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Surgery_Schwartz. and vomiting, cause respiratory depression, reduce gastrointestinal motility, worsen urinary retention, induce endocrine dysfunc-tion, and suppress the immune system.87 There have been a number of randomized controlled trials that have shown that as opioid administration increases, pain scores and postoperative nausea and vomiting increase.121-129 Exposure to any fentanyl or opioid in the operating room worsens postoperative pain scores and should therefore be limited or omitted.122,123,127,129 Opioid containing PCAs have been the standard for opioid administra-tion because of their safety and efficacy in patients to control the administration of opioids. However, because a PCA only offers opioid medication, there is the possibility that the desired analgesic effect will be associated with the aforemen-tioned complications of opioids. Despite their disadvantages, opioids are still quite useful in the treatment of pain. However, the ERAS protocols focus on opioids as a single component


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Surgery_Schwartz. the aforemen-tioned complications of opioids. Despite their disadvantages, opioids are still quite useful in the treatment of pain. However, the ERAS protocols focus on opioids as a single component of a comprehensive pain relief strategy, not as the mainstay for treatment. Instead, multimodal 45Complications andpostoperative morbidityNormovolemiaVolume statusHypervolemia consequences• Hyperchloremic acidosis• Pulmonary edema• Impaired wound healing• Anastamotic dehiscence• Decreased tissue perfusion• Altered coagulation• Multiple organ failureHypovolemia consequences• Reduced intravascular volume• Hypotension• Endothelial dysfunction• Altered coagulation• Decreased renal blood flow• HypoxiaFigure 50-4. Volume status affects postoperative morbidity. (Reproduced with permission from Francis N, Kennedy RH, Ljungqvist O, et al: Manual of Fast Track Recovery for Colorectal Surgery. London: Springer-Verlag; 2012.)Brunicardi_Ch50_p2113-p2136.indd 211901/03/19 9:39 AM 2120SPECIFIC


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Surgery_Schwartz. Francis N, Kennedy RH, Ljungqvist O, et al: Manual of Fast Track Recovery for Colorectal Surgery. London: Springer-Verlag; 2012.)Brunicardi_Ch50_p2113-p2136.indd 211901/03/19 9:39 AM 2120SPECIFIC CONSIDERATIONSPART IITable 50-2Analgesic medications ADVANTAGESDISADVANTAGESOpioids141Relieve pain immediately after administrationWorsen pain scores after opioids wear offIncrease postoperative opioid requirementsCentral Nervous System: Euphoria/dysphoria Sedation Respiratory depression Nausea/vomiting Cough suppressionCardiovascular: Bradycardia/tachycardia Arterial/venous dilationRenal: Antidiuretic Increased sodium resorption Urinary retentionGastrointestinal: Decreased motility Constipation Biliary colicEndocrine: Stimulates release of antidiuretic hormone Stimulates release of prolactin Stimulates release of somatotropin Decreases luteinizing hormoneImmunologic: Decreased immune system function Cancer growthNSAIDs142Reduce inflammationSynergistic effect with opioidsRenal


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Surgery_Schwartz. prolactin Stimulates release of somatotropin Decreases luteinizing hormoneImmunologic: Decreased immune system function Cancer growthNSAIDs142Reduce inflammationSynergistic effect with opioidsRenal insufficiencyIncreased bleedingDelay healingAdverse cardiovascular riskLocal anesthetics140Opioid-sparing effectDecrease PONVReduce ileusPossible anticancer effectCardiac toxicityCentral nervous system toxicityKetamine136,137,143Opioid-sparing effectMay prevent opioid-induced hyperalgesia and chronic pain syndromesDysphoriaHallucinationsGabapentinoids130-135Opioid-sparing effectReduce opioid side effectsReduce postoperative painVisual disturbancesanalgesia should be emphasized by utilizing multiple medi-cations to limit postoperative pain and therefore opioid use. Multimodal analgesia mitigates the side effects of opioids by opioid reduction and enhances pain management. Preoperative and postoperative administration of acetaminophen and cele-coxib or other nonsteroidal anti-inflammatory


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Surgery_Schwartz. the side effects of opioids by opioid reduction and enhances pain management. Preoperative and postoperative administration of acetaminophen and cele-coxib or other nonsteroidal anti-inflammatory drugs, as well as gabapentin have been shown to be efficacious.130-135 Intra-operatively, the utilization of ketamine, lidocaine, and magne-sium, act as adjunctive measures to limit pain and have been utilized to reduce the utilization of opioids in the postoperative period.136-140 Administration of lidocaine and ketamine can also be continued in the postoperative setting (Table 50-2).Neuraxial opioid analgesia, the administration of opioids through either the intrathecal or epidural route, can be accom-plished by either a single shot (both spinal and epidural) or catheter-based therapy (epidural). The use of opioids by this route was shown to have improved pain relief when compared to preoperative oral, IV, or intramuscular morphine.144 Further, neuraxial opioid analgesia is associated with


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Surgery_Schwartz. The use of opioids by this route was shown to have improved pain relief when compared to preoperative oral, IV, or intramuscular morphine.144 Further, neuraxial opioid analgesia is associated with lower postopera-tive pain scores in adults and children who undergo surgery.145 Neuraxial analgesia can also be performed with local anesthetic only. Finally, the American Pain Society (APS) recommends the utilization of such postoperative analgesic methods in patients who undergo major surgeries, including thoracic and abdominal Brunicardi_Ch50_p2113-p2136.indd 212001/03/19 9:39 AM 2121OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50procedures, cesarean sections, and hip and lower-extremity sur-geries; this is especially recommended for patients at risk for cardiopulmonary complications or prolonged ileus.145Multimodal analgesia can also include regional analgesic techniques such as peripheral nerve blocks, paravertebral blocks, plexus blocks, and local


