Surgery: An Integrative Approach

Preparing for surgery

As you prepare for surgery, talk with your oncology and surgical teams about ways to build your resilience.

On this page:

How can preparing for surgery help you?

The state of your general health can have a huge impact on your ability to respond to and recover from surgery. Better general health and resilience can prevent or reduce some of the complications of surgery. Time invested before surgery can speed your recovery, improve your quality of life, and perhaps improve your cancer outcomes.

A few body terrainthe internal conditions of your body, including nutritional status, fitness, blood sugar balance, hormone balance, inflammation and more factors are known to interact with surgery.

• Longer hospital and/or intensive care unit (ICU) stays after surgery among people with diabetes with poor glycemic control (modest evidence)

If you have high blood sugar or diabetes, talk to your doctor about how to safely lower your blood sugar before surgery.

• Longer surgery times, higher illness (morbidity) after surgery, higher conversion to surgery and to open surgery, and higher risk of infection and other complications related to surgery among people who are obese (good evidence)
• Higher risk of surgical site infection among people who are obese (modest evidence)

If you are planning surgery to treat cancer, you may not have time to lose a lot of weight before your procedure, but even a few pounds can improve your outcomes. Increasing your activity level in the days and weeks before surgery provides benefits even without a change in your weight. Even if you are not able to lower your weight, we encourage you to ask your oncology and surgical teams what you can do to improve your health and optimize your surgical outcomes.

Helpful link

Body composition

Loss of muscle tissue (sarcopenia) is linked to higher risk of worse outcomes after surgery: 

• Higher risk of complications after surgery among people with loss of muscle tissue or poor cardiopulmonary fitness before surgery (good evidence)
• Longer hospital stays after surgery among people with colorectal cancer with low skeletal muscle mass and density (modest evidence)
• Much better survival among people with colorectal cancer with greater muscle density after diagnosis or before surgery (preliminary evidence)significant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently)

We are still researching body composition; these assessments are from our research so far.

Expert approach: Lise Alschuler, ND, FABNO, and Karolyn Gazella 

CancerChoices advisor Lise Alschuler, ND, FABNO, and her co-author Karolyn Gazella list five key body pathways to target in making your body less hospitable to cancer. Four of those pathways most relevant to prevention or 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.

Plan ahead to improve recovery after surgery

Getting your body ready for surgery and collaborating with your surgery team about anesthesia and nutrition can improve your recovery after surgery.

Prehabilitation: preparing your body for surgery

Similar to rehabilitation after injury, “prehabilitation” optimizes your health and function before surgery. Through nutrition, exercise, and managing anxiety, prehabilitation (prehab) gets you into better shape. Prehab can help your body deal with the impact of surgery.¹Lambert JE, Hayes LD, Keegan TJ, Subar DA, Gaffney CJ. The impact of prehabilitation on patient outcomes in hepatobiliary, colorectal, and upper gastrointestinal cancer surgery: a PRISMA-accordant meta-analysis. Annals of Surgery. 2021 Jul 1;274(1):70-77. Time spent building your physical and emotional reserves before surgery is an investment that can pay you back during recovery. 

Research shows these benefits of prehab: 

• Shorter hospital stays (approximately 2 days) after some surgeries²Lambert JE, Hayes LD, Keegan TJ, Subar DA, Gaffney CJ. The impact of prehabilitation on patient outcomes in hepatobiliary, colorectal, and upper gastrointestinal cancer surgery: a PRISMA-accordant meta-analysis. Annals of Surgery. 2021 Jul 1;274(1):70-77. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis. Gastroenterology. 2018 Aug;155(2):391-410.e4. 
• Less pain after surgery among people participating in total-body prehabilitation before surgery³Santa Mina D, Clarke H et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy. 2014 Sep;100(3):196-207.
• Better physical performance both immediately before surgery and 4 to 8 weeks after surgery⁴Lau CSM, Chamberlain RS. Prehabilitation programs improve exercise capacity before and after surgery in gastrointestinal cancer surgery patients: a meta-analysis. Journal of Gastrointestinal Surgery. 2020 Dec;24(12):2829-2837.
• Fewer complications after surgery⁵Heger P, Probst P et al. A systematic review and meta-analysis of physical exercise prehabilitation in major abdominal surgery (PROSPERO 2017 CRD42017080366). Journal of Gastrointestinal Surgery. 2020 Jun;24(6):1375-1385; Marmelo F, Rocha V, Moreira-Gonçalves D. The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: systematic review and meta-analysis. European Journal of Preventive Cardiology. 2018 Mar;25(4):404-417. 
• Better heart and lung function during surgery⁶Howard R, Yin YS et al. Taking control of your surgery: impact of a prehabilitation program on major abdominal surgery. Journal of the American College of Surgeons. 2019 Jan;228(1):72-80.
• Less anxiety and decreased body fat percentage before surgery, and better physical function 4 and 26 weeks after surgery⁷Santa Mina D, Hilton WJ et al. Prehabilitation for radical prostatectomy: a multicentre randomized controlled trial. Surgical Oncology. 2018 Jun;27(2):289-298.

