolate the effect of prehabilitation from postoperative ERAS components. Future large-scale randomized controlled trials are warranted to validate these findings and standardize protocols. In conclusion , The implementation of a multimodal prehabilitation program is associated with significantly reduced postoperative morbidity, shorter hospital stays, and improved intraoperative metrics in patients undergoing major HPB surgery. These findings support the integration of prehabilitation into standard surgical pathways to optimize recovery. Declarations Ethical Approval This study was approved by the Institutional Review Board of the Royal Thai Army Medical Department. Funding This study did not receive any funding. Author Contribution PB: Study concept, design, data analysis, and writing the manuscript. NM, VC: Data collection and interpretation. AT: Data collection and critical review. PF: Statistical analysis and editing. SH: Study supervision and final approval. Conflict of Interest Registration The authors declare that they have no conflicts of interest. Guarantor Pipit Burasakarn, MD, PhD. Hyperlink to your specific registration (must be publicly accessible and will be checked) N/A Consent The requirement to obtain written informed consent from each patient was waived because of the study’s retrospective design. Provenance and peer review Not commissioned, externally peer-reviewed. Funding: The authors declare that this study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: The authors declare that they have no conflicts of interest. Author Contributions: PB: Study concept, design, data analysis, and writing the manuscript. NM, VC: Data collection and interpretation. AT: Data collection and critical review. PF: Statistical analysis and editing. SH: Study supervision and final approval. All authors have reviewed and approved the final version of the manuscript. Data Availability Statement: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics Approval: The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department. References Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY et al (2012) Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg 16(9):1727–1735 Christopher CN, Kang DW, Wilson RL, Gonzalo-Encabo P, Ficarra S, Heislein D et al (2023) Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review. Nutrients. ;15(24) Chang PJ, Hendifar AE, Gresham G, Ngo-Huang A, Oberstein PE, Parker N et al (2025) Exercise Guidelines in Pancreatic Cancer Based on the Dietz Model. Cancers (Basel). ;17(4) Lubbad O, Mahmood WU, Shafique S, Singh KK, Khera G, Sajid MS (2025) Effect of prehabilitation in patients undergoing hepatobiliary and pancreatic cancer resections: A systematic review and meta-analysis. World J Gastrointest Endosc 17(9):109029 Molenaar CJL, Minnella EM, Coca-Martinez M, Ten Cate DWG, Regis M, Awasthi R et al (2023) Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 158(6):572–581 Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196 Joliat GR, Kobayashi K, Hasegawa K, Thomson JE, Padbury R, Scott M et al (2023) Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 47(1):11–34 Melloul E, Lassen K, Roulin D, Grass F, Perinel J, Adham M et al (2020) Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 44(7):2056–2084 Dunne DF, Jack S, Jones RP, Jones L, Lythgoe DT, Malik HZ et al (2016) Randomized clinical trial of prehabilitation before planned liver resection. Br J Surg 103(5):504–512 Luther A, Gabriel J, Watson RP, Francis NK (2018) The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review. World J Surg 42(9):2781–2791 Dagorno C, Sommacale D, Laurent A, Attias A, Mongardon N, Levesque E et al (2022) Prehabilitation in hepato-pancreato-biliary surgery: A systematic review and meta-analysis. A necessary step forward evidence-based sample size calculation for future trials. J Visc Surg 159(5):362–372 Tsukagoshi M, Harimoto N, Araki K, Kubo N, Watanabe A, Igarashi T et al (2021) Impact of preoperative nutritional support and rehabilitation therapy in patients undergoing pancreaticoduodenectomy. Int J Clin Oncol 26(9):1698–1706 Chu P, Wang Z, Zhi L (2022) Effects of accelerated rehabilitation surgery on the clinical prognosis of patients undergoing pancreaticoduodenectomy for pancreatic cancer. Minerva Gastroenterol (Torino) 68(2):253–255 Yao B, Chen Y, Chen H, Feng X, Ma X (2025) Study on the role of postoperative rehabilitation based on the ERAS concept for patients undergoing pancreaticoduodenectomy: Protocol for a randomized controlled clinical trial. Adv Clin Exp Med 34(5):821–829 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8977273","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600865257,"identity":"0a812a7c-2116-47d5-b435-f9a25448ea49","order_by":0,"name":"Pipit Burasakarn","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAs0lEQVRIiWNgGAWjYFACHiA+YAPnJhCrJQ3GMyBay2EStJhL9x77+OPM+Tz+aQcYP/xg+JNHUIvlnHPJs3lu3C6WuJ3ALNnDYFBMUIvBjRxjZoYPtxM3SCcwSAP5iQ3EaGH88eEcSAvzb6K1MPDcOADSwkacLSC/MPOcSQb6JbHNssfAmLAWYIgdZvxxzC6Pf3by4Rs/KuSIcJgEhE5gYGAEKjYgpB5VyygYBaNgFIwCHAAAWS89+IE9pVsAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-7239-3646","institution":"Phramongkutklao