Evidence-Based Practice of Early Post-Operative Mobilization for Whipple Surgery Patients' Selected Outcomes

Background: Early postoperative mobilization is an important aspect of postoperative care, as it has been demonstrated to improve a range of patient-reported outcomes. Aim of the study: The present study aims to evaluate the effect of evidence-based practice of early post-operative mobilization for Whipple surgery patients' selected outcomes . Subjects and method: Design : A quasi-experimental research design was used to achieve the purpose of the present study . Subjects: convenience sample consists of 60 subjects who underwent Whipple surgery and were assigned randomly into two equal groups (study and control), thirty patients in each group. Tools of data collection: The researchers used four tools to achieve the study aim and collect the required data as follows: Tool I: Structured interview. Tool II: Visual analog pain scale (VAS). Tool III: Six-Minute Walking Test. Tool IV : Evaluation of the incidence of postoperative complications. Results: There were statistically significant differences between the control and study groups on the 6th day indicating that the study group had a higher mean distance walk than the control group (14.4 + 2.4 & 3.8 + 0.6) respectively. The study group had lower mean pain scores than control group ( 3.9 + 0.9 &4.7 + 1) respectively. Also, there were statistically significant differences between the control and study groups in relation to occurrence of falls during the 2nd week (X 2 =4.320, p-value=0.038). Conclusion: the impact of implementing evidence-based mobilization on patient care outcomes corroborates those documented in scholarly works. Recommendation: post-operative Whipple surgery early mobilization according to the patient individual abilities and hemodynamic stabilization should started to be done by surgical nurses for improving patients’ outcomes as falls, distance patient able to walk as well as pain.


Introduction
Despite technical breakthroughs and progress in patient care, major abdominal surgery is one of the surgical applications that result in a considerable loss of functional capacity and complications for patients.In randomized controlled trials (RCTs), the complication rate after major abdominal surgery has been reported as between 30% and 60% (Schwab, Brindl, Studier-Fischer, Tu, Gsenger, et al., 2020).The Whipple procedure is the preferred surgical treatment for resectable and borderline resectable pancreatic ductal adenocarcinoma patients (Jarnagin, Chapman, Dematto, and Vauthey, 2022).The pancreaticoduodenectomy is the only cure for pancreatic cancer (Koyuncu & Iyigun, 2022).Because of the complicated and difficult intraabdominal dissection and digestion system restoration, this surgical treatment presents enormous challenges.This technique has generally been associated with increased mortality and perioperative morbidity due to its complexity.
The effectiveness of pancreaticoduodenectomy is dependent on a careful screening for surgical patients' resectability using an abdominal computed tomography scan.Nurses, physiotherapists, counselors, and oncologists all play critical roles in providing the best possible care to cancer patients (D'Cruz, Misra, and Shamsudeen, 2023).Nurse care is focused on assessing weight, general aches, symptoms, and vital signs.A loss of weight, balance of fluids, nausea, fecal, and urine color must all be checked for patients.Because of the forced loss of pancreatic enzymes, it is critical to check the fatty stool's existence to guarantee optimal lipid intake adjustment.A medical nursing team should ensure that dietary balance is properly assessed before and after surgical therapy.Early postoperative mobility may reduce complications associated with surgery by avoiding prolonged rest in bed (Pederson, Padwal, Warkentin, Holroyd-Leduc, Wagg, et al., 2020).Mobilization procedures are required to achieve early participation.The care plan emphasizes the significance of rigorous preoperative assessment, education, and preparation, as well as meticulous postoperative monitoring and assistance.Nurses have an important role in partnering with the healthcare team, offering comfort and reassurance to individuals and their families, and supporting a quick recovery.The treatment plan also addresses early mobilization protocols to minimize the risks of Whipple operation problems such as infection, pancreatic fistula, and gastrointestinal issues.Effective nursing interventions are required to recognize and address these problems as soon as possible (Sarwar, 2023).
Complications as wound dehiscence (where a wound fails to heal, whereby the wound re-opens in the days following surgery may be caused by poor tissue perfusion), local pain, accidental dislodgment, and short-term readmission are among post-operative complications that commonly occur post Whipple surgery (Rosen & Manna, 2023) 2019), the nursing process approach provides high-quality postsurgery care for patients based on a careful assessment which in turn leads to good planning this planning is reflected in excellent implementation and finally with accurate evaluation and reassessment to provide high quality and best practice care based on evidence-based research, especially for patient post-Whipple surgery.However, post-operative mobilization based on the patient individual abilities should be assessed in the pre and postoperative period.It might involve shifting from sitting to standing and then walking.On POD 1, successful mobilization was defined as remaining upright for more than six hours, and on POD 2, walking for at least thirty meters.Prior to surgery, discuss the postoperative objectives with the patients and their carers and emphasize the advantages of the mobilization protocol with an illustrated pamphlet.Following surgery, the investigator highlights to the patients the advantages of early mobilization.The researcher was in charge of carrying out the mobilization protocol, and by reminding the patients of the necessary time to be mobilized, the patient's choice was also incorporated into this procedure (Tang, Liu, Ma, Lv, Jiang, et al  .However, no supporting data for the effect of evidence-based practice of early post-operative mobilization following Whipple surgery on patients' outcomes, the recent study was aimed to evaluate the effect of evidence-based practice of early post-operative mobilization for Whipple surgery patients' selected outcomes in terms of early mobilization, postoperative pain score, and the incidence of postoperative complications.

