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
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Surgical Effects on Cancer Outcomes
- 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.
- Low body temperature (hypothermia) experienced as part of surgery may affect outcomes. In human studies, mild hypothermia further suppresses immune function already suppressed by the stress response associated with abdominal surgery.4
- Blood clots, neutrophil extracellular traps (NETs) and low oxygen levels (hypoxia) may increase risk of recurrence after surgery.5
"The process of enhancing physical fitness before an operation to enable the patient to withstand the stress of surgery has been termed prehabilitation."6 Prehabilitation involves preoperative exercise, nutrition therapy, and techniques to reduce anxiety.
Nutritional intervention before surgery can improve outcomes by reducing infection complications and the effects of surgical stress, such as inflammation. For this reason, the American Society of Anesthesiologists no longer recommends long fasts before surgery.7
In her book The Breast Cancer Companion: A Complementary Care Manual: Third Edition, Barbara MacDonald, ND, LAc, recommends an anti-inflammatory diet for at least two weeks before surgery. This diet is high in vegetables, fruits, grains and healthy protein, but follow your care team's advice if you have food allergies or specific nutritional needs. See Eating Well for more information about making health-promoting food choices.
Attention to nutrition before surgery is especially important if the patient is malnourished. Note that "the definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated."8
Immunonutrition involves influencing the activity of the immune system with specific nutrients. Arginine, glutamine, branched chain amino acids, omega-3 fatty acids and nucleotides have been studied most often.9 Meta-analyses have found that immunonutrition before surgery in malnourished patients was more beneficial than conventional nutrition support near the time of surgery, resulting in notable reductions in infections and in length of hospital stay.10
Using primarily non-drug approaches, such as cognitive and behavioral coping techniques, can help patients manage anxiety in a relatively brief period:11
- Positive reframing of thoughts, such as with cognitive behavioral therapy
- Participating in favorite daily activities
- Maintaining social contact
BCCT advisor Lise Alschuler, ND, FABNO, and Gazella describe integrative approaches to preparing for, mitigating side effects from and enhancing outcomes of cancer surgery in their The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. See chapters 6 and 7.
Fitness and Surgical Outcomes
Low skeletal muscle mass and density are associated with greater longer hospital stays and higher risks of postsurgical complications and both short-term and long-term mortality in colorectal cancer patients12 and greater mortality in patients with advanced non-small cell lung cancer.13 A fitness program to increase muscle mass and density may be helpful.
Surgical Pain Control
Discuss pain management options with your surgeon and anesthesiologist.
Drug-based Pain Management
- Opioid-based intravenous patient controlled analgesia: Compared to epidural analgesia in laparoscopic surgery, opioid-based intravenous patient controlled analgesia (IV PCA) using fentanyl showed comparable pain control, faster return of bowel function, fewer overall complications, and shorter hospital stays, plus less need of drugs to maintain blood pressure.14
- Continuous surgical wound infiltration with local anesthetics used after laparoscopic colorectal surgery reported similar pain control efficacy as opioid-based IV PCA (above) in at least some patients.15
- Thoracic epidural analgesia (TEA) was more effective than IV-PCA (see above) after open colorectal cancer surgery, with a positive impact on bowel function, dietary intake, patient satisfaction and early mobilization in a small trial16
- Quadratus lumborum block (QLB): more effective postoperative analgesia than the transversus abdominis plane block17
- Transabdominus plane (TAP) blocks for anesthesia with laparoscopic and robotic-assisted colorectal cancer surgery reduced length of hospital stay, use of postoperative narcotics and time until patient was walking and resumed bowel function as part of an enhanced recovery program.18
- A small pilot study investigated patients undergoing a laparoscopic resection of colorectal cancer receiving a multimodal pain management protocol (administered after induction anesthesia using a bilateral TAP block and local abdominal cavity infiltration with long-acting local anesthetic liposomal bupivacaine. Patients on this protocol required fewer opioids during surgery, had shorter stays in the post-anesthesia care unit (PACU), less pain following surgery, less use of narcotics and a shorter hospital stay compared to a group that received no block or local wound infiltration.19
- In a randomized clinical trial, parecoxib [a COX 2 selective inhibitor NSAID] before surgical incision (compared to administration after incision) in colorectal cancer surgery reduced morphine use following surgery and reduced IL-6 production (indicating an anti-inflammatory effect) without affecting morphine-related side effects.20
Non-drug Pain Management
- One study found patients undergoing elective colorectal surgical procedures who used guided imagery experienced considerably less pain both before and after surgery and used 50 percent fewer narcotics after surgery compared to patients receiving routine perioperative care..24
- Patient characteristics may affect the success of guided imagery in managing pain. “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.”25
Options with less published evidence regarding effectiveness.