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Surgery_Schwartz. cardiopulmonary complications or prolonged ileus.145Multimodal analgesia can also include regional analgesic techniques such as peripheral nerve blocks, paravertebral blocks, plexus blocks, and local infiltration, which can reduce postoperative physiological stress and decrease complications associated with surgery as part of a regimen.146 These techniques have been shown to reduce the amount of opioids required for analgesia and also have been shown to reduce the adverse events seen with epidural local anesthetics (such as urinary reten-tion and hypotension) and/or opioid-containing PCAs. Postoperative Nausea and Vomiting PreventionPostoperative nausea and vomiting (PONV) is very common and can cause significant distress to patients, with the incidence of vomiting at approximately 30%, nausea at 50%, and the com-bination of PONV as high as 80%. All result in poor patient satisfaction, increased recovery room length of stay, and higher costs to the health-care system.147-152 This


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Surgery_Schwartz. nausea at 50%, and the com-bination of PONV as high as 80%. All result in poor patient satisfaction, increased recovery room length of stay, and higher costs to the health-care system.147-152 This could further increase the time to first feeding, which in turn may prolong ileus and/or hospital stay.Dr. Gan and colleagues developed a consensus guideline for the management of nausea and vomiting and details the risk and possible choices for the treatment of PONV.153 Risk factors include female sex, history of PONV or motion sick-ness, nonsmoking, younger age, general versus regional anes-thesia, use of volatile anesthetics and nitrous oxide, postoperative opioids, duration of anesthesia, and the type of surgery including cholecystectomy, laparoscopy, gynecologi-cal, and strabismus. The strategies for avoiding PONV include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and


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Surgery_Schwartz. The strategies for avoiding PONV include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative opioids, and adequate hydration.150,152,154-159 The medications to prevent, abort, and reduce PONV include perphenazine, aprepitant, dexamethasone, scopolamine, dolasetron, granisetron, and ondansetron, among others.160-164 PONV should be tar-geted before it occurs for optimal prevention (Fig. 50-5). Early Nutrition and Postoperative Ileus PreventionPostoperative ileus is the most common cause of prolonged hospital stay and readmissions following surgery on the diges-tive tract, occurring in up to 19% of cases.165 Not only is this adverse to the individual patient clinically, this also results in doubling of the total cost of the index hospital stay and thus carries a tremendous socioeconomic impact globally.166 Numer-ous risk factors contribute to postoperative ileus and


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Surgery_Schwartz. this also results in doubling of the total cost of the index hospital stay and thus carries a tremendous socioeconomic impact globally.166 Numer-ous risk factors contribute to postoperative ileus and include open surgery, increased surgery length of time, blood transfu-sion, fasting, fluid overload, opioids, postoperative nausea and vomiting, and other pharmacological agents. While some risk factors are unavoidable in certain patients, others are modifi-able, and therefore minimization of the risk of postoperative ileus is achievable.Nasogastric tubes (NGTs) were previously used prophy-lactically to prevent ileus, limit distension on the gastrointestinal anastomosis, as well as to prevent pulmonary complications. However, NGT use actually delays return of gastrointesti-nal activity and increases pulmonary complications without preventing anastomotic leaks in numerous types of surgery, including gastroduodenal, biliary, trauma, and esophageal.167-169 Therefore, the routine use of NGTs


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Surgery_Schwartz. pulmonary complications without preventing anastomotic leaks in numerous types of surgery, including gastroduodenal, biliary, trauma, and esophageal.167-169 Therefore, the routine use of NGTs for prophylaxis should be avoided.Addressing the numerous risk factors for postoperative ileus has a benefit on the reduction of the incidence of postoper-ative ileus. For example, mitigating the surgical trauma through 67Risk Factors:History of PONV/motion sicknessNonsmokerFemale sexPostoperative opioidsEmetogenic surgeryLow:Choose 1 treatmentMedium/High:Choose 2 treatmentsTotally intravenous anesthesiaRegional anesthesiaDexamethasoneAntidopaminergic5-HT3 antagonistDimenhydrinateScopolaminePatientPerphenazineFigure 50-5. Risk factors of and treatment options for postoperative nausea and vomiting. PONV = postoperative nausea and vomiting.Brunicardi_Ch50_p2113-p2136.indd 212101/03/19 9:39 AM 2122SPECIFIC CONSIDERATIONSPART IIminimally invasive surgery and meticulous surgery with mini-mal blood


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Surgery_Schwartz. = postoperative nausea and vomiting.Brunicardi_Ch50_p2113-p2136.indd 212101/03/19 9:39 AM 2122SPECIFIC CONSIDERATIONSPART IIminimally invasive surgery and meticulous surgery with mini-mal blood loss reduces postoperative ileus, either directly by limiting the inflammatory response with smaller incisions or indirectly through reduced opioid use.170-174 Anesthetic tech-nique can also aid in prevention of postoperative nausea and vomiting, which in turn reduces the need for parenteral opioids, a known risk factor for postoperative ileus. Multimodal pain strategies and neuraxial blocks reduce opioid use and therefore minimize nausea, improve early enteral nutrition, limit intra-venous fluid administration, and improve ambulation. Main-tenance of normovolemia in the perioperative setting should be achieved as fluid overload and dehydration both negatively affect return of bowel function, length of stay, and complica-tions.105,106,175 Clearly, each facet of the perioperative care


