Pre- and Post-surgery Health

Also indexed as: Perioperative Health

Major surgery causes serious stress to the body. The body’s immune system is weakened and gastrointestinal function is changed after major surgery, leaving the body vulnerable to infection and in a state of nutritional insufficiency.1 Steps can be taken using natural approaches to strengthen the body before and after surgery, enhance defenses, prevent complications, and speed recovery.

Checklist for Pre- and Post-surgery Health

Rating Nutritional Supplements Herbs
3Stars Glutamine
Nutritional formulas supplemented with nutrients, taken after surgery		  
2Stars Arginine
Fish oil
Iron (if deficient or for major surgery)
Ribonucleic acid (RNA)
Taurine
Vitamin C (if deficient)		 Ginger
1Star Fructo-oligosaccharides (FOS)
Selenium
Vitamin A
Vitamin B1
Vitamin B12
Vitamin B6
Vitamin E
Zinc		 Curcumin (from turmeric)
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

How is it treated? Conventional treatment includes adequate rest, nutrition, fluid intake, and proper care of the surgical wounds. Pain symptoms are managed according to the level of discomfort and include medications such as nonsteroidal anti-inflammatory drugs (e.g., Advil®, Alleve®, Motrin®), acetaminophen (e.g., Tylenol®), and prescription narcotics. Doctors may also recommend glucocorticoids (e.g., prednisone, Hydrocortone®, Prelone®) to reduce inflammation. Antibiotics may also be used to treat bacterial infections.

Dietary changes that may be helpful: Malnutrition, either before or after surgery, has a negative effect on recovery from surgery.2 3 4 5 6 Malnutrition is common among the elderly and chronically ill even in developed countries, and one study found that half of older general surgery patients had moderate to severe malnutrition from protein deficiency.7

Being malnourished prior to surgery was associated with increased post-operative inflammation in one recent preliminary study.8 A study of patients requiring lung surgery found that those who were better nourished prior to surgery had shorter hospital stays and required less intensive post-surgery care.9 Dietary restriction and even fasting is often required prior to certain types of surgery. However, one study found that a four- to eight-day calorie-restricted diet lowered nutritional health and caused decreased immune system activity in pre-surgery patients, but adding a nutritional formula providing extra calories and protein reduced this negative effect of the restricted diet.10 In another study, the clear liquid diet commonly recommended to patients before colon surgery was compared with a liquid diet providing protein, calories, and other nutrients; the patients who received extra nutrition prior to surgery had shorter hospital stays than those who received only clear liquids.11 After reviewing animal and human studies comparing fasting and clear liquid pre-surgery diets to pre-surgery diets including liquid carbohydrate formulas, some authorities recommend a carbohydrate formula rather than fasting in preparation for surgery.12

Liquid diets using specially prepared nutritional formulas containing all necessary nutrients are frequently used around the time of surgery, especially in patients who cannot eat solid food. Studies have also shown that use of nutritional formulas soon after surgery has a positive effect on recovery time after cesarean section13 and reduces rates of infection after abdominal surgeries.14 Reviews of nutrition research on all types of surgery patients have concluded that undernourished patients will have better results if they receive supplemental nutrition before and after surgery, and that supplemental nutrition is more helpful when given orally rather than directly to the bloodstream (intravenously).15 16 17 Whether people who are not malnourished benefit from these diet supplements is unknown.

After major surgery, it is sometimes necessary to supply nourishment by a route that bypasses the digestive tract, such as intravenously, rather than by mouth. This form of nutrition is known as “parenteral,” while food taken into the digestive tract is known as “enteral.” While there is debate about whether parenteral nutrition is less healthful than enteral nutrition,18 the decision to use one or the other is a complicated one, and should be discussed in individual cases with the treating physician.

Lifestyle changes that may be helpful: Smoking compromises overall health and is associated with poorer outcomes of many types of surgery.19 20 21 Smoking may lessen the nausea and vomiting commonly experienced after surgery due to effects of anesthesia, according to a preliminary study,22 but the disadvantages far outweigh this single possible benefit.

Nutritional supplements that may be helpful: Vitamin A plays an important role in wound healing,23 and one animal study suggests that vitamin A deficiency might contribute to poor recovery after surgery.24 Vitamin A may be particularly beneficial to post-surgical patients who are using corticosteroid medications. These medications typically slow wound healing, and a number of animal studies have found that both topical and oral vitamin A reverse this effect; however, vitamin A does not change healing time in animals not given corticosteroids.25 26 27 Similar results have been reported for topical vitamin A in some human cases, and these researchers suggest a topical preparation containing 200,000 IU of vitamin A per ounce for improved surgical wound healing in patients using corticosteroids after surgery.28 Topical vitamin A may also reduce scarring in patients taking corticosteroids.29

