Evaluating the Impact of Multimodal Prehabilitation with High Protein Oral Nutritional Supplementation (HP ONS) with Beta-Hydroxy Beta-Methylbutyrate (HMB) on Sarcopenic Surgical Patients-Interim Analysis of the HEROS Study

Abstract

Background: Multimodal prehabilitation programs, which may incorporate nutritional supplementation and exercise, have been developed to combat sarcopenia in surgical patients to enhance post-operative outcomes. However, the optimal regime remains unknown. The use of beta-hydroxy beta-methylbutyrate (HMB) has beneficial effects on muscle mass and strength. However, its effect on muscle quality in the perioperative setting has yet to be established. This study aims to explore the impact of a multimodal prehabilitation program using a bundle of care that includes high-protein oral nutritional supplementation (HP ONS) with HMB and resistance exercise on muscle quality and functional outcomes in sarcopenic surgical patients.

Methods: Sarcopenic adult patients undergoing elective major gastrointestinal surgeries were recruited for this pilot interventional cohort study. They were enrolled in a 2-4-week multimodal prehabilitation program comprising resistance exercise, nutritional supplementation, vitamin supplementation, comorbid optimization and smoking cessation. Participants were provided three units of HP ONS with HMB per day pre-operatively. The primary outcome was changes in intramuscular adipose tissue (IMAT) as a proxy of muscle quality, assessed using Artificial Intelligence (AI)-aided ultrasonography. Secondary outcomes include changes in anthropometric measurements and functional characteristics. Outcomes were measured before prehabilitation, after prehabilitation and 1 month post-operatively.

Results: A total of 36 sarcopenic patients, with a median age of 71.5 years, were included in this study. There was an increase in the IMAT index after two weeks of prehabilitation (p = 0.032) to 1 month after surgery (p = 0.028). Among functional parameters, improvement was observed in gait speed (p = 0.01) after two weeks of prehabilitation, which returned to baseline post-operatively. The median length of hospital stay was 7 (range: 2-75) days.

Conclusions: The increase in the IMAT index in a sarcopenic surgical cohort undergoing prehabilitation may be due to altered muscle metabolism in elderly sarcopenic patients. A prehabilitation regime in sarcopenic patients incorporating HP ONS with HMB and resistance exercise is feasible and is associated with increased gait speed.

Keywords: beta-hydroxy beta-methylbutyrate; intramuscular adipose tissue; oral nutritional supplementation; prehabilitation; sarcopenia.

Figure 1

A patient’s peri-operative journey through the HEROS study.

Figure 2

Box and whiskers plot of the IMAT index over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month), which showed a significant increase from Week 0 to Week 2, that is sustained to Post-Op 1 Month. IMAT: intramuscular adipose tissue. ***: p < 0.05. ∘: outlier > 1.5 standard deviations from the mean.

Figure 3

Box and whiskers plot of ultrasound-derived IMAT index over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month) for the subgroup analysis of patients aged ≥ 65 years, which shows a significant increase after prehabilitation. IMAT: intramuscular adipose tissue. ***: p < 0.05. ∘: outlier > 1.5 standard deviations from the mean.

Figure 4

Box and whiskers plot of physiotherapist-measured outcomes over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month). (a) Handgrip strength, (b) 30 s chair rise, (c) functional reach, (d) 6-min walk test, and (e) gait speed. 6-min walk test and gait speed both showed improvement from Week 0 to Week 2, before returning to baseline at Post-Op 1 Month. ***: p < 0.05. ∘: outlier > 1.5 standard deviations from the mean.

Figure 4

Box and whiskers plot of physiotherapist-measured outcomes over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month). (a) Handgrip strength, (b) 30 s chair rise, (c) functional reach, (d) 6-min walk test, and (e) gait speed. 6-min walk test and gait speed both showed improvement from Week 0 to Week 2, before returning to baseline at Post-Op 1 Month. ***: p < 0.05. ∘: outlier > 1.5 standard deviations from the mean.

Figure 5

Box and whiskers plot of dietitian-measured outcomes over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month), of which none were statistically significant. (a) Mid-arm circumference, (b) mid-arm muscle circumference, (c) mid-arm muscle area and (d) triceps skinfold. *: far outlier > 3 standard deviations from the mean. ∘: outlier > 1.5 standard deviations from the mean.

Figure 6

Box and whiskers plot of (a) weight and (b) BMI over the peri-operative window (Week 0, Week 2 and Post-Op 1 Month). While statistically significant, the actual change in weight and BMI are small and unlikely to be of clinical significance. BMI: body mass index. ***: p < 0.05. ∘: outlier > 1.5 standard deviations from the mean.