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Surgery_Schwartz. should be achieved as fluid overload and dehydration both negatively affect return of bowel function, length of stay, and complica-tions.105,106,175 Clearly, each facet of the perioperative care pro-cess is intricately intertwined to the next and has implications in total body homeostasis.Other measures may also assist in the prevention of post-operative ileus; however, the role of each in the setting of an ERAS pathway is unclear. Chewing gum is hypothesized to reduce postoperative ileus by stimulating the cephalovagal reflex and is considered a form of sham feeding. Prior to the introduction of ERAS, the use of chewing gum in multiple abdominal surgeries demonstrated faster intestinal recovery with variable impact on length of stay.176-178 Following the use of ERAS and associated early enteral feeding, the benefit of chewing gum is less clear.179,180 Alvimopan is a mu opioid recep-tor antagonist that is administered prior to surgery and twice daily postoperatively. Pooled analysis


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Surgery_Schwartz. enteral feeding, the benefit of chewing gum is less clear.179,180 Alvimopan is a mu opioid recep-tor antagonist that is administered prior to surgery and twice daily postoperatively. Pooled analysis of phase III trials dem-onstrated a reduction in postoperative NGT use, faster return of bowel function, and earlier discharge by 0.7 days.181 However, following ERAS implementation, small studies demonstrate a reduction in ileus and length of stay with the use of alvimopan in open surgeries without a benefit in laparoscopic surgery.182-184MobilizationThough no metric of mobilization has been clearly defined, early mobilization following surgery is an important compo-nent of ERAS that accelerates the return to baseline functional status. Prolonged postoperative bedrest leads to decondition-ing, increased deep venous thrombosis risk, and loss of muscle mass. Deterioration of mobility and activities of daily living can be seen in older patients after only 2 days of hospitalization.185


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Surgery_Schwartz. increased deep venous thrombosis risk, and loss of muscle mass. Deterioration of mobility and activities of daily living can be seen in older patients after only 2 days of hospitalization.185 Therefore, preoperative encouragement of an exercise program and perioperative mobilization can have dramatic impacts on not only the elderly but all patients undergoing surgery. Patients that begin a preoperative exercise program are more active post-operatively and have a faster return to baseline exercise capacity when compared to patients undergoing a postoperative exercise program.186 As patients in an ERAS program are directed to spend time out of bed and to ambulate, early mobilization is therefore encouraged. Many other facets of ERAS will assist in this early mobilization: postoperative nausea prevention, limit-ing drain use, and improved pain control. Setting preoperative expectations of mobility through patient education in the clinic setting and postoperative nursing unit engagement


Surgery_Schwartz

Surgery_Schwartz. prevention, limit-ing drain use, and improved pain control. Setting preoperative expectations of mobility through patient education in the clinic setting and postoperative nursing unit engagement in promot-ing mobility provide the proper setting for improved patient compliance with early and frequent mobilization. However, compliance with this is highly variable and difficult to track and may be hindered if pain in inadequately controlled or if the patient is tethered to devices such as drains, catheters, and IVs. As with other components of ERAS, engagement of all provid-ers of patient care from outpatient nursing, to inpatient nursing, physicians, and physical therapists, will improve compliance not only with mobility but often with other components as well. Reinforcement of expectations can be achieved with preopera-tive educational pamphlets, postoperative daily task lists, mobil-ity logs, and pedometers.ERAS in CRSAs the initial development of ERAS pathways occurred in colon


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Surgery_Schwartz. can be achieved with preopera-tive educational pamphlets, postoperative daily task lists, mobil-ity logs, and pedometers.ERAS in CRSAs the initial development of ERAS pathways occurred in colon surgery patients, the largest preponderance of data exists in this surgical specialty with the first ERAS guidelines developed in 2012 after many studies demonstrated positive outcomes apply-ing the basic tenets of ERAS surgery.81 In 1997, Henrik Kehlet published the initial series of patients, applying novel periopera-tive care strategies to colon resection patients.2,3 Following this, several groups also applied these principles to colon resection patients. These studies demonstrated that the principles of early mobilization, early feeding, and optimized intravenous fluid administration resulted in patients tolerating a diet sooner, faster return of bowel function, and earlier discharge.187-189 Further-more, these studies elucidated reduction in complications such as urinary tract infections,


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Surgery_Schwartz. patients tolerating a diet sooner, faster return of bowel function, and earlier discharge.187-189 Further-more, these studies elucidated reduction in complications such as urinary tract infections, ileus, and cardiopulmonary compli-cations. Nygren et al also demonstrated that muscle strength and lung function were less reduced after colon resection within an enhanced recovery protocol compared to traditional periopera-tive care.187 Additionally, as ERAS is expected to diminish the metabolic and hormonal stress response to surgery, attenuation of TNF-α, IL-1β, IL-6, and IFG-γ occurred after ERAS cases when compared to traditional perioperative care, and cortisol levels were not found to increase immediately postoperatively in ERAS, while those with traditional perioperative care experi-enced immediate and sustained cortisol elevation.190Larger series of patients followed with Delaney et al pub-lishing a single institutional experience of 1000 consecutive laparoscopic colectomy patients