Selenium is a mineral nutrient with an important role in immune function and infection prevention,30 31 32 and selenium deficiency has been reported in patients after intestinal surgery.33 A controlled trial of critically ill patients, including some with recent major surgery, found that those receiving daily intravenous selenium injections for three weeks showed less biochemical signs of body stress compared with unsupplemented patients. The amount used in this trial was 500 mcg twice daily for the first week, 500 mcg once daily for the second week, and 100 mcg three times daily for the third week.34

Zinc is another mineral nutrient important for proper immune system function and wound healing.35 One study found most surgery patients recovering at home had low dietary intakes of zinc.36 Low blood levels of zinc have been reported in patients after lung surgery.37 38 In one study this deficiency lasted for up to seven days after surgery and was associated with higher risk of pneumonia,39 while another study found an association between post-operative zinc deficiency and fatigue.40 Poor post-operative wound healing is also more common in people with zinc deficiency.41 Zinc supplements given to patients before surgery prevented zinc deficiency in one study, but the effect of these supplements on post-surgical health was not evaluated.42

One preliminary study found iron levels to be reduced after both minor and major surgeries, and iron supplementation prior to surgery was not able to prevent this reduction.43 A controlled trial found that intravenous iron was more effective than oral iron for restoring normal iron levels after spinal surgery in children.44 One animal study reported that supplementation with fructo-oligosaccharides (FOS) improved the absorption of iron and prevented anemia after surgery,45 but no human trials have been done to confirm this finding. Some researchers speculate that iron deficiency after a trauma such as surgery is an important mechanism for avoiding infection, and they suggest that iron supplements should not be given after surgery.46

Patients who have undergone major surgery frequently need blood transfusions to replace blood lost during the procedure. Studies have found that 18 to 21% of surgery patients were anemic prior to surgery,47 48 and these anemic patients required more blood after surgery than did non-anemic surgery patients. Supplementation with iron prior to surgery was found in a controlled trial to reduce the need for blood transfusions, whether or not iron deficiency was present.49 Iron supplements (99 mg per day) given before and for two months after joint surgery in another controlled trial improved blood values but did not change the length of hospitalization or the risk of post-operative fever.50 Pre-operative iron supplementation in combination with a medication that stimulates red blood cell production in the bone marrow is considered by some doctors to be an effective way to minimize the need for post-operative blood transfusions.51

Vitamin C deficiency can be detrimental to immune function in hospitalized patients,52 and one study found that half of surgery patients recovering at home had low dietary intakes of vitamin C.53 Vitamin C is also a critical nutrient for wound healing,54 55 but studies of vitamin C supplementation have shown only minor effects on the healing of surgical wounds.56 57

Some studies of surgery patients,58 59 though not all, 60 have found that blood levels of vitamin E decrease during and after surgery. Animal research suggests that vitamin E may prevent skin scarring when used topically after surgery,61 but a human study reported disappointing results.62 Vitamin E taken by mouth may interfere with blood clotting63 ; therefore, use of vitamin E before surgery should be discussed with the surgeon. No research on either the usefulness or hazards of vitamin E supplementation around surgery has been done.

Vitamin B1, given as intramuscular injections of 120 mg daily for several days before surgery, resulted in less reduction of immune system activity after surgery in a preliminary trial.64 In a controlled trial, an oral B vitamin combination providing 100 mg of B1, 200 mg of vitamin B6, and 200 mcg of vitamin B12 daily given for five weeks before surgery and for two weeks following surgery also prevented post-surgical reductions in immune activity.65 However, no research has explored any other benefits of B vitamin supplementation in surgery patients.

Glutamine, one of the most abundant amino acids in the body, supports the health of the cells lining the gastrointestinal tract and is important for immune function.66 Glutamine is depleted when the body is under stress, including the stress of surgery.67 Blood levels of glutamine decrease following surgery, and as they return to normal, their increase parallels the increase in immune cells.68 Two controlled trials have shown that the use of glutamine-enriched intravenous formulas, providing approximately 20 grams of glutamine per day, resulted in increased immune cell activity and shorter hospital stays.69 70 Double-blind studies report that patients receiving intravenous formulas supplemented with glutamine after surgery had better nutritional status and better health outcomes, including fewer infections and other complications, compared with patients receiving regular formulas.71 72

The amino acid arginine has a role in immune function, infection prevention, and tissue repair after injury, including surgery.73 Animal research suggests that supplemental arginine may improve the outcomes in cardiovascular74 and colon surgeries.75 Other animal studies suggest a possible role for arginine in prevention of adhesions, a painful type of internal scarring that can occur with surgery.76 Human trials of formulas including arginine are discussed below, but the benefits of supplemental arginine alone have not been studied in surgery patients.