Hospital","correspondingAuthor":true,"prefix":"","firstName":"Pipit","middleName":"","lastName":"Burasakarn","suffix":""},{"id":600865258,"identity":"c5488eef-45b3-46fd-ad7a-1ab9fcde8e8d","order_by":1,"name":"Nattaporn Maneepairoj","email":"","orcid":"","institution":"Phramongkutklao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nattaporn","middleName":"","lastName":"Maneepairoj","suffix":""},{"id":600865259,"identity":"aa231de1-db8a-4fbb-aecc-10a6188fd079","order_by":2,"name":"Vachiraluck Chalokool","email":"","orcid":"","institution":"Phramongkutklao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vachiraluck","middleName":"","lastName":"Chalokool","suffix":""},{"id":600865260,"identity":"1075e6e9-5d7f-4153-803e-14f45e25ca5b","order_by":3,"name":"Anuparp Thienhiran","email":"","orcid":"","institution":"Phramongkutklao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anuparp","middleName":"","lastName":"Thienhiran","suffix":""},{"id":600865261,"identity":"99aeadcf-5229-4c77-af09-4badde6c0e0f","order_by":4,"name":"Sermsak Hongjinda","email":"","orcid":"","institution":"Phramongkutklao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sermsak","middleName":"","lastName":"Hongjinda","suffix":""},{"id":600865262,"identity":"ee6d7573-d1cd-4e86-aed2-4ce10a9f7ed9","order_by":5,"name":"Pusit Fuengfoo","email":"","orcid":"","institution":"Phramongkutklao Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pusit","middleName":"","lastName":"Fuengfoo","suffix":""}],"badges":[],"createdAt":"2026-02-26 11:37:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8977273/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8977273/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104373992,"identity":"795deca9-6787-4b85-98e1-25cec5d3a848","added_by":"auto","created_at":"2026-03-11 06:04:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54686,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFlowchart of Participants and Setting. Comparing the Historical Control Group (2020-2021) and Prehabilitation Group (2022-2023).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8977273/v1/bbd86af7ae5e86a8e3cc6890.jpg"},{"id":104373991,"identity":"5386eac8-8087-4c08-8ee0-4fad1e82f924","added_by":"auto","created_at":"2026-03-11 06:04:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":80220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe Multimodal Prehabilitation Program\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8977273/v1/1cb5129275babd06299c7678.jpg"},{"id":104406101,"identity":"2afdd643-302f-4f77-a758-054ebd05527d","added_by":"auto","created_at":"2026-03-11 12:24:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1087930,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8977273/v1/314b6f80-4318-40ca-8a74-8d0608dd9c09.pdf"}],"financialInterests":"","formattedTitle":"Impact of a Multimodal Prehabilitation Program on Perioperative Outcomes in Hepatopancreatobiliary Surgery: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMajor abdominal surgeries, particularly hepato-pancreato-biliary (HPB) resections, present significant clinical challenges. These complex procedures are associated with substantial risks of postoperative complications, leading to prolonged hospitalizations, increased mortality, and elevated healthcare costs. Approximately 18% of patients undergoing these surgeries experience major complications within 30 days, with mortality rates reaching 2.7% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrehabiliation has emerged as a proactive approach to address these challenges. It involves preparing patients both physically and psychologically before surgery[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], aiming to enhance their overall health and functional capacity. By implementing personalized exercise and providing psychological support tailored to individual needs, prehabilitation seeks to mitigate the risks associated with surgery and improve recovery outcomes.\u003c/p\u003e \u003cp\u003eIn the context of hepato-biliary and pancreas surgery, where the stakes are particularly high due to the complexity of procedures and potential for postoperative complication, the role of prehabilitation becomes increasingly pertinent. This approach not only aims to reduce the incidence of complication but also strives to shorten recovery times, improve patients satisfaction, and ultimately decrease healthcare costs associated with prolonged hospital stays and intensive care [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the impact of prehabilitation on perioperative outcomes in hepatobiliary and pancreas surgery, specifically focusing on postoperative complication, morbidity and 30 days mortality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Ethics\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study was conducted at Phramongkutklao Hospital. The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department. Informed consent from each patient was waived owing to the retrospective design of the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Setting\u003c/h3\u003e\n\u003cp\u003eData was collected from electronic medical records of patients undergoing hepatectomy and pancreatectomy between January 2020 and December 2023. A standardized multimodal