Integrative Approaches and Surgery

Enhanced Recovery after Surgery (ERAS)

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach to the care of the surgical patient. Implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient.

A 2017 review concluded that ERAS protocols have resulted in shorter length of hospital stay by 30 to 50 percent and similar reductions in complications, while also reducing readmissions and costs.1

ERAS protocols are designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery. Key elements of ERAS protocols:2

  • Preoperative counselling
  • Optimization of nutrition
  • Standardized analgesic and anesthetic regimens
  • Early mobilization

We'll be adding much more information to this page over time.

Surgical Effects on Cancer Outcomes

Some factors common with surgery may affect the immune reponse, altering the body terrain to be more favorable to cancer growth:3

  • Stress: The stress response surrounding surgery is linked to immune suppression and increased tumor retention, with the stress level in cancer patients is associated with the degree of postoperative immune suppression. See below the discussion of propranolol and other beta blockers.
  • Hypothermia (low body temperature) experienced as part of surgery may affect outcomes. In human studies, the immune response associated with abdominal surgery is further suppressed by mild hypothermia.4

Surgical Pain Control

Discuss pain management options with your surgeon and anesthesiologist.

Anesthesia and Cancer Recurrence

While anesthesia reduces a patient’s experience of pain during surgery, it may also impair numerous immune functions.5 On the other hand, pain itself can promote stress hormones and cascade into negative effects.6

A balance is needed for reducing pain and minimizing potential immune suppression from anesthesia. A small study found that a combined epidural and light general anesthesia reduced the stress response in patients undergoing open heart surgery and provided a better quality of postoperative pain control.7  8

Small studies have found these effects of the type of anesthesia on cancer recurrence:

  • Paravertebral anesthesia and analgesia combined with general anesthesia for breast cancer surgery reduced the risk of recurrence or metastasis during the initial years of follow-up compared to general anesthesia combined with postoperative morphine analgesia.9
  • General anesthesia-epidural analgesia reduced the risk of biochemical cancer recurrence in prostate cancer patients compared to general anesthesia-opioid analgesia.10

Post-surgical Pain Management Effects

Infection

Morphine—and perhaps other opioids—may increase susceptibility to infection in humans.11

Immune Function

  • Opioids:
    • Tramadol: A small study found that tramadol and morphine both had similar pain-management effects in patients undergoing gynecological cancer surgery, but tramadol led to less postoperative immunosuppression, for example.12  
    • If opioids are indicated, lower doses may disrupt your immune system function less than larger doses.13
    • Some evidence indicates that abrupt withdrawal from opioids also suppresses the immune system.14
  • Non-drug measures that can reduce inflammation, pain and opioid use:
    • Transcutaneous electrical nerve stimulation (TENS)15
    • Pulsed electromagnetic fields16
    • Options with less evidence regarding effectiveness:
      • Electroacupuncture17
      • Transcutaneous electrical acupoint stimulation (TEAS)18

Proliferation or Recurrence

Morphine—and perhaps other opioids—may stimulate breast tumor growth in rodents.19

Natural Products and Surgery: What You Need to Know

Before surgery, your surgeon and anesthesiologist will want to know what drugs and supplements/natural products you’re taking. If they don’t ask about natural products or supplements, you need to tell them about any you’re taking. Reasons for this:

  • Usually you are told to stop eating and drinking at midnight before your surgery. There may be some pills you still need to take, and your doctors will tell you which ones to take with a small amount of water.
  • Some intended effects, as well as side effects and interactions of drugs and natural products, can increase the risk for complications during or shortly after surgery. Examples:20
    • Anticoagulants—drugs and supplements that “thin the blood”—can increase your risk of bleeding.
    • Drugs or supplements with sedative effects may interact with your anesthesia or sedatives and increase the time to wake up after surgery.
    • Some products might interfere with your ability to clear the anesthesia and other drugs from your system.
    • Others might suppress your immune system.

Many more interactions are possible. Follow your medical team’s directions.

Natural Products to Avoid before Surgery

Some general guidelines regarding stopping natural products before surgery:

  • Tell you surgeon and anesthesiologist about all drugs, natural products and supplements that you are taking.
  • The American Society of Anaesthesiologists advises patients to stop taking herbal medicines at least two weeks before surgery.21
  • Several integrative oncology physicians are more specific about which to stop and when. These lists are not all-inclusive, so be sure to tell you doctor of all products you are taking.

Two Weeks before Surgery

Avoid taking the following natural products or pharmaceuticals that increase your risk of bleeding:22

Natural products

Pharmaceuticals

  • Alfalfa
  • Astragalus
  • Bromelain
  • Capsicum
  • Devil’s claw
  • Dong quai (Angelica sinensis)
  • Essential fatty acids (EFAs): fish oil and other omega-3s, flax oil, evening primrose oil (EPO), borage
  • Gingko
  • Ginseng

Nonsteroidal anti-inflammatory drugs (NSAIDs):

  • Aspirin
  • Celecoxib (Celebrex)
  • Ibuprofen (Motrin, Advil)
  • Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
  • Others (MedicineNet)

Five to Ten Days before Surgery

Stop cleansing and detoxification regimens and stop taking natural products that affect your liver’s ability to clear anesthesia, sedatives, pain medications, and other surgical drugs.23

  • Garlic
  • Grapefruit juice
  • Kava
  • Methionine

Products Recommended before Surgery

Some drugs and supplements—including nutritional food supplements—might be recommended to help “build you up” before surgery as well as help your tissues heal after surgery. For recommendations of natural products to take before surgery, see the following protocols, programs and plans:

For more information on the implications of taking herbal medicines just before, during and after surgery, see The peri-operative implications of herbal medicines.24

Off-label, Overlooked or Novel Cancer Approaches (ONCAs)

Surgery and Metastasis—and  Therapies That May Reduce Risk

Some studies in humans and animals suggest that surgery may be associated with metastasis25 —possibly from the inflammatory response of wound healing. Some researchers suggest that the flood of stress hormones associated with surgery may also contribute to the metastatic process following surgery.

Read more

Propranolol and other beta blockers have shown good effects in blocking both cancer growth and metastasis (see at right):

  • Chronic restraint stress (CRC) promotes colorectal cancer cell growth in human cells grafted onto mice. The adrenoceptor antagonists phentolamine and propranolol significantly inhibited this cell growth.30
  • Some research suggest that people not already using beta blockers who are diagnosed with non-small cell lung cancer or early breast cancer may want to ask their healthcare providers whether to take beta blockers for two days before and three days after cancer surgery.31

Other Therapies and Surgery

Randomized studies indicate that guided imagery and other mind-body approaches can reduce or eliminate emotional and physical side effects of surgery and other treatments:

  • Relaxation with guided imagery and other mind-body techniques have been highly effective in reducing anxiety before, during and after surgery in both adults and children.32

Guided imagery can significantly reduce pain and the need for pain medication following surgery.33

  • One study found patients undergoing elective colorectal surgical procedures who used guided imagery experienced considerably less  anxiety and pain both before and after surgery and used 50 percent fewer narcotics after surgery compared to patients receiving routine perioperative care..34 Another small study found that “patients who achieved a meaningful improvement in pain with analgesic imagery reported greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms than those who did not achieve a meaningful reduction in pain.”35
  • Guided imagery and suggestion reduces the time for patients’ bowels to return to normal functioning after surgery,36

Read more in Guided Imagery.

Written by Laura Pole, RN, MSN, OCNS; with review by Nancy Hepp, MS; most recent update on June 23, 2020.

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