Pre-habilitation to Improve Outcomes in Patients Undergoing Liver Resection for Cancer

• Change in six minute walk test [ Time Frame: 8 weeks pre-op and 1 week pre-op ] [ Designated as safety issue: No ]
  The primary outcome is patient-relevant, functional walking capacity as measured by the six-minute walk test (6MWT). The 6MWT evaluates the ability of an individual to maintain a moderate level of physical activity over a time period reflective of the activities of daily living
  
  

• post-operative complications [ Time Frame: 30 days ] [ Designated as safety issue: No ]
  Postoperative complications including surgical site infection, other infectious complications (such as pneumonia, urinary tract infection, line sepsis), bile leak, hemmorrhage, deep vein thrombosis, etc., will be recorded and scored using the Clavien Classification.
  
  
• Health-related quality of life (HRQL) [ Time Frame: 8 and 1 week pre-operatively, 4 and 8 weeks post-operatively ] [ Designated as safety issue: No ]
  Health-related quality of life (HRQL) as measured by the acute (1 week recall period) SF-36 health survey. The SF-36 is the most widely used HRQL measure and has been validated for surgical population; Canadian norms are also available.
  
  
• Physical activity level [ Time Frame: 8 and 1 weeks pre-operatively, 4 and 8 weeks post-operatively ] [ Designated as safety issue: No ]
  Physical activity level will be measured through the Community Health Activities Model Program for Seniors (CHAMPS) questionnaire. The CHAMPS is a self-reported measure of physical activity, comprising 41 activities evaluated according to the total number of hours done during an average week.
  
  
• Depression and anxiety [ Time Frame: 8 and 1 weeks pre-operatively, 4 and 8 weeks post-operatively ] [ Designated as safety issue: No ]
  Depression and anxiety will be assessed by The Hospital Anxiety and Depression Scale (HADS), a 14-question measure with seven items each for depression and anxiety. HADS generates separate scores for anxiety and depression as well as a combined score of psychological distress.
  
  
• Fatigue [ Time Frame: 8 and 1 weeks pre-operatively, 4 and 8 weeks post-operatively ] [ Designated as safety issue: No ]
  Fatigue will be assessed using a visual analog scale (1-10) and the Brief Fatigue Inventory (BFI). The BFI assesses the level of fatigue and its impact on activities of daily living44
  
  
• Nutritional status [ Time Frame: 8 and 1 weeks pre-operatively, 4 and 8 weeks post-operatively ] [ Designated as safety issue: No ]
  Nutritional status will be assessed through subjective and objective evaluations.Body composition will be measured by bioimpedance assay.Assessment of usual food intake will be performed using the 3-day, 24-hour food recall method. The scored Patient Generated Subjective Global Assessment (sPG-SGA) is a validated questionnaire used to assess the nutritional and functional status of cancer patients.
  
  

Patients scheduled for elective liver resection be will be approached andrandomized to one of two groups using a computer generated block randomisation scheme. The first group (pre-hab) will receive both nutritional supplementation and a prehabilitation program as outlined below. The second group (nutrition) will receive only nutritional supplementation. Both groups will be given a post-operative exercise program.

Once randomized, the subjects will be called by the research co-ordinator and an appointment will be made for the initial assessment. After the study is explained and consent obtained, subjects will be tested on 6MWT, followed by a 30 minute rest period during which various questionnaires assessing physical activity, quality of life, fatigue and nutritional status will be completed with the aid of the coordinator.

The prehabilitation program will last a minimum of four weeks and a maximum of 8 weeks.

Surgery will be performed by one of the HPB surgeons at the McGill University Health Center. Surgical approach, including laparoscopic or open surgery will be at the discretion of the surgeon. Perioperative care will follow an Enhanced Recovery After Surgery (ERAS)-based clinical care pathway27, 28, a fast-track care plan including patient education, afferent neural blockade, multimodal analgesia, early oral intake and mobilization, early removal of catheters and drains, and a planned 6-8 day hospital admission. This pathway has already been implemented at the Royal Victoria Hospital as part of standard patient care.