Surgery: An Integrative Approach

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This section does not replicate the other information on this page but provides additional details or context most relevant to professionals.

Clinical practice guideline

Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes.

More information: 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 of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient.

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:¹Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change practice? Canadian Urological Association Journal. 2011;5(5):342-348. 

Helpful links on ERAS

Pędziwiatr M, Mavrikis J et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Medical Oncology. 2018 May 9;35(6):95.

Taurchini M, Del Naja C, Tancredi A. Enhanced recovery after surgery: a patient centered process. Journal of Visualized Surgery. 2018 Feb 27;4:40.

Immunonutrition

Immunonutrition involves using specific nutrients to influence the activity of the immune system. Arginine, glutamine, branched chain amino acids, omega-3 fatty acids, and nucleotides have been studied most often.²Calder PC. Immunonutrition in surgical and critically ill patients. British Journal of Nutrition. 2007;98 Suppl 1:S133-S139. 

• Substantially fewer infections and infectious complications but no evidence of an effect on 30-day mortality after elective curative surgery for a solid malignant tumor among people treated with immunonutrition orally before surgery (and some continuing after surgery) compared to controls not receiving immunonutrition in a meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of 22 RCTsrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects³Buzquurz F, Bojesen RD, Grube C, Madsen MT, Gögenur I. Impact of oral preoperative and perioperative immunonutrition on postoperative infection and mortality in patients undergoing cancer surgery: systematic review and meta-analysis with trial sequential analysis. BJS Open. 2020 Oct;4(5):764-775.
• Substantially fewer infections and shorter hospital stays, but no evidence of an effect on mortality after surgery among people receiving immune-enhancing nutrition compared to standard enteral nutrition in meta-analyses of 12,⁴Beale RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: a systematic review of clinical outcome. Critical Care in Medicine. 1999 Dec;27(12):2799-805. 11,⁵Heys SD, Walker LG, Smith I, Eremin O. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials. Annals of Surgery. 1999 Apr;229(4):467-77. and 22 RCTs,⁶Heyland DK, Novak F et al. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA. 2001 Aug 22-29;286(8):944-53. many of which included people with cancer
• Fewer infectious and noninfectious complications after surgery, shorter hospital stays and better clinical outcomes among people with gastrointestinal cancer undergoing surgery with enteral immunonutrition before, during and/or after surgery compared to standard enteral nutrition in a meta-analysis of 27 RCTs⁷Song GM, Tian X et al. Immunonutrition support for patients undergoing surgery for gastrointestinal malignancy: preoperative, postoperative, or perioperative? a bayesian network meta-analysis of randomized controlled trials. Medicine (Baltimore). 2015 Jul;94(29):e1225.

Further evidence

Surgery and subsequent metastasis

Tohme S, Simmons RL, Tsung A. Surgery for cancer: a trigger for metastases. Cancer Research. 2017 Apr 1;77(7):1548-1552.

Preclinical evidence of greater tumor growth and metastasis among people using morphine:

• Mammary tumor growth in rodents treated with morphine⁸Gupta K, Kshirsagar S et al. Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and promotes breast tumor growth. Cancer Research. 2002 Aug 1;62(15):4491-8. 
• Immune escape (a key mechanism of cancer progression and metastasis) of human non-small cell lung cancer cells treated with morphine-3-glucuronide⁹Wang K, Wang J et al. Morphine-3-glucuronide upregulates PD-L1 expression via TLR4 and promotes the immune escape of non-small cell lung cancer. Cancer Biology & Medicine. 2021 Feb 15;18(1):155-171.

Managing symptoms and side effects: preclinical evidence

Liver regeneration

• Improved phospholipid biosynthesis, hepatocyte proliferation, liver regeneration and survival after partial hepatectomy in gnotobiotic mice colonized with a minimal SCFA-producing microbial community compared to controls¹⁰Yin Y, Sichler A et al. Gut microbiota promote liver regeneration through hepatic membrane phospholipid biosynthesis. Journal of Hepatology. 2023 Jan 18:S0168-8278(23)00009-0.

Expert approaches

Barbara MacDonald, ND, LAc

Gurdev Parmar, ND, FABNO, and Tina Kaczor, ND, FABNO

Helpful links for professionals

Intake form

Diljeet K Singh, MD, DrPH, with Virginia Oncology Associates Integrative Gynecology Oncology, has generously shared with us an intake form suitable for assessing supplement and medication use and lifestyle behaviors that may need adjustment before surgery. Open the PDF intake form ›

Prehabilitation

McKenna NP, Bews KA et al. Assessing malnutrition before major oncologic surgery: one size does not fit all. Journal of the American College of Surgeons. 2020;230(4):451-460.

Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. European Journal of Surgical Oncology. 2018;44(7):919-926.

Anesthesia and postoperative pain control

Society for Integrative Oncology (SIO) and American Society of Clinical Oncology Training Modules: Procedural or Surgical Pain ›

More Evidence to Support Restrictive Opioid Prescribing after Cancer Surgery—Significant decreases in prescription days, doses, refill requests, with few patient complaints ›

Links below are to PubMed searches regarding use in cancer and surgery for each approach.

Pharmaceutical pain control

Non-pharmaceutical pain control

Keep reading about integrative approaches to surgery

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