- Electroacupuncture26 and transcutaneous electrical acupoint stimulation (TEAS)27
- Transcutaneous electrical nerve stimulation (TENS)28
- Pulsed electromagnetic fields effective in most29 but not in all studies30
Anesthesia and Cancer Recurrence
While anesthesia reduces a patient’s experience of pain during surgery, it may also impair numerous immune functions.31 On the other hand, pain itself can promote stress hormones and cascade into negative effects.32
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.33
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.34
- General anesthesia-epidural analgesia reduced the risk of biochemical cancer recurrence in prostate cancer patients compared to general anesthesia-opioid analgesia.35
Effects of Pain Management Approaches Following Surgery
Managing Side Effects Other Than Pain
- 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.36
- Guided imagery and suggestion reduces the time for patients’ bowels to return to normal functioning after surgery.37
Morphine—and perhaps other opioids—may increase susceptibility to infection in humans.38
Immune Function or Inflammation
- Opioids have been connected with immune system suppression:
- 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.39
- If opioids are indicated, lower doses may disrupt your immune system function less than larger doses.40
- Some evidence indicates that abrupt withdrawal from opioids also suppresses the immune system.41
- Non-drug measures that may reduce inflammation:
Proliferation or Recurrence
Substituting epidural analgesia for opioids following surgery may improve cancer outcomes. A review of prostate cancer patients undergoing surgery found that epidural analgesia was associated with substantially less risk of biochemical cancer recurrence.45
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:46
- 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.
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.47
- 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 that increase your risk of bleeding:48
- Devil’s claw
- Dong quai (Angelica sinensis)
- Essential fatty acids (EFAs): fish oil and other omega-3s, flax oil, evening primrose oil (EPO), borage
- Goji berries
- Green tea capsules
- Red clover
- Turmeric (curcumin)
- Vitamin E
- Vitamin K
- Willow bark
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.49
- Grapefruit juice
- Milk thistle
- N acetyl cysteine
- St. John’s wort
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:
- Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Care. New York: Bantam Dell. 2009. Chapter 22, The Surgical Support Program.
- Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010. Chapter 6, Supporting Your Body during Conventional Treatment; see the section on “Support before and after surgery”.
- MacDonald B. The Breast Cancer Companion: A Complementary Care Manual: Third Edition. (self-published, Amazon, 2016). Chapter 4, Preparing for Surgery, and Appendix 2, Handout on Preparing for Breast Cancer Surgery with Naturopathic Medicine.
For more information on the implications of taking herbal medicines just before, during and after surgery, see The peri-operative implications of herbal medicines.50
Off-label, Overlooked or Novel Cancer Approaches (ONCAs) and Surgery
ONCAs to Avoid before Surgery
Avoid taking the following nonsteroidal anti-inflammatory drugs (NSAIDs) that increase your risk of bleeding for two weeks before surgery unless your medical team directs otherwise:51
- Celecoxib (Celebrex)
- Ibuprofen (Motrin, Advil)
- Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
- Others (MedicineNet)
Some studies in humans suggest that surgery may be associated with metastasis52 —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.