Operational definition Whipple Surgery (pancreatoduodenectomy):
Whipple operationally defined as surgery of the pancreas, stomach, duodenum, and biliary duct systems with a duration of less than two hours and with an expected loss of blood of less than 500 ml.Evidence-based practice of early Mobilization It's operationally defined as mobility assessment and intervention to mobilize patients earlier from day 0 postoperative.This also included information on the significance of early mobilization in the postoperative period, how to mobilize, potential scenarios that may arise during mobilization, etc.It might involve shifting from sitting to standing and then walking.Early mobilization: is operationally defined as spending more than six hours on postoperative day one (POD 1) sitting up.

Sample size calculations
The sample size was estimated using the G*Power 3.1.9.7 software application with alpha error probability 0.05, 90% power of the study, and 0.82 effect size (Abdelmowla, Abdelmowla, Taha, Elkoussy, and Sayed, 2023).The calculated sample size was 27 patients for each group and added 10% because of dropout to be 30 patients for each group.

Tools of data collection
Four tools were used by the researchers for collecting the data and achieving the aim of the study as following: Tool I: Structured interview: It was developed by the researchers to collect baseline data to achieve the aim of the study and included the Demographic and clinical data: It consisted of the following items which related to age, gender, work status, education level and marital status, and number of attached drains.

Tool II: The visual analogue pain scale (VAS):
The scale was adopted by Bain, Ondimu, Hallam, and Ashwood (2005).It shows a simple way to record estimates of subjectively of the intensity of pain.Pain intensity was assessed using a 10-centimeter VAS.Participants marked a line on the scale rating from 0 (no pain) to 10 (worst possible pain).The distance in millimeters from the '0' mark to the participant's mark was recorded as the VAS score.

Scoring system
The measurement parameters include five items: -The grade (0) means no pain.
-The grade (10) means worst pain.-Permission was obtained officially from the director of the hospital and the head of the surgical department.