prehabilitation program was implemented institution-wide in January 2022. Consequently, the study compared two cohorts: a Prehabilitation Group (patients operated on between January 2022 and December 2023) and a Historical Control (Non-Prehabilitation) Group (patients operated on between January 2020 and December 2021). (Shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIntervention\u003c/em\u003e: The Prehabilitation Program The prehabilitation protocol consisted of a 4-week preoperative regimen focusing on four pillars: exercise, nutrition, psychological support, and smoking cessation:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExercise\u003c/strong\u003e \u003cp\u003eUnsupervised moderate aerobic exercise (30 minutes/day, 3 times/week) and respiratory training using a triflow spirometer (5\u0026ndash;10 times/hour).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNutrition\u003c/strong\u003e \u003cp\u003eDietary optimization guided by a nutritionist, targeting 30\u0026ndash;35 kcal/kg/day and 1.5 g/kg/day of protein, supplemented with multivitamins and Vitamin D.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePsychology\u003c/strong\u003e \u003cp\u003eMandatory consultation with a psychologist to manage anxiety and stress.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePostoperative Care\u003c/strong\u003e \u003cp\u003eAll patients in the prehabilitation group were managed under an Enhanced Recovery After Surgery (ERAS) pathway [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] (shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eOutcomes and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were perioperative complications, defined according to the Clavien-Dindo classification [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and 30-day mortality. Continuous variables were compared using the Student\u0026rsquo;s t-test or the Mann\u0026ndash;Whitney U test and are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range [IQR]). Categorical variables were analyzed using the Chi-square test or Fisher\u0026rsquo;s exact test and are reported as counts (percentages). All analyses were performed using STATA/IC 14.0 (StataCorp), with statistical significance defined as a two-sided P value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and Clinical Characteristics\u003c/h2\u003e \u003cp\u003eA total of 359 patients were included in the analysis: 197 in the Prehabilitation group (149 hepatectomy, 48 pancreatectomy) and 162 in the Non-Prehabilitation group (104 hepatectomy, 58 pancreatectomy). In the Prehabilitation group, the mean age was 60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2 years, 68% were male, and the mean BMI was 24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 kg/m\u0026sup2;. Baseline body weight and BMI did not differ significantly between groups. However, serum albumin levels within 3 days before surgery were significantly higher in the Prehabilitation group compared to controls (4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42 g/dL vs. 3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 g/dL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the change in serum albumin from diagnosis to surgery was significantly more favorable in the Prehabilitation group (+\u0026thinsp;0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35 vs. \u0026minus;0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These differences persisted in both hepatectomy and pancreatectomy subgroups. (shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Prehabilitation group (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrehabilitation\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHepatectomy Non-Prehabilitation (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatectomy prehabilitation (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePancreatectomy Non-Prehabilitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePancreatectomy prehababilitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.99\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.81\u0026thinsp;\u0026plusmn;\u0026thinsp;13.19\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.566\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.47\u0026thinsp;\u0026plusmn;\u0026thinsp;12.36\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.68\u0026thinsp;\u0026plusmn;\u0026thinsp;12.17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e59.14\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e61.23\u0026thinsp;\u0026plusmn;\u0026thinsp;16.09\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e76 (73.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e110 (73.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e26 (44.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.595\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Weight\u003c/p\u003e \u003cp\u003e(Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.41\u0026thinsp;\u0026plusmn;\u0026thinsp;12.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.01\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e66.84\u0026thinsp;\u0026plusmn;\u0026thinsp;12.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e62.85\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e62.83\u0026thinsp;\u0026plusmn;\u0026thinsp;14.