Propranolol and other beta blockers have shown good effects in blocking both cancer growth and metastasis.
- Preliminary human studies suggest that use of the beta-blocker propranolol during the time of surgery is associated with reduced levels of metastasis.53
- ropranolol administered peri-operatively may reduce the establishment of brain metastases in patients with triple-negative breast cancer.54 A 2016 review suggested that propranolol be added to standard of care for nonmetastatic cancers as a strategy to reduce the rate of metastasis.55
- Some research suggests 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 a few days around the time of cancer surgery.56
- Combined use of the beta blocker propranolol and the anti-inflammatory etodolac for five days before surgery has been used safely to reduce metastases and mortality. However, propranolol and etodolac should not be used in patients with asthma, cardiovascular disease, diabetes or low blood pressure.57
Use of the non‐steroidal anti‐inflammatory drug (NSAID) ketorolac before surgery also shows promise in reducing metastasis. In animals with primary syngeneic Lewis lung carcinoma, ketorolac before surgery—but not after—prevented both inflammation and “surgery-induced dormancy escape”, a process that can lead to tumor growth and metastasis.58
The type of surgery you have will determine when you can start eating and what kind of diet you will be able to eat right after surgery. Surgeries involving the mouth, throat, abdomen or digestive tract will likely lead to more restricted diets.
Once you are able to progress beyond clear liquids, an anti-inflammatory, nutrient-dense diet high in vegetables, fruits, whole grains and sources of high quality protein for at least two but ideally six weeks after surgery is recommend by experts in integrative oncology, such as Barbara MacDonald, ND, LAc. Ask your surgeon or registered dietician about dietary restrictions, such as a diet low in fiber or low in salt.
Recovery and Remission Maintenance
BCCT does not recommend any particular remission maintenance approach. The strategies provided here are supported by evidence of improved outcomes.
Several imbalances in your terrain can make your body more susceptible to infection, slower to heal wounds and/or more favorable to cancer. Balancing these factors in relation to surgery, wound healing and reducing recurrence risk is especially important:59
- Chronic inflammation
- Insulin resistance/glycemia
- Imbalanced stress chemistry, including hormones/melatonin
- Compromised immunity, such as from chemotherapy, surgery, anesthesia or opioid use
- Impaired blood clotting (coagulopathy)
BCCT advisor Keith Block, MD, in his book Life over Cancer: The Block Center Program for Integrative Cancer Care recommends an integrative program to address these terrain factors in chapters 14-19.
BCCT advisor Lise Alschuler, ND, FABNO, and Karolyn Gazella, list five key body pathways to target in making your body inhospitable to cancer. Four of those pathways most relevant to prevention/management of surgical complications are the immune system, insulin resistance, inflammation, and hormonal balance (including stress hormones). Their books describe key actions to balance these pathways:
- The Definitive Guide to Thriving after Cancer (chapters 1-5)
- The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing, chapters 8-11.
Barbara MacDonald, ND, FABNO, advises about natural approaches to consider, including guidance on reducing inflammation, support through surgery (including wound healing), recurrence prevention and monitoring after conventional treatment is completed. See chapters 1 and 4 in The Breast Cancer Companion: A Complementary Care Manual: Third Edition, a guide for oncology naturopaths in caring for those with breast cancer. Much of her information is relevant to other cancers and preparing for surgery.
In Textbook of Naturopathic Oncology: A Desktop Guide of Integrative Cancer Care. 1st edition, naturopathic oncologists Gurdev Parmar and Tina Kaczor discuss considerations for naturopathic care before and after surgery to optimize recovery, reduce pain, reduce risk post-surgical infections, and possibly reduce risk of metastasis.60
Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; most recent update on September 30, 2020.
- Beth Israel Medical Center and the Balm Foundation: Preparing for Surgery
- Gurdev Parmar and Tina Kaczor: Textbook of Naturopathic Oncology