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Surgery_Schwartz. immediate and sustained cortisol elevation.190Larger series of patients followed with Delaney et al pub-lishing a single institutional experience of 1000 consecutive laparoscopic colectomy patients with short length of stay and low readmission and mortality rates.191 The protocol was further applied to rectal surgery with success.187,192 Meta-analyses and systematic reviews demonstrate less opioid use, shorter length of stay, decreased morbidity, and no increase in readmission rates for laparoscopic or open colon or rectal resections when an ERAS protocol is utilized.193-197 Several groups have even discharged patients in as little as 24 hours following colon resec-tion, with Gignoux et al even discharging patients on the same day.198-200 ERAS can also be applied to octogenarian patients with compliance to the protocols and with no increased readmis-sion or mortality rates.201 Also, patients with diverting stomas can benefit from ERAS protocols, though diverting ileostomy may slightly


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Surgery_Schwartz. compliance to the protocols and with no increased readmis-sion or mortality rates.201 Also, patients with diverting stomas can benefit from ERAS protocols, though diverting ileostomy may slightly delay discharge over patients with no ileostomy.202Adherence to the numerous tenets of ERAS is inversely related to length of stay postoperatively in colorectal sur-gery.203,204 When compliance with ERAS measures is lower, length of stay is longer. The strongest predictors for shorter duration of stay include preoperative carbohydrate loading, no nasogastric tube, early mobilization, early oral nutrition, totally intravenous anesthesia, early removal of urinary catheter, and the use of nonopioid analgesia. Predictors for deviation from an ERAS program and thus resultant longer length of stay include pathologic diagnosis, intraoperative complications, high blood loss, surgery length, lack of mobilization, emesis, persistent use of intravenous fluids, reinsertion of urinary catheter, and poor


Surgery_Schwartz

Surgery_Schwartz. pathologic diagnosis, intraoperative complications, high blood loss, surgery length, lack of mobilization, emesis, persistent use of intravenous fluids, reinsertion of urinary catheter, and poor pain control.205-208 Though readmissions are no higher than traditional perioperative care, several factors have been impli-cated in readmission, including poor ERAS compliance and Brunicardi_Ch50_p2113-p2136.indd 212201/03/19 9:39 AM 2123OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50preoperative neoadjuvant chemoradiation.209,210 Predictive tools using artificial neural networks may assist in clinical decision-making.209 The most common reasons for readmission include bowel obstruction and skin and soft tissue infection. While patient and quality outcomes are clearly important, the added benefit of cost savings has been demonstrated. Surgery using the tenets of ERAS is both less costly for direct and indirect costs to the hospital and effective.211


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Surgery_Schwartz. are clearly important, the added benefit of cost savings has been demonstrated. Surgery using the tenets of ERAS is both less costly for direct and indirect costs to the hospital and effective.211 Furthermore, patients in an ERAS program returned to work faster and had less caregiver burden, resulting in huge indirect savings as well.6ERAS in Hepatopancreaticobiliary SurgeryAn initial experience applying an ERAS protocol in 61 con-secutive patients undergoing liver resection demonstrated 92% of patients tolerating a diet on postoperative day 1, a reduction in length of stay from 8 to 6 days, and no increased readmis-sions or morbidity.212 A subsequent randomized trial in patients undergoing open major liver resection demonstrated a length of stay reduction from 7 to 4 days with a decrease in medically related postoperative complications and no increase in surgi-cal complications or readmission; ERAS patients also reported improved quality of life over controls.213 Several


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Surgery_Schwartz. a decrease in medically related postoperative complications and no increase in surgi-cal complications or readmission; ERAS patients also reported improved quality of life over controls.213 Several meta-analyses have similarly supported the use of ERAS protocols in liver surgery, citing reduced morbidity, hospital stays, cost, and time to recovery of bowel function without increasing mortality or readmission rates.214-216 When adherence to all elements of an ERAS protocol for liver resection was less, hospital length of stay was longer.217In 2012, the ERAS Society published recommendations for patients undergoing pancreaticoduodenectomy after several studies published early outcomes in this surgical population.82 Patients undergoing pancreaticoduodenectomy often have high rates of delayed gastric emptying; the use of ERAS has reduced the incidence of delayed gastric emptying by nearly half, thus allowing earlier feeding in this complex patient population.218,219 Additionally, multiple


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Surgery_Schwartz. gastric emptying; the use of ERAS has reduced the incidence of delayed gastric emptying by nearly half, thus allowing earlier feeding in this complex patient population.218,219 Additionally, multiple prospective cohort or retrospective stud-ies have shown that ERAS protocols offer significant benefit to patients undergoing both distal pancreatectomy and pancre-aticoduodenectomy with reduced hospital stay and complica-tions.220-226 Several meta-analyses or systematic reviews have confirmed shorter length of stays, decreased complications, and lower cost with ERAS protocols.227-230 Furthermore, the use of ERAS protocols in elderly patients undergoing pancreaticoduo-denectomy continue to show improved outcomes in length of stay and morbidity, showing that ERAS protocols allow this more fragile patient population to recover faster.231,232ERAS in Gastrectomy and EsophagectomyPatients undergoing foregut surgery have notoriously been sub-jected to prolonged periods of nasogastric tube