Plan ahead for better recovery

Your team’s choice of analgesia and a protocol called enhanced recovery after surgery (ERAS) can both improve your well-being and recovery after surgery. These preparations must be made by the oncology/surgery team.

Enhanced recovery after surgery (ERAS) 

A protocola package of therapies combining and preferably integrating various therapies and practices into a cohesive design for care combining counseling, specific nutritional and anesthesia approaches, and a quick return to patient movement (mobility) after surgery is linked to several better outcomes. 

Ask if your surgical team uses this approach. More about ERAS is in Are you a health professional? ›

ERAS in combination with other therapies

ERAS with an integrated traditional Chinese and Western medicine approach is linked to lower markers of inflammation (CRP, IL-6, IL-8, and TNF-β) and stress (cortisol), lower reported pain, and earlier defecation after surgery among people with gastrointestinal tumors (preliminary evidence).¹⁶Zhao H, Sun W. Effect of enhanced recovery after surgery with integrated traditional Chinese and western medicine on postoperative stress response of patients with gastrointestinal tumors. Computational and Mathematical Methods in Medicine. 2022 Jul 8;2022:3663246.

Plan ahead to prevent surgical complications

First, find out how much time you can take before surgery to develop a plan and prepare for surgery.

Preparing your body for surgery

Discuss which risk factors you can improve before surgery and come up with a plan of actions to take. Actions may include controlling hypertension, stress, high blood sugar, and other conditions, or stopping smoking.

Consider incorporating stress-management practices in the weeks leading up to surgery. Many people find imagery practices specific to preparing for surgery to be helpful. See Guided Imagery ›

In addition to effective stress-management practices, use emotional support, counseling, and pre-surgery medication as appropriate to help reduce psychological stress before surgery.

If you typically clean an animal litter box or bird cage, find someone else to clean it before and for several weeks after your surgery.

Optimizing your surgical environment

Infection rates tend to be higher on average with less-experienced surgeons. A pretty good rule of thumb for having good experience is to consider surgeons who have done at least four of your specific type of surgery per month for five years.

Inform your surgical team of any supplements, herbs, or other therapies you’re using before your surgery.

If you have financial or social barriers to good care before or after surgery, ask to be referred to an oncology social worker or oncology navigator for assistance.

Schedule your surgery as an outpatient (ambulatory) procedure rather than as an inpatient hospital stay, if possible.

Ask your surgeon if a laparoscopic or minimally Invasive approach is available for your surgery.

Discuss your options for anesthesia and pain control after surgery.

Immediately before surgery

Avoid becoming dehydrated before surgery.

See if you can postpone surgery if you develop a cold, flu, pneumonia, or other infection shortly before your scheduled surgery.

Plan ahead to reduce your risk of recurrence or metastasis

Research has shown that a few minor additions or modifications to your surgery can reduce your risk of recurrence or metastasis after surgery. Also see the impacts of anesthetics in On your surgery day ›

• Combined use of the beta blocker propranolol and the anti-inflammatory etodolac for 5 days before surgery has been used safely to reduce metastases and mortality. However, this combination may not be safe in patients with asthma, cardiovascular disease, diabetes, bleeding risk, gastrointestinal ulcers, or low blood pressure.¹⁷Haldar R, Ben-Eliyahu S. Reducing the risk of post-surgical cancer recurrence: a perioperative anti-inflammatory anti-stress approach. Future Oncology. 2018;14(11):1017-1021; Mills GA, Horn JR. Beta-blockers and glucose control. Drug Intelligence and Clinical Pharmacy. 1985 Apr;19(4):246-51. Our note: Both of these medications have side effects: propranolol decreases blood pressure, and etodolac may increase the risk of bleeding and increases the risk of heart attack long-term.
• Taking precautions to prevent blood clots, neutrophil extracellular traps (NETs), and low oxygen levels (hypoxia) may reduce recurrence after surgery, although this may decrease healing.¹⁸Hiller JG, Perry NJ, Poulogiannis G, Riedel B, Sloan EK. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews Clinical Oncology. 2018 Apr;15(4):205-218.
• People with early breast cancer receiving peritumoral injection of 0.5% lidocaine 7 to 10 minutes before surgery had slightly better disease-free survival and 5-year overall survival and lower risk of distant recurrence after surgery as first-line therapy without prior neoadjuvant treatment in a very large RCTrandomized 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 effects¹⁹Badwe RA, Parmar V et al. Effect of peritumoral infiltration of local anesthetic before surgery on survival in early breast cancer. Journal of Clinical Oncology. 2023 Apr 6:JCO2201966.