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight\u003c/p\u003e \u003cp\u003e(CM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e163.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e165.19\u0026thinsp;\u0026plusmn;\u0026thinsp;7.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e161.95\u0026thinsp;\u0026plusmn;\u0026thinsp;7.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e161.15\u0026thinsp;\u0026plusmn;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003cp\u003e(Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.63\u0026thinsp;\u0026plusmn;\u0026thinsp;4.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e23.92\u0026thinsp;\u0026plusmn;\u0026thinsp;3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin at diagnosis\u003c/p\u003e \u003cp\u003e(g/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin Before Surgery\u003c/p\u003e \u003cp\u003e(g/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin difference\u003c/p\u003e \u003cp\u003e(g/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.017*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e44 (75.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e37 (77.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (65.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e92 (88.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e128 (85.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor hepatectomy\u003c/p\u003e \u003cp\u003ePancreaticoduodenectomy\u003c/p\u003e \u003cp\u003eDistal pancreatectomy\u003c/p\u003e \u003cp\u003eOthers pancreatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30 (28.84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e55 (36.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e43 (74.13%)\u003c/p\u003e \u003cp\u003e13 (22.42%)\u003c/p\u003e \u003cp\u003e2 (3.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e37 (77.08%)\u003c/p\u003e \u003cp\u003e10 (20.83%)\u003c/p\u003e \u003cp\u003e1 (2.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eIndependent t test and Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative Outcomes\u003c/h2\u003e \u003cp\u003eThe Prehabilitation group demonstrated significantly favorable intraoperative metrics. Operative time was shorter (300 vs. 310 min, P\u0026thinsp;=\u0026thinsp;0.037) and estimated blood loss was lower (400 vs. 500 mL, P\u0026thinsp;=\u0026thinsp;0.002) compared to the control group. Subgroup analysis revealed these benefits were consistent in pancreatectomy patients (Operative time: P\u0026thinsp;=\u0026thinsp;0.048; Blood loss: P\u0026thinsp;=\u0026thinsp;0.008). Additionally, the requirement for blood transfusion was significantly lower in the hepatectomy subgroup (P\u0026thinsp;=\u0026thinsp;0.036).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative Outcomes\u003c/h3\u003e\n\u003cp\u003eThe length of hospital stay (LOS) was significantly shorter in the Prehabilitation group (median 6 vs. 9 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This reduction was observed in both hepatectomy (6 vs. 7.5 days, P\u0026thinsp;=\u0026thinsp;0.042) and pancreatectomy (7 vs. 13 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) subgroups. ICU length of stay did not differ between groups. Overall morbidity was significantly lower in the Prehabilitation group (58 vs. 76 events, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, major morbidities were significantly reduced in the pancreatectomy subgroup. There was no statistically significant difference in 30-day mortality between the groups (shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Prehabilitation group (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrehabilitation\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHepatectomy Non-Prehabilitation (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHepatectomy prehabilitation (n\u0026thinsp;=\u0026thinsp;149)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePancreatectomy Non-Prehabilitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePancreatectomy prehabilitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e310 (240, 480)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e300 (240, 360)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240 (200, 360)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e250 (210, 300)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e510 (420, 600)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e480 (360, 540)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.048*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss(ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500 (300, 1000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400 (200, 700)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e500 (250, 1000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e400 (200, 700)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e600 (400, 1000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e425 (225, 725)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for blood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (22.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.036\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26 (44.