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Surgery_Schwartz. fragile patient population to recover faster.231,232ERAS in Gastrectomy and EsophagectomyPatients undergoing foregut surgery have notoriously been sub-jected to prolonged periods of nasogastric tube decompression and resultant starvation while surgical dogma dictated this fast-ing time diminished the risk of complications from anastomotic leak. Nevertheless, more liberal removal of the nasogastric tube and limited fasting, as components of ERAS protocols, have demonstrated improved recovery and outcomes. Randomized controlled trials demonstrate that removal of the nasogastric tube in the operating room and early feeding, as components in an ERAS program, result in shorter length of stay, fewer grade III or higher postoperative complications, and faster return to baseline weight and functional status.233,234 Multiple nonran-domized studies and meta-analyses verify reduction in length of stay and no increase in complications.235-238 In 2014, consen-sus guidelines for ERAS after


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Surgery_Schwartz. functional status.233,234 Multiple nonran-domized studies and meta-analyses verify reduction in length of stay and no increase in complications.235-238 In 2014, consen-sus guidelines for ERAS after gastrectomy were published, and these include no routine use of nasogastric decompression, early feeding within the first postoperative day, and early consider-ation for nutritional support if the patient is malnourished or unable to maintain at least 60% of caloric requirements.239Esophagectomy surgery is notoriously complicated and fraught with complications secondary to multiple factors includ-ing surgical complexity and medical comorbidity. Postoperative management is governed by the idiosyncrasies of the operating surgeon more so than many other specialties and therefore het-erogeneous. While studies of ERAS in gastrectomy suggest no routine use of nasogastric tubes and include early feeding, most ERAS programs for esophagectomy encompass all components not related to feeding, but


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Surgery_Schwartz. While studies of ERAS in gastrectomy suggest no routine use of nasogastric tubes and include early feeding, most ERAS programs for esophagectomy encompass all components not related to feeding, but prolonged nasogastric decompression remains.240 Many of these patients, however, do receive early enteral nutrition through the use of jejunostomy tubes com-monly placed at the time of resection. When defined protocols are followed in this cohort of patients, length of stay is reduced, and complications and readmissions are, at a minimum, not increased.241-243 Systematic reviews demonstrate a reduction in length of stay, anastomotic leak, and pulmonary complications without increased mortality or readmission.244,245ERAS in Bariatric SurgeryBariatric surgeons have applied clinical pathways to both the preoperative and postoperative periods for many years, which have resulted in improved outcomes. The adoption of ERAS protocols in these clinical pathways has offered further success for these


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Surgery_Schwartz. the preoperative and postoperative periods for many years, which have resulted in improved outcomes. The adoption of ERAS protocols in these clinical pathways has offered further success for these patients. A randomized trial for laparoscopic sleeve gastrectomy demonstrated a reduced length of stay to 1 day post-operatively in ERAS patients, and others have also discharged patients on postoperative day 1 following Roux-en-Y gastric bypass.246-248 Furthermore, earlier discharge of patients on post-operative day 1 has not been demonstrated to increase resource utilization, with no increase in patient phone calls, emergency department visits, or readmissions.249 A meta-analysis confirms success of ERAS in bariatric surgery with reduction of length of stay without increase in complication or complication sever-ity, while a second meta-analysis demonstrates an increase in minor complications without increasing patient morbidity.250,251 Following a thorough review of the literature


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Surgery_Schwartz. or complication sever-ity, while a second meta-analysis demonstrates an increase in minor complications without increasing patient morbidity.250,251 Following a thorough review of the literature supporting its use, the ERAS Society published guidelines for ERAS bariatric pro-tocols in 2016.84ERAS in Other Surgical SpecialtiesThough ERAS has been applied more broadly to complex abdominal surgery, there is surprising little data in its use in large ventral hernia repair and other abdominal wall reconstruc-tive techniques. Three studies report experience in open large ventral hernia repair with varying techniques of abdominal wall reconstruction including myofascial release.252-254 Each study cites faster return of gastrointestinal function and reduction in length of stay by up to 2.5 days. Furthermore, there were no increases in readmission, postoperative complications, or reop-eration. Though no long-term follow-up, there is no report that early feeding results in intestinal compromise


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Surgery_Schwartz. there were no increases in readmission, postoperative complications, or reop-eration. Though no long-term follow-up, there is no report that early feeding results in intestinal compromise from “tight” clo-sure or early hernia recurrence. In fact, as ERAS reduces the incidence of postoperative vomiting and ileus, it is likely very beneficial for this patient population.ERAS has been introduced to non–general surgery subspe-cialties as well. Complex urological procedures such as radical cystectomy have trialed ERAS over the last decade with favor-able results. In this patient population, length of stay was reduced, and complications were similar to or reduced when Brunicardi_Ch50_p2113-p2136.indd 212301/03/19 9:39 AM 2124SPECIFIC CONSIDERATIONSPART IIcompared to baseline controls.255-257 Similarly, ERAS has been applied to both minimally invasive and open complex cytore-ductive gynecological oncology surgery with favorable results for earlier discharge and decreased pain.258-263


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Surgery_Schwartz. Similarly, ERAS has been applied to both minimally invasive and open complex cytore-ductive gynecological oncology surgery with favorable results for earlier discharge and decreased pain.258-263 Total joint replacement surgery in orthopedics has also used ERAS with improved early mobility, a significant length of stay reduc-tion, and decreased morbidity.264,265 Setting Up an ERAS ProgramThe successful implementation of an enhanced recovery pro-gram depends heavily upon cultural change and excellent orga-nizational behavior. As the ERAS program encompasses so many facets of patient care, the implementation team should not only include surgeons and anesthesiologists but also inpa-tient and outpatient nurses, pharmacists, information technology specialists, compliance officers, and hospital administration.Initial strategy for ERAS implementation should define the scope of practice change by identifying the current state and the goal state of care. Protocol content can be discussed in a