Reliability and validity
-Written consent was obtained from all the participants to participate in the study after clarifying the study's aim, and participants were assured about the confidentiality of the data which would be used only to achieve the aim of the current study.The nature of all tools will not cause any physical or emotional harm to participants.Furthermore, the researchers highlighted that the participation is completely voluntary, and the secrecy of the participants was maintained through coding all data and putting all the files in a closed cabinet.Also, the participants informed that the refusal of participation in the present study would not influence their care.The study would cause no harm to the patients.Patient privacy and confidentiality will be assured.
-Permission to implement the study was obtained officially from the director of setting after submitting an official letter from the Faculty of Nursing Dean explaining the purpose of the study and data collection methods.
- The researchers designed four nursing educational sessions to be provided for the patient and to be conducted for each patient individually.
-The final part includes a table outlining the mobilization management process.Implementation phase -The researchers designed four nursing educational sessions provided for the patient and to be conducted for each patient individually; each session duration was 45to 60 minutes through face-to-face interview to help improve the patient's performance of mobilization.At the end of each session, the researchers review the previously learned information.
-The first training session (theoretical): The intervention group patients were contacted by the researchers in their rooms on the day of admission and information was presented about the training brochure of mobilization.This included information about Whipple surgery, the value of early mobilization, and supporting the incision site in the postoperative period issues that may occur during mobilization and postoperative complications.
-The second session (practical) patients were provided training about the evidencebased mobilization protocol and how to do mobilization post-surgery which included: Starting from day zero in which the patient was still confined to bed, the mobilization in this phase was positioning (every two hours' side lying, high fowler and supine position.Furthermore, the range of motion exercises of each joint as flexion, extension, internal and external rotation, and dorsiflexion.repeated five times for each joint.At the end of the session allow patient time for revision and reinforcement.Also, the researchers enabled each patient to redemonstrate the previously learned exercise. -The third training session (practical): once patients stabilized on day one postoperatively in the intermediate care unit, started sitting in bed and dangling their legs as follows: -Instruct the patient to bend both knees and place his/her feet firmly on the bed.Turn to the side and keep the shoulders and hips straight.the bowed knees should be towards the edge of the bed and push the upper hand down into the mattress, bringing the lower elbow underneath his/herself.Then push down on his/her arms while lowering the legs on the side of the bed to sit up.Sit at the edge of the bed, hands on the mattress for support.Repeat five times as tolerated.-Also, perform belly breathing exercises and support the incision site as follows: belly breathing exercises: patient educated to inhale deeply and gently through the nose, widening the lower rib cage and allowing the abdominal (belly) to travel forward.Hold for three to five seconds.Then exhale gently and completely through pursed lips.
Moreover, not to force his/her breath out.
Repeat once every hour.-from day two till discharge patients can start sitting on a chair beside the bed, walking around inside the room then walking in the corridor of the unit starting by 10 -15-minute walk and then increasing gradually.At the end of the session allow the patient time for revision and reinforcement along with redemonstration of previously learned exercises.
-The fourth session:(practical session) -Pelvic tilt exercise: The patient is trained to sleep flat supine with knees bent then gently rock the pelvis up and flatten his/her back on the bed.also, rock back to the starting point and repeat 5 times, 2-3 times a day in the first two weeks after surgery.
-Ankle pumped exercise: The patient was educated to move his/her ankles up and down for one minute and then relax both feet.Instruct the patient to repeat five times and then relax.-Redemonstrate all exercises learned in the previous sessions.At the end of the session allow the patient to freely ask questions and answer them.
-Evaluation -At day zero postoperatively, mobilization was assessed and recorded for each patient of both groups using tools II and III.
-Moreover, for both groups, data regarding the mobilization training and the process, time of passage of flatus, and postoperative pain.
-Each patient of both groups was assessed for the development of postoperative complications using tool IV.
-  (2) shows that both the control and the study groups were unable to walk on the first day, and the control group was unable to walk until the third day, while the study group started walking on the second day.Moreover, there were significant statistical variations between both groups on 2 nd day (t-test=8.515,p-value=0.000)till the last day of the study on the 6 th day (t-test=23.376,p-value=0.000),indicating that the study group had higher mean distance walk than the control group Table (3) shows that there was no statistically significant difference between control and study groups during the 1st and 2 nd days of the study.There was a statistically significant difference between the control and study groups since 3 rd day (t-test=4.181,p-value=0.000)till the last day of the study at the 6 th day (t-test=3.500,p-value=0.001),indicating that the study group had lower mean pain scores than the control group.