Taurine is an amino acid abundantly present in the body that also appears to have an important role in immune cell functions.77 A preliminary trial found that patients receiving an oral formula enriched with taurine (1 gram per liter) beginning two days before surgery and continuing until five days after surgery had less inflammation after surgery compared with those receiving a standard formula.78

Omega-3 fatty acids have anti-inflammatory properties,79 and animal studies suggest that supplementation with omega-3 fatty acids may improve recovery and prevent infection after surgery.80 81 A controlled human trial found that intravenous nutritional formulas containing omega-3 fatty acids given post-operatively lowered the production of inflammatory chemicals compared with standard nutritional formulas.82 Other human studies of omega-3 fatty acid-supplemented nutritional formulas used in surgery patients have included other supplemental nutrients as well and are discussed below.83

Ribonucleic acid (RNA) is a member of the nucleotide family of biomolecules and supports protein synthesis and cell growth. During times of physical stress, RNA helps stimulate immune cell division and activity,84 85 and is needed in greater amounts. Animal studies show that nucleotides given in the diet support the immune response and decrease death rates in infected animals.86 87 88 In human infants, those fed nucleotide-enriched formulas have healthier gastrointestinal systems and better immune function than do those fed ordinary formulas.89 90 91 RNA is included in some oral and intravenous nutritional formulas used for surgery patients, and these formulas are discussed below.

Research on post-surgical recovery has explored the usefulness of liquid nutritional formulas supplemented with several nutrients believed to improve immune function and to speed the healing process. The most common of these supplemental nutrients are certain amino acids, essential fatty acids, and nucleotides.92 Several controlled trials, some of which were double-blind, showed that giving an oral formula containing arginine, RNA, and omega-3 fatty acids from fish oil either after surgery93 94 or before and after surgery95 96 97 98 resulted in decreased inflammation, less reduction of immune cell function, fewer complications of surgery, and shorter hospital stays. The formula most commonly used in these studies contains 12.5 grams of arginine, 3.3 grams of omega-3 fatty acids, and 1.2 grams of RNA per liter, as well as additional iron, zinc, selenium, copper, and vitamin C. Typically, 1 to 1.5 liters per day was consumed by the surgery patients. One controlled trial, however, found that this enriched formula was no better than a standard formula when they were given only before surgery.99 An analysis of 12 studies comparing traditional formulas with immune-enhancing formulas concluded that surgery patients receiving the supplemented formulas had the same risk of death, but that they had fewer infections and shorter hospital stays.100

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: A recent study found that 24% of surgery patients had taken herbal supplements before their surgeries, and 50 different herbs had been used among these patients.101 Little research exists, however, on the safety or efficacy of herbs before surgery. Some researchers and healthcare providers are concerned about possible harmful interactions between herbs and medications used around or during surgery, or the possibility that some herbs may increase bleeding during and after surgery.102 103 The use of herbs around the time of surgery should be discussed with a knowledgeable healthcare practitioner.

Nausea and vomiting can be experienced post-operatively as a result of anesthesia. Ginger (Zingiber officinale) has antinausea properties and has been examined for its ability to prevent post-operative nausea and vomiting in several controlled trials. In two of these controlled trials, ginger was found more effective than placebo and equal to an antinausea medication;104 105 however, in two other controlled trials ginger was not found to have any benefit.106 107 A review considering the results of these trials concluded that one gram of ginger taken before surgery prevents nausea and vomiting slightly better than placebo, but this difference is not significant.108

Turmeric (Curcuma longa) is an herb with anti-inflammatory effects.109 One trial found curcumin (from turmeric) at 400 mg three times daily was more effective than either placebo or anti-inflammatory medication for relieving post-surgical inflammation. However, as the different treatment groups had different degrees of inflammation at the start of the study, firm conclusions cannot be drawn from this study.110

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Acupressure can be used to prevent nausea and vomiting. Wristbands designed to apply pressure to acupuncture points on the forearm were shown to effectively prevent post-operative nausea and vomiting in seven controlled trials,111 112 113 114 115 116 and were as effective as an antinausea medication in another.117 One controlled trial found no benefit from acupressure wristbands.118 Acupuncture 119 and transcutaneous electrical nerve stimulation (TENS) of a wrist acupuncture point120 have also been shown to be effective for post-operative nausea and vomiting in controlled trials. A controlled comparison study found that electroacupuncture of the wrist points controlled post-operative nausea and vomiting as well as antinausea medication and better than TENS, but both electro-acupuncture and TENS helped more than no treatment.121 A comprehensive review of research on acupuncture, electroacupuncture, TENS, acupoint stimulation, and acupressure for post-operative nausea and vomiting found these techniques to be more effective than placebo and as effective as commonly prescribed medications in adults but not in children.122 However, laser stimulation of the acupuncture points on the wrists both before and after surgery was effective for children in one controlled trial.123

References:

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