Over the last decade a substantial amount of research has been completed aimed at reducing perioperative stress, maintaining postoperative function and accelerating recovery after surgery. In many types of surgeries, the use of a multi-pronged approach to reduce surgical stress has been shown repeatedly to decrease rates of complications, improve recovery and shorten hospital length of stay.
What can be done preoperatively?
Smoking – It is well known that the risk of postoperative complications is greater in patients who smoke. In particular, infections and wound, lung, and brain complications are more common in patients who smoke. While smoking cessation for at least 4 weeks is ideal for reducing lung and wound-healing complications, shorter periods prior to surgery may still be beneficial but not to the same degree. After 8 weeks of smoking cessation, the risk is similar to those who have never smoked.
Alcohol abuse – Surgical patients who consume over 4 drinks daily have a 2-3 fold increased risk for postoperative complications (heart, lung infection, wound healing, bleeding and brain) compared to patients who consume less than 2 drinks daily. Preoperative abstinence from alcohol is recommended to reduce postoperative complications but the evidence to support this recommendation is weaker. The duration of abstinence required to reduce alcohol’s negative effects varies from 2-8 weeks depending on the organ (e.g. heart vs brain vs liver).1
Anemia – Anemia (low red cell blood count) is seen in about 30% of patients presenting for surgery and is a risk factor for complications but so is the administration of blood-products. Optimizing the red cell count before surgery without transfusion is then the best option and this can be done by providing oral or intravenous iron or intravenous erythropoietin (a hormone produced by the kidney that stimulates red blood cell production in the bone marrow).
Exercise – Reduced exercise capacity before surgery is a risk factor for postoperative complications and long-term disability. Exercise training prior to surgery may therefore improve outcomes by allowing the body to tolerate greater levels of stress. Although moderate exercise such as walking might be easier to accomplish given sufficient time, the shorter time period from decision to surgery to actual surgery date means that a supervised high-intensity interval training programs over 3-4 weeks may be the best choice.2 While it is clear that such exercise will improve functional capacity, studies to determine whether preoperative exercise will change postoperative outcomes are underway but have not been completed.
Nutrition – It is estimated that more than one in every three hospitalized patients is malnourished at admission and that only 3% of these patients are being properly identified and treated. The surgical stress response, which can result in muscle breakdown, increases protein requirements even further. Thus, patients at risk of malnutrition should receive high-protein oral nutritional supplements for 2-4 weeks prior to surgery.3
What can be done postoperatively?
Prevention of nausea and vomiting – Nausea and vomiting after surgery is a common occurrence and may result in dehydration and inadequate nutritional intake leading to a prolonged hospital stay. Female patients, those with a history of nausea/vomiting or motion sickness and non-smokers are at increased risk. Thus, patients with risk factors should ideally be treated prophylactically during surgery with antiemetics (drugs used to prevent or treat nausea/vomiting).
Pain management – Adequate pain control is essential to enhanced recovery after surgery. In general, techniques that avoid or use less opioid drugs result in getting out of bed sooner, faster return of bowel function, fewer complications, and reduced length of stay. Using a combination of drugs (multimodal approach) that rely on several pain reducing mechanisms along with regional anesthesia techniques (spinal/epidural or nerve blocks, when possible) is optimal.
Early mobilization – Prolonged bed rest is associated with greater lung complications, blood clots, higher blood sugars, and decreased muscle strength. Early mobilization is therefore an important component of improving the recovery process. However, just like exercise in the preoperative period, getting out of bed and exercising some as soon as possible after surgery does increase functional capacity but the evidence that it improves outcomes remains mixed with some studies showing benefit but others that showing no change.
Nutritional care – Delays in restarting a normal diet by mouth is known to increase infectious complications and prolong the recovery period. Thus, many (but not all) patients should receive food by mouth from the day of surgery. Even when they are able to eat, the postoperative period is often characterized by lowered overall oral intake. Furthermore, during this recovery period, there is greater breakdown of muscle protein in order increase the availability of glucose to meet energy needs. Thus, additional oral nutritional supplements are often needed.4
1. Bradley KA, Rubinsky AD, Sun H, et al. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med. 2011;26(2):162-169.
2. Whittle J, Wischmeyer PE, Grocott MPW, Miller TE. Surgical Prehabilitation: Nutrition and Exercise. Anesthesiol Clin. 2018;36(4):567-580.
3. Williams DGA, Molinger J, Wischmeyer PE. The malnourished surgery patient: a silent epidemic in perioperative outcomes? Curr Opin Anaesthesiol. 2019;32(3):405-411.
4. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS((R))) Society Recommendations: 2018. World J Surg. 2019;43(3):659-695.