Self care to prepare yourself for surgery

Expert approach: Barbara MacDonald, ND, FABNO

Dr. MacDonald recommends an anti-inflammatory diet high in vegetables, fruits, grains, and healthy protein. Dr. MacDonald suggests following this diet for at least two weeks before surgery unless your care team advises otherwise due to any food allergies or your specific nutritional needs.

Natural products, medications, and surgery

Before your surgery, your surgeon and anesthesiologist will need to know what medications, supplements, and natural products you’re taking.

You may be told to quit eating and drinking several hours before your surgery, but you may still need to take certain medications. Your doctors will tell you which ones to take with a small amount of water. If you are on an ERAS protocol (mentioned above), you might be asked to drink a high carbohydrate drink a few hours before surgery.)

Sometimes doctors forget to ask about any supplements and vitamins you take. If they don’t ask, you need to tell them. Your entire team needs to know about any natural products or supplements you are taking. 

Both drugs and natural products can have effects that could be harmful in surgery or during your recovery. Examples:²⁰Hodges PJ, Kam PC. The peri-operative implications of herbal medicines. Anaesthesia. 2002 Sep;57(9):889-99.

• Anticoagulants—drugs and supplements that reduce coagulation, commonly called “blood thinners”—can increase your risk of serious bleeding.
• Drugs or supplements with sedative effects may interact with your anesthesia or sedatives and delay your wake-up time after surgery.
• Some products might interfere with your ability to clear the anesthesia and other drugs from your system.
• Other products might suppress your immune system.

Many more interactions are possible. The American Society of Anaesthesiologists advises patients to stop taking herbal medicines at least two weeks before surgery.²¹Hodges PJ, Kam PC. The peri-operative implications of herbal medicines. Anaesthesia. 2002 Sep;57(9):889-99. Several prescription and over-the-counter medications may also need to be stopped before surgery. Follow your medical team’s directions.

Keep an up-to-date list of all the medications, vitamins, and supplements you are taking and your doses. You can keep a notebook to record this information, or you can use one of several phone apps. Ask your team if you have questions about any medication you are taking or they prescribe. 

Medications to avoid before surgery

We strongly encourage you to talk with your oncology and surgical teams before stopping any medications you have been prescribed. 

Some examples of medications your doctor may ask you to stop before surgery; this is not a complete list: 

Natural products to avoid before surgery

Discontinue two weeks before surgery

Avoid taking the following natural product supplements that increase your risk of bleeding:²²MacDonald B. The Breast Cancer Companion: A Complementary Care Manual: Third Edition. (self-published, Amazon, 2016); Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010; Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Treatment. New York: Bantam Dell. 2009.

Discontinue 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. Unless your doctor advises you to take melatonin, discontinue use to avoid magnifying the effects of anesthesia.²³MacDonald B. The Breast Cancer Companion: A Complementary Care Manual: Third Edition. (self-published, Amazon, 2016); Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010; Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Treatment. New York: Bantam Dell. 2009.

Helpful link

Expert approaches: natural 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 these protocols, programs, and plans.

Commentary

Microbiome, surgery, and probiotics

CancerChoices Senior Clinical Consultant Laura Pole, RN, MSN, OCNS: Integrative physician and CancerChoices advisor Keith Block, MD, and other clinician researchers suggest using prebiotics or probiotics › before and after surgery to reduce the risk of infection and keep the protective inner lining of the intestines (mucosal barrier) healthy. This is backed by research, as described in our handbook.

Your Microbiome

I encourage you to consult your surgeon and/or an integrative oncologist—such as a naturopathic oncologist or functional medicine physician—to recommend specific probiotics you can take as well as other measures to protect and restore your microbiome. Finding Integrative Oncologists and Other Professionals ›

Minimizing the stress from surgery

Surgery may be an important, even life-saving, part of your treatment plan. But surgery itself brings trauma to your body—sometimes in ways that can alter your body terrainthe internal conditions of your body, including nutritional status, fitness, blood sugar balance, hormone balance, inflammation and more to support tumor growth. This could be through stress, low body temperature, and blood clots, for instance. Some aspects of surgery may affect your immune response and other body terrain factors, possibly making your terrain temporarily more favorable for cancer growth. Preparing for and minimizing your stress response can have long-term benefits.

Your body’s stress response

Inflammation

Even if you’re feeling calm, incisions and the removal of tumors, organs, or other tissue creates trauma to your body. The trauma will create an inflammatory response in your body. Out-of-balance inflammation is a terrain factor related to cancer growth.