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Surgery_Schwartz. administration.Initial strategy for ERAS implementation should define the scope of practice change by identifying the current state and the goal state of care. Protocol content can be discussed in a small group of engaged stakeholders. Once the protocol ele-ments are defined, all stakeholders should review and discuss the protocol in detail in order to identify barriers to implementa-tion, identify solutions to these barriers, and finalize the proto-col. This allows for all stakeholders to remain engaged and have ownership in the protocol. Appropriate informational resources for hospital and office staff education are created in order to have a thorough and successful educational campaign. Patient informational resources should also be developed in order to set clear expectations throughout the perioperative process. Addi-tionally, and importantly, standardized order sets are also devel-oped to ensure that all components of an ERAS program have little variation in order to improve


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Surgery_Schwartz. the perioperative process. Addi-tionally, and importantly, standardized order sets are also devel-oped to ensure that all components of an ERAS program have little variation in order to improve compliance. A final imple-mentation date is defined after coordinating that all stakeholders are indeed ready for launch. Appropriate educational campaigns are performed in a timely fashion prior to final implementation to outpatient office staff, inpatient units, preoperative and post-operative care units, operating room personnel and physicians, and midlevel providers and trainees (Fig. 50-6).Compliance and auditing should be done with relative frequency in the beginning, from weekly to biweekly and then monthly. Team meetings with all stakeholders present allow the team to address any issues in timely fashion with a mul-tidisciplinary approach and thus upholds accountability. The frequency of checkpoint meetings can be reduced over time. Sharing data of successes and failures keeps the team


Surgery_Schwartz

Surgery_Schwartz. timely fashion with a mul-tidisciplinary approach and thus upholds accountability. The frequency of checkpoint meetings can be reduced over time. Sharing data of successes and failures keeps the team engaged. It is also recommended that a financial team be employed. The financial savings after adoption of an ERAS protocol can be substantial from reduction in length of stay, medication use, and resource utilization. Ideally, a portion of the cost savings should be funneled back into the ERAS program in order to ensure program maintenance and compliance and also to assist with expansion to other service lines or patient care improvement projects.TRADITIONAL CHINESE MEDICINE IN SURGICAL PATIENTSHistory of Traditional Chinese MedicineTraditional Chinese medicine is one of China’s outstanding national cultural heritages and the quintessence of China, shar-ing a deep history and common homology with the Chinese culture.266 It is derived from the rich experience and theoretical knowledge


Surgery_Schwartz

Surgery_Schwartz. national cultural heritages and the quintessence of China, shar-ing a deep history and common homology with the Chinese culture.266 It is derived from the rich experience and theoretical knowledge that Chinese people have used to combat disease for thousands of years. The achievements of traditional Chinese medicine caught the attention of the world because it examines each function of the human organism and adjusts those func-tions to achieve ultimate balance.Traditional Chinese medicine is the oldest medicine in China. It is a medical system with unique theory, style, diagno-ses, and treatments, which were gradually formed throughout the historical medical practice of the Chinese nation. Its devel-opment not only depended on the practice but also resulted from the systemic mode of thinking and Chinese philosophy of protecting life shape. Yet, it is a traditional subject that still stands in the modern world of science.Traditional Chinese medicine theory mainly resulted from the


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Surgery_Schwartz. and Chinese philosophy of protecting life shape. Yet, it is a traditional subject that still stands in the modern world of science.Traditional Chinese medicine theory mainly resulted from the summary of practice and was continuously enriched and developed in practice. As early as 2000 years ago, Huang Di Nei Jing wrote the earliest existing theory of traditional Chinese medicine in China, and it summarized the treatment experience and medical theory to that time. Combining the achievements of other natural science branches and simple materialism and dialectical thinking of the Chinese culture, Huang Di Nei Jing comprehensively expounded the knowledge of human anatomy, physiology, and pathology and also stated the diagnosis, treat-ment, and prevention of disease, thus founding the preliminary theoretical basis of traditional Chinese medicine.Based on herbal remedies of primitive people, Shen Nong Ben Cao was the earliest existing monograph on herbal pharma-cology in China.267 It summed


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Surgery_Schwartz. theoretical basis of traditional Chinese medicine.Based on herbal remedies of primitive people, Shen Nong Ben Cao was the earliest existing monograph on herbal pharma-cology in China.267 It summed the study of herbology to date, including 365 kinds of drugs until the Han Dynasty. Long-term clinical practice and modern scientific research show that the effects of the drugs described in the book are mostly correct.In the third century, the famous physician Zhongjing Zhang of the Eastern Han Dynasty delved into the classical medical books such as Su Wen, Zhen Jing, and Nan Jing and extensively collected the effective prescriptions, combining this with his own clinical experience. He published a famous book about typhoid fever, Shang Han Bing Za Lun. This book established the theoretical system and treatment principles that applied dialectical therapy of Chinese medicine and influenced the future of traditional Chinese medicine.In 610 a.d., Yuanfang Chao et al wrote Treatise on the