Table (4)
shows that there were significant statistical variations between both groups regarding the occurrence of falls during 1 st week (X 2 =5.934, p-value=0.015)and 2 nd week (X 2 =4.320, p-value=0.038).Additionally, there were no significant statistical differences between both groups about the incidence of accidental drain dislodgment and wound dehiscence.However, the control group had a greater readmission rate than the study group, which is statistically significant at p-value=0.02Research evidence concluded that early postoperative mobilization has been linked to significantly lower complication rates and better postoperative outcomes (Nishijima, Baba, Murotani, Tokai, Watanabe et al., 2020; Rosowicz, Brody, Lazar, Bangla, Panahi et al., 2022).Also, the present study aimed to evaluate the effect of evidence-based practice of early post-operative mobilization for Whipple surgery patients' selected outcomes in terms of early mobilization, postoperative pain score, and the incidence of postoperative complications.The study results proved that all medical and demographic variables did not have significant change statistically between both groups, with male patients primarily in the fifty-and sixtyyear-old age range dominating both categories.The findings were consistent with Egyptian research conducted by Abdelmowla et al., (2023) on patients undergoingpancreatoduodenectomy.The study examined the effect of nursing instructions and oral postoperative nutritional supplementation on patient outcomes and found there was no significant statistical difference in both medical data and demographics of the two groups, with a predominance of male patients in both groups between the ages of fifty and sixty years.Additionally, Zubair, Khan Sherwani, Ahmad, Tahir, Khalil, et al., (2022) reported that the mean age of the patients they evaluated was fifty-three years in their retrospective study about the spectrum of postoperative complications and outcomes after pancreaticoduodenectomy.In contrast, Lavu et al., (2019) found that the mean of the studied patients age was sixty-five years.This may be attributed to variations in the study sample and setting.Moreover, Takagi, Yoshida, Yagi, Umeda, Nobuoka, et al. (2019) discovered that there were more males than females in both groups performing pancreaticoduodenectomy in their controlled randomized trial regarding the effect of an enhanced recovery after surgery protocol.Also, Lof, Benedetti Cacciaguerra, Aljarrah, Okorocha, Jaber, et al. (2020) reported that no significant statistical variations were seen between both groups regarding their demographics, with more male patients than female patients.Additionally, Jamal et al., (2020) found that the median age of the studied patients was fifty-three years with more males than females.In contrast, Dalgatov, Kozodaeva, Titkova, Smirnova, and Sazhin (2021) showed that in both groups, there are more female patients than male patients.The present results of the study demonstrated that whereas the study group began walking on the second day, the control group was unable to walk on the first day and remained unable to walk until the third day.Also, a significant statistical difference was observed between the control and study groups from the second day of the study to the sixth, suggesting that the study group had a higher mean distance walk than the control group.This comes to Koyuncu & Iyigun's (2022) findings, which indicated that the structured early mobilization protocol manages mobilization effectively and improves outcomes of patient health care as patients in the intervention group began mobilizing earlier than those of the control group, based on a postoperative comparison of the two groups.Additionally, Fukushima, Adachi, Hanada, Tanaka, Oikawa, et al. (2021) emphasized the importance of early mobilization for patients undergoing pancreatoduodenectomy in their retrospective cohort study about the role of early mobilization on the clinical course of patients who underwent pancreatoduodenectomy.Similarly, Vermişli, Çakmak, Muezzinoğlu, Aslan, and Baydur (2021) discovered that the intervention group had a mean mobilization time that was higher than the control group in the first twenty-four hours following surgery and that this difference was statistically significant.Additionally, Melloul, Lassen, Roulin, Grass, Perinel et al., (2020) stated that from day zero, early and active mobilization should be promoted.Furthermore, according to Gustafsson, Scott, Hubner, Nygren, Demartines, Francis, et al. ( 2019), patients should be mobilized as soon as possible after surgery because prolonged immobilization is linked to several negative consequences.Early mobilization through patient education and encouragement is a crucial part of improved recovery after surgery programs.Also, Nelson, Bakkum-Gamez, Kalogera, Glaser, Altman, et al. (2019) reinforced early mobilization within twentyfour hours of surgery.Concerning postoperative pain, the study's findings revealed that there was no statistically significant difference between control and study groups during 1 st and 2 nd days of the study.There was a statistically significant difference between the control and study groups from the 3rd day till the last day of the study at the 6th day, indicating that the study group had lower mean pain scores than the control group.Along the same lines, Ni et al., (2022) highlighted the significance of early mobilization when they discovered that, from the fourth postoperative day, the pain scores of the early standardized activity group were lower significantly than those of the control group.Similarly, Okul & Oral (2023) discovered that the intervention group's mean pain severity scores at 24 hours and fifteen days postoperatively were significantly lower than those of the control group, supporting their conclusion that early mobilization lowers the level of pain.In terms of postoperative complications following Whipple surgery, the researchers discovered a significant statistical difference between both control and study groups concerning the incidence of falls during the first and second week, with the control group experiencing more falls than the study group.Additionally, the control group had a greater readmission rate than the study group which is statistically significant at p-value=0.020.Considering the importance of early mobilization in improving the clinical outcomes following the Whipple surgery, the application of mobilization protocol was shown to be effective in improving the patients' selected outcomes after the surgery through improving the mean distance walk, alleviating the postoperative pain, and reducing the incidence of postoperative complication.

Conclusion:
The current research study has revealed a significant statistical improvement between the control and study groups on the 6th day indicating that the study group had a higher mean distance walk than the control group.
Also, the study group had lower mean pain scores than the control group respectively.Moreover, there were significant statistical differences between the control and study groups about the occurrence of falls during the 2nd week.

Figure ( 1 )
Figure (1): Percentage distribution of the numbers of abdominal drains among control and study groups (n=60).

Sosnova, Zeitlberger et al., 2020). Tool IV: Evaluation of incidence of postoperative complications in terms of: -Falls: are
measured through reviewing incident reports that contain the following items: Bjelkaroy, Benth, Simonsen, Siddiqui, Cheng et al., (2024) tested the reliability of the scale and found that the intraclass correlation coefficient of the VAS was 0.97 and reported that the VAS had excellent test-retest reliability.The scale validity was assessed using Pearson's correlation coefficients of the baseline scores of VAS and it was a valid and reliable scale with the smallest errors in the measurement of acute pain.Tool III: Six-Minute Walking Test It was developed in the 1960s by Balka to examine the functional capacity of healthy individuals (Koyuncu & Iyigun, 2022).Also, the test was utilized to examine the functional capacity of patients in the preoperative period.It measures the distance the individual can walk over a total of 6 minutes on a flat hard surface.The individual is allowed to self-pace and rest as needed as they move back and forth along a designated route.

Koyuncu & Iyigun 2022; Chan et al., 2021; Lavu et al., 2019).
Arabic training colored brochure was developed by the researchers about mobilization after surgery and distributed to the patients of the study group.The first part of the brochure presents guidance about the value of early mobilization postoperatively.The second part comprises various stages of mobilization images, including incremental position adjustments.The final part includes a table outlining the mobilization process.