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e20 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (1, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (0, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (2, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehospital stay(day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6, 12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.5 (6, 9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (5, 9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.042*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13 (10, 15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7 (6, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Morbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (46.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (29.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (31.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (13.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e43 (74.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e38 (79.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (24.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (20.93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 (7.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.017*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorbidities\u003c/p\u003e \u003cp\u003e(Clavien-Dindo\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality, yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.847\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eIndependent t test or Mann-Whitney test and Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that a multimodal prehabilitation program is associated with improved perioperative outcomes in patients undergoing major HPB surgery. We observed significant reductions in operative time, blood loss, length of hospital stays, and overall morbidity following the implementation of our institutional protocol.\u003c/p\u003e \u003cp\u003eThe surgical management of hepatopancreatobiliary (HPB) malignancies, specifically through hepatectomy and pancreatectomy, represents some of the most physiologically demanding procedures in modern medicine. As the patient demographic for these surgeries increasingly includes older and frailer individuals, the concept of prehabilitation, a multimodal intervention involving exercise, nutritional optimization, and psychological support, has gained prominence. While prehabilitation offers significant clinical benefits by enhancing physiological reserve, it also presents logistical and oncological challenges that must be critically evaluated.\u003c/p\u003e \u003cp\u003eThe primary argument for implementing prehabilitation is the mitigation of postoperative morbidity through the improvement of \"functional reserve.\" Patients with pancreatic and liver cancers often present with malnutrition and sarcopenia, both of which are independent predictors of poor surgical outcomes. A landmark randomized clinical trial by Dunne et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. demonstrated that a four-week structured exercise program significantly improved aerobic capacity in patients undergoing liver resection. Consequently, these patients exhibited a greater resilience to surgical stress, leading to reduced postoperative complications and shorter hospital stays. Furthermore, prehabilitation empowers patients, transforming them from passive recipients of care into active participants, which can significantly alleviate preoperative anxiety and improve overall quality of life.\u003c/p\u003e \u003cp\u003eHowever, the implementation of prehabilitation is not without significant disadvantages. The most pressing concern regarding hepatectomy and pancreatectomy is the delay to surgery. In the context of aggressive malignancies such as pancreatic ductal adenocarcinoma, the window for curative resection is narrow. There is a theoretical concern that delaying surgery by four to six weeks to accommodate a prehabilitation program could allow for tumor progression or metastasis. While a systematic review by Luther et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] suggests that a short delay for prehabilitation does not negatively impact oncological survival, the anxiety regarding tumor growth remains a significant psychological burden for patients and clinicians alike.\u003c/p\u003e \u003cp\u003eWhile the clinical benefits of prehabilitation are increasingly recognized, rigorous statistical validation remains a priority for the surgical community to standardize care. Dagorno et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] conducted a critical systematic review and meta-analysis published in the Journal of Visceral Surgery to address the heterogeneity in current research. Their analysis confirmed that prehabilitation significantly reduces overall morbidity, specifically pulmonary complications, in hepato-pancreato-biliary (HPB) surgery. However, they notably emphasized the need for higher-quality evidence, providing specific sample size calculations to guide future randomized controlled trials. This work underscores that while the current signal for benefit is strong, powering future studies correctly is a \"necessary step forward\" to firmly establish these protocols as the undisputed standard of care.