Surgery initiates a local inflammatory response, starting with the incision, which the body interprets as a wound. Circulating tumor cells are drawn to wounds, infection sites and tissue trauma, setting up a microenvironment in distant organs conducive to the survival and growth of tumor cells. This is called a premetastatic niche. In addition, systemic inflammation—such as in metabolic syndrome, chronic stress response or chronic insomnia—also creates a microenvironment supportive to tumors.

The type of surgery—whether open surgery or laparoscopic surgery—has a great impact on the resulting inflammation. The more extensive the surgery, the greater your inflammatory response. The type of surgery has a greater impact than the choice of anesthetic and pain management techniques (epidural versus intravenous analgesia) on inflammation.

More extensive surgery could tip the stress-inflammatory response in the direction of metastasis even when the primary tumor is successfully removed. The wound-healing process can release immune system chemicals known to promote tumor growth.²⁴Haldar R, Ben-Eliyahu S. Reducing the risk of post-surgical cancer recurrence: a perioperative anti-inflammatory anti-stress approach. Future Oncology. 2018;14(11):1017-1021; Khanna AK, Perez ER, Laudanski K, Moraska A, Cummings KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014;3(1):31-45; Hiller JG, Perry NJ, Poulogiannis G, Riedel B, Sloan EK. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews Clinical Oncology. 2018 Apr;15(4):205-218; Dang Y, Shi X, Xu W, Zuo M. The effect of anesthesia on the immune system in colorectal cancer patients. Canadian Journal of Gastroenterology & Hepatology. 2018 Apr 1;2018:7940603. Abdominal/pelvic surgery is associated with metastasis across the peritoneal cavity.²⁵Hiller JG, Perry NJ, Poulogiannis G, Riedel B, Sloan EK. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews. Clinical Oncology. 2018;15(4):205-218.

Immune function

Stress—both physical and emotional/mental—can suppress your immune system, which can impact tumor progression. The use of anesthesia during surgery also stresses your body,²⁶Khanna AK, Riveros Perez E, Laudanski K, Moraska A, Cummings III KC. Perioperative care and cancer recurrence: Is there a connection? World Journal of Anesthesiology. 2014 Mar 27;3(1):31-45. although we are not implying that you should undergo surgery without anesthesia. However, some techniques that can reduce your need for anesthesia may reduce the stress load and its impacts on your immune system. We discuss these in On your surgery day ›  

Surgery is a major source of stress and is linked to immune suppression that “may predispose already immunosuppressed cancer patients to tumor spread.”²⁷Vallejo R, Hord ED, Barna SA, Santiago-Palma J, Ahmed S. Perioperative immunosuppression in cancer patients. Journal of Environmental Pathology, Toxicology and Oncology. 2003;22(2):139-46.The greater your body’s stress level, the greater the suppression of your immune system following surgery. This is likely one reason that surgery has been linked to an increased risk of metastasis.²⁸Horowitz M, Neeman E, Sharon E, Ben-Eliyahu S. Exploiting the critical perioperative period to improve long-term cancer outcomes. Nature Reviews. Clinical Oncology. 2015 Apr;12(4):213-26. 

The physical stress of surgery on your body is similar to the stress brought on by sudden, intense exercise. Like with exercise, you can prepare for surgery similarly to building up your strength and stamina before an intense exercise event. Just like with training for a marathon, Improving your physical fitness prior to surgery can improve your recovery.²⁹Howard R, Yin YS et al. Taking control of your surgery: impact of a prehabilitation program on major abdominal surgery. Journal of the American College of Surgeons. 2019 Jan;228(1):72-80. 

Blood clots 

Blood clots can be life-threatening and may increase your risk of cancer recurrence after surgery.³⁰Hiller JG, Perry NJ et al. Perioperative events influence cancer recurrence risk after surgery. Nature Reviews Clinical Oncology. 2018 Apr;15(4):205-218. Often doctors will give an injection under the skin before or after surgery to prevent blood clots. Your surgical team may also put special boots on your legs during surgery and while you are admitted to the hospital to reduce this risk. These measures are important to keep you safe and improve your cancer outcomes.

Managing anxiety before surgery

Anxiety can take a toll on your body. It releases hormones and chemicals that lower your immune response and uses energy reserves better left for your surgery and healing. 

Anxiety is linked to these outcomes:

• Lower health-related quality of life, lower cognitive performance and self-perception of worse memory and attention before surgery among people with clinically relevant anxiety, mostly for brain tumors (modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently))
• More depressive symptoms after surgery among people with clinically relevant anxiety before surgery, mostly for brain tumors (modest evidence)
• Lower Quality of Recovery Scale scores among people with higher anxiety before and/or after elective abdominal surgery (preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently))

Helpful links for promoting calm

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