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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. 

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

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:

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

MacDonald B. The Breast Cancer Companion—A Complementary Care Manual: Third Edition. Self-published. 2016.

Naturopathic physician Barbara MacDonald provides information about breast cancer, its conventional treatment, and natural approaches to enhancing treatment, managing side effects, reducing risk of recurrence, and healthy living after cancer treatment is completed.

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

In their 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.

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

Pharmaceutical pain control

Opioid-based intravenous patient-controlled analgesia (meta-analysesa 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)

Transabdominal plane (TAP) blocks 

Multimodal pain management protocol 

Parecoxib 

Non-pharmaceutical pain control

Keep reading about integrative approaches to surgery

Authors

Laura Pole, RN, MSN, OCNS

Senior Clinical Consultant
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Laura Pole is senior clinical consultant for CancerChoices. Laura is an oncology clinical nurse specialist who has been providing integrative oncology clinical care, navigation, consultation, and education services for over 40 years. She is the co-creator and co-coordinator of the Integrative Oncology Navigation Training at Smith Center for Healing and the Arts in Washington, DC. Laura also manages the “Media Watch Cancer News That You Can Use” listserv for Smith Center/Commonweal. In her role as a palliative care educator and consultant, Laura has served as statewide Respecting Choices Faculty for the Virginia POST (Physician Orders for Scope of Treatment) Collaborative as well as provided statewide professional education on palliative and end-of-life care for the Virginia Association for Hospices and Palliative Care.

For CancerChoices, Laura curates content and research, networks with clinical and organizational partners, brings awareness and education of integrative oncology at professional and patient conferences and programs, and translates research into information relevant to the patient experience as well as clinical practice.

Laura sees her work with CancerChoices as a perfect alignment of all her passions, knowledge and skills in integrative oncology care. She is honored to serve you.

Laura Pole, RN, MSN, OCNS Senior Clinical Consultant

Nancy Hepp, MS

Lead Researcher and Program Manager
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Ms. Hepp is a researcher and communicator who has been writing and editing educational content on varied health topics for more than 20 years. She serves as lead researcher, program manager, and writer for CancerChoices. Her graduate work in research and cognitive psychology, her master’s degree in instructional design, and her certificate in web design have all guided her in writing and presenting information for a wide variety of audiences and uses. Nancy’s service as faculty development coordinator in the Department of Family Medicine at Wright State University also provided experience in medical research, plus insights into medical education and medical care from the professional’s perspective.

Nancy Hepp, MS Lead Researcher and Program Manager

Reviewer

Whitney You, MD, MPH

Research Consultant
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Dr. You is a physician specializing in maternal-fetal medicine (MFM) with a specific interest in cancer in the context of pregnancy. She completed a postdoctoral fellowship in health services research with a focus in health literacy and received a Master of Public Health.

Whitney You, MD, MPH Research Consultant

Last update: February 13, 2024

CancerChoices provides information about integrative in cancer care, a patient-centered approach combining the best of conventional care, self care and evidence-informed complementary care in an integrated plan cancer care. We review complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture therapies and self-care lifestyle actions and behaviors that may impact cancer outcomes; examples include eating health-promoting foods, limiting alcohol, increasing physical activity, and managing stress practices to help patients and professionals explore and integrate the best combination of conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy and complementary therapies and practices for each person.

Our staff have no financial conflicts of interest to declare. We receive no funds from any manufacturers or retailers gaining financial profit by promoting or discouraging therapies mentioned on this site.

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