\u003c/p\u003e \u003cp\u003eIn the specific context of pancreaticoduodenectomy, the integration of nutritional support with physical therapy appears to be particularly effective. Tsukagoshi et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] demonstrated that a combined preoperative strategy of rehabilitation and nutritional support could mitigate the impact of sarcopenia, a common condition in pancreatic cancer patients that severely compromises recovery. Their findings suggest that optimizing nutritional status is a prerequisite for effective physical rehabilitation; without it, exercise alone may not yield the desired physiological resilience required for such invasive procedures.\u003c/p\u003e \u003cp\u003eFinally, prehabilitation must be viewed as the foundational step in the broader continuum of \"accelerated rehabilitation\" and Enhanced Recovery After Surgery (ERAS). Chu et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] observed that accelerated rehabilitation protocols significantly improve the clinical prognosis of patients undergoing pancreaticoduodenectomy, suggesting that preoperative preparation is essential for enabling this rapid postoperative recovery. This holistic approach is currently driving new research frontiers, as evidenced by Yao et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Their recently published protocol for a randomized controlled trial highlights the evolving focus on integrating postoperative rehabilitation based on ERAS concepts, reinforcing the idea that surgical success depends on a seamless transition from preoperative optimization to postoperative reconditioning.\u003c/p\u003e \u003cp\u003eA primary concern in oncologic prehabilitation is the potential delay to surgery. However, our program was integrated without compromising oncologic safety, aligning with systematic reviews suggesting that the benefits of physical optimization outweigh the theoretical risks of short delays.\u003c/p\u003e \u003cp\u003eInterestingly, we observed improvements in intraoperative factors such as blood loss and operative time. While prehabilitation primarily targets patient physiology, these findings may reflect the synergistic effect of the ERAS pathway applied postoperatively in the intervention group, or potentially better patient compliance and physiological tolerance during anesthesia.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, it is a single-center, retrospective study using a historical control, which introduces potential bias from temporal changes in surgical technique or perioperative care independent of prehabilitation. Second, the ERAS protocol was applied specifically to the prehabilitation group, making it difficult to isolate the effect of prehabilitation from postoperative ERAS components. Future large-scale randomized controlled trials are warranted to validate these findings and standardize protocols.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn conclusion\u003c/b\u003e,\u003c/p\u003e \u003cp\u003eThe implementation of a multimodal prehabilitation program is associated with significantly reduced postoperative morbidity, shorter hospital stays, and improved intraoperative metrics in patients undergoing major HPB surgery. These findings support the integration of prehabilitation into standard surgical pathways to optimize recovery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Royal Thai Army Medical Department.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePB: Study concept, design, data analysis, and writing the manuscript.\u003c/p\u003e\n\u003cp\u003eNM, VC: Data collection and interpretation.\u003c/p\u003e\n\u003cp\u003eAT: Data collection and critical review.\u003c/p\u003e\n\u003cp\u003ePF: Statistical analysis and editing.\u003c/p\u003e\n\u003cp\u003eSH: Study supervision and final approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor\u0026nbsp;\u003c/strong\u003ePipit Burasakarn, MD, PhD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHyperlink to your specific registration (must be publicly accessible and will be checked)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement to obtain written informed consent from each patient was waived because of the study’s retrospective design.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot commissioned, externally peer-reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors declare that this study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e PB: Study concept, design, data analysis, and writing the manuscript. NM, VC: Data collection and interpretation. AT: Data collection and critical review. PF: Statistical analysis and editing. SH: Study supervision and final approval. All authors have reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY et al (2012) Risk of morbidity and mortality following hepato-pancreato-biliary surgery. J Gastrointest Surg 16(9):1727\u0026ndash;1735\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristopher CN, Kang DW, Wilson RL, Gonzalo-Encabo P, Ficarra S, Heislein D et al (2023) Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review. Nutrients. ;15(24)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang PJ, Hendifar AE, Gresham G, Ngo-Huang A, Oberstein PE, Parker N et al (2025) Exercise Guidelines in Pancreatic Cancer Based on the Dietz Model. Cancers (Basel). ;17(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLubbad O, Mahmood WU, Shafique S, Singh KK, Khera G, Sajid MS (2025) Effect of prehabilitation in patients undergoing hepatobiliary and pancreatic cancer resections: A systematic review and meta-analysis. World J Gastrointest Endosc 17(9):109029\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolenaar CJL, Minnella EM, Coca-Martinez M, Ten Cate DWG, Regis M, Awasthi R et al (2023) Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 158(6):572\u0026ndash;581\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187\u0026ndash;196\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoliat GR, Kobayashi K, Hasegawa K, Thomson JE, Padbury R, Scott M et al (2023) Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 47(1):11\u0026ndash;34\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelloul E, Lassen K, Roulin D, Grass F, Perinel J, Adham M et al (2020) Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 44(7):2056\u0026ndash;2084\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunne DF, Jack S, Jones RP, Jones L, Lythgoe DT, Malik HZ et al (2016) Randomized clinical trial of prehabilitation before planned liver resection. Br J Surg 103(5):504\u0026ndash;512\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuther A, Gabriel J, Watson RP, Francis NK (2018) The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review. World J Surg 42(9):2781\u0026ndash;2791\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDagorno C, Sommacale D, Laurent A, Attias A, Mongardon N, Levesque E et al (2022) Prehabilitation in hepato-pancreato-biliary surgery: A systematic review and meta-analysis. A necessary step forward evidence-based sample size calculation for future trials. J Visc Surg 159(5):362\u0026ndash;372\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsukagoshi M, Harimoto N, Araki K, Kubo N, Watanabe A, Igarashi T et al (2021) Impact of preoperative nutritional support and rehabilitation therapy in patients undergoing pancreaticoduodenectomy. Int J Clin Oncol 26(9):1698\u0026ndash;1706\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu P, Wang Z, Zhi L (2022) Effects of accelerated rehabilitation surgery on the clinical prognosis of patients undergoing pancreaticoduodenectomy for pancreatic cancer. Minerva Gastroenterol (Torino) 68(2):253\u0026ndash;255\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYao B, Chen Y, Chen H, Feng X, Ma X (2025) Study on the role of postoperative rehabilitation based on the ERAS concept for patients undergoing pancreaticoduodenectomy: Protocol for a randomized controlled clinical trial. Adv Clin Exp Med 34(5):821\u0026ndash;829\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8977273/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8977273/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Hepato-pancreato-biliary (HPB) surgeries carry high risks of postoperative complications. This study evaluates the impact of a multimodal prehabilitation program on perioperative outcomes in patients undergoing hepatectomy and pancreatectomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: We conducted a retrospective cohort study at Phramongkutklao Hospital involving patients operated on between 2020 and 2023. Patients were divided into a Prehabilitation group (2022–2023, n=197), who underwent a 4-week program of exercise, nutritional support, and psychological counseling, and a historical Control group (2020–2021, n=162). Primary outcomes were postoperative complications and 30-day mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: The Prehabilitation group showed significantly improved preoperative serum albumin levels compared to controls (p \u0026lt; 0.001). Intraoperatively, the Prehabilitation group had significantly shorter operative times (300 vs. 310 min, p=0.037) and reduced blood loss (400 vs. 500 ml, p=0.002). Postoperatively, the Prehabilitation group exhibited a significantly shorter length of hospital stay (median 6 vs. 9 days, p \u0026lt; 0.001) and lower overall morbidity (p \u0026lt; 0.001). No significant difference was observed in 30-day mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: Multimodal prehabilitation effectively reduces hospital stay, blood loss, and postoperative complications in HPB surgery, supporting its implementation to optimize surgical recovery.\u003c/p\u003e","manuscriptTitle":"Impact of a Multimodal Prehabilitation Program on Perioperative Outcomes in Hepatopancreatobiliary Surgery: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 06:04:21","doi":"10.21203/rs.3.rs-8977273/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3db84264-5eec-4133-a4a6-b3dde4b05ad4","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T06:04:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 06:04:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8977273","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8977273","identity":"rs-8977273","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}