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Surgery_Schwartz. system and treatment principles that applied dialectical therapy of Chinese medicine and influenced the future of traditional Chinese medicine.In 610 a.d., Yuanfang Chao et al wrote Treatise on the Etiology of Various Diseases, which is the earliest exiting mono-graph on causes of symptomatology in China. This book also recorded the intestinal anastomosis, abortion, tooth extraction, and other operations, indicating the breadth of surgery practiced at that time. Subsequently, the ancient Chinese government in 659 a.d. issued Tang Xiu Ben Cao; it was not only the first phar-macopoeia of ancient China but also the first national pharma-copoeia of the world. It was published 883 years earlier than the Nuremberg Pharmacopoeia, which was issued by the European Nuremberg government in 1542 a.d.The Tang Dynasty physician Simiao Sun authored Bei Ji Qian Jin Yao Fang and Qian Jin Yi Fang. In these two books, clinical subjects, acupuncture, dietary therapy, disease preven-tion, and life


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Surgery_Schwartz. a.d.The Tang Dynasty physician Simiao Sun authored Bei Ji Qian Jin Yao Fang and Qian Jin Yi Fang. In these two books, clinical subjects, acupuncture, dietary therapy, disease preven-tion, and life preservation were discussed. These were an out-standing achievement of the time, especially in the prevention and treatment of nutritional deficiency diseases.Between the 12th and 14th centuries, i.e., the Jin and Yuan eras of China, several new Chinese medicine theories emerged. There were four representative scholars. Wansu Liu (1120–1200 a.d.) thought the symptoms of shanghan (exogenous febrile disease) were related to “excessive internal heat,” so the herbal 8Brunicardi_Ch50_p2113-p2136.indd 212401/03/19 9:39 AM 2125OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50Figure 50-6. Implementation process of an enhanced recovery after surgery pathway. ERAS = enhanced recovery after surgery; CRNA = certified registered nurse anesthetist; NP = nurse


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Surgery_Schwartz. MEDICINECHAPTER 50Figure 50-6. Implementation process of an enhanced recovery after surgery pathway. ERAS = enhanced recovery after surgery; CRNA = certified registered nurse anesthetist; NP = nurse practitioner; PA = physician assistant; IT = information technology; PACU = postanesthesia care unit; APP = advanced practice provider; LOS = length of stay; PCA = patient-controlled analgesia.Define ERAS teamSite workflow meetingsCommunication & trainingImplementation & initial monitoringDefine site-specific teamleaders:• Anesthesiologist• Surgeon• Quality nurse coordinatorDefine implementation teammembers, including:Anesthesiologists, surgeons,nurses, CRNAs, NPs, PAs,fellows, residents, ITIntro team meeting• General ERAS overview with core leadership teamDiscuss protocol logistics and workflow:• Site meetings to discuss logistics of implementing ERASEscalation of site issues tocore team• Site leadership to escalate issues to leadership teamImplementation planning:• Site leadership team


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Surgery_Schwartz. Site meetings to discuss logistics of implementing ERASEscalation of site issues tocore team• Site leadership to escalate issues to leadership teamImplementation planning:• Site leadership team to ensure all workflow issues have been addressed and implementation date plannedProtocol & order set training:• Clinic• Pre-Op nurses• PACU nurses & anesthesia• Floor nurses• APPsMonthly monitoring of keyoutcomes × 3 mos(minimum):Including: Overall LOS, Post-OpLOS, 30-day readmission andPCA utilization, and othersMonthly meeting × 3 mos(minimum):• Discussion of initialimplementation issues• Include all members of site-specific implementation teamImplement protocol &order set go-liveMonthly checkpointmeeting with ERASleadershipGo-live communication:ERAS site coordinator tocommunicate go-live date forprotocol & order set to siteteam and ERAS projectmanagerGo-live date must be givento ERAS PM at least 1month prior to go-liveERAS nurse educator toliaise with site championsERAS order set to


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Surgery_Schwartz. date forprotocol & order set to siteteam and ERAS projectmanagerGo-live date must be givento ERAS PM at least 1month prior to go-liveERAS nurse educator toliaise with site championsERAS order set to beimplemented up to twoweeks prior to theprotocol for order entryERAS leadership teamto provide outcomesto ERAS site teamBrunicardi_Ch50_p2113-p2136.indd 212501/03/19 9:39 AM 2126SPECIFIC CONSIDERATIONSPART IIcharacteristics of cold and cool were used in treatment, and this was known as the “cold and cool” treatment style. Congzheng Zhang (approximately 1156–1228 a.d.) thought the cause of disease was “exogenous evil” (exogenous pathogenic factor) invading the human body; therefore, the treatment focused on “eliminating evil,” through the diaphoresis, emetic, and/or purgative methods, which were known as the “offensive pre-cipitation” style. Dongyuan Li (1180–1251 a.d.) proposed that “internal injury of viscera causes various diseases,” and pyretic tonification of the spleen and


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Surgery_Schwartz. which were known as the “offensive pre-cipitation” style. Dongyuan Li (1180–1251 a.d.) proposed that “internal injury of viscera causes various diseases,” and pyretic tonification of the spleen and stomach was emphasized in the treat-ment, known as the “invigorating the spleen” style. Zhenheng Zhu (1281–1358 a.d.) thought “yang was always excessive, while yin was always insufficient” in the body, so the treatment was focused on nourishing yin and cutting down heat, which was known as the “nourishing yin” style.In approximately the 11th century, the Chinese began to use human pox vesicle exposure as vaccination to prevent smallpox and thus pioneered the field of medical immunology and vaccination. In the 17th to 19th centuries, due to the epi-demics of infectious diseases, the seasonal febrile disease theory developed. This theory broke the traditional Chinese medicine long-term conception that the pathogens invaded from the sur-face to the inside of the body. In the mid-17th century


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Surgery_Schwartz. disease theory developed. This theory broke the traditional Chinese medicine long-term conception that the pathogens invaded from the sur-face to the inside of the body. In the mid-17th century when bacteriology had not yet appeared, this was undoubtedly a great pioneering work and laid the groundwork for the epidemiology of the spread of disease.In the period from the Opium War (1838–1842 a.d.) to the founding of the People’s Republic of China in 1949 a.d., Western medicine was introduced to the continent of China. However, Western medicine and Chinese medicine theories were unique to each other. There was almost no interchange between them, either in theory or in practice; yet together, they formed a unique and relatively mature theoretical system. In the 1920s to 1930s, Western medicine proposed abolishing Chinese medicine. At the same time, Chinese medicine did not deny the merits of Western medicine but thought that Chinese medicine was superior to Western medicine. However,


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Surgery_Schwartz. proposed abolishing Chinese medicine. At the same time, Chinese medicine did not deny the merits of Western medicine but thought that Chinese medicine was superior to Western medicine. However, there were several advocates to combine the theories who published such works as “Chinese Medicine for Main, Western Medicine for Use,” “Using Their Respective Strengths, Reaching the Same Goal by Different Means,” and “Chinese Medicine Treat Internal Disease, Western Medicine Treat Surgical Disease.”268 In short, the pervasive opinion was to learn from the other’s strong points to make up for one’s deficiencies. This forged the trail for establishing modern Chinese integrative medicine.In the past decade, a series of significant progresses and breakthroughs have been made in the modern study of tradi-tional Chinese medicine theory and its application to clinical practice. For example, acupuncture anesthesia can be used for small splint fixation, and the treatment of acute abdomen inte-grates


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Surgery_Schwartz. Chinese medicine theory and its application to clinical practice. For example, acupuncture anesthesia can be used for small splint fixation, and the treatment of acute abdomen inte-grates both traditional Chinese and Western medicine.269 Most lately, Tu Yo Yo’s team found that artemisinin, derived from the wormwood plant, treats malaria, and the team was awarded the Nobel Prize in 2015.Clearly, integration of traditional Chinese medicine with modern science and technology will advance knowledge and treatment. Modern diagnostic instruments and techniques have become auxiliary methods of clinical diagnosis and treatment of traditional Chinese medicine, making up for the deficiency of the traditional “four ways of diagnosis” methods and improv-ing the accuracy and efficiency of traditional Chinese medicine diagnosis and treatment. Thus, modern science and technology’s infiltration, transformation, and integration in all aspects of Chi-nese medicine will be one of the distinctive


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Surgery_Schwartz. Chinese medicine diagnosis and treatment. Thus, modern science and technology’s infiltration, transformation, and integration in all aspects of Chi-nese medicine will be one of the distinctive characteristics of the future development of Chinese medicine.In summary, traditional Chinese medicine and pharmacy are an important part of the splendid culture of the Chinese nation, making outstanding contributions over thousands of years because of its systemic theory, distinctive treatment methods, sig-nificant efficacy, and abundant historical documentation. Modern Chinese medicine includes traditional Chinese medicine and thus offers integrated and superior health service. This integration of Eastern and Western medical ideas and philosophies are important for the future of this modern medical era.270 Preoperative Nutritional OptimizationMany surgical abdominal diseases have a long incubation period before clinical presentation, during which time the patients may develop malnutrition


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Surgery_Schwartz. era.270 Preoperative Nutritional OptimizationMany surgical abdominal diseases have a long incubation period before clinical presentation, during which time the patients may develop malnutrition including specific nutrient deficiencies and hypoproteinemia. These comorbidities directly influence the sur-gical treatment and postoperative effect of the patient undergoing an operation. In this setting, some experts advocate the use of parenteral nutrition and other adjunctive nutritional measures. These measures can often improve the patient’s nutritional sta-tus, but they are difficult to popularize because of the high cost of treatment and common complications with parenteral nutrition.In traditional Chinese medicine theory, it is thought that there are a variety of “asthenic symptoms” in patients who need surgical treatment and that applying the treatment principle of “treating deficiency with tonification” improves conditions throughout the body. On the basis of the traditional Chinese


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Surgery_Schwartz. who need surgical treatment and that applying the treatment principle of “treating deficiency with tonification” improves conditions throughout the body. On the basis of the traditional Chinese medicine theory of the “concept of holism” and “treatment according to syndrome differentiation,” the all nourishing decoction (Shiquan Dabu decoction) and Buzhong Yiqi decoc-tion are used in patients with the “deficiency of vital energy and blood syndrome” before surgery and have achieved good results.271-275 Similar success has been shown with the Shenmai injection and Astragalus injection.276,277 For example, when tra-ditional Chinese medicine is used effectively to treat patients with breast cancer before an operation, it enhances the general body status, improves the patient’s energy, and regulates the liver and kidney functions, which ultimately promotes the suc-cess of the operation and controls progression of the tumor.278,279Bowel Preparation for SurgeryIn gastrointestinal surgery, the


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Surgery_Schwartz. the liver and kidney functions, which ultimately promotes the suc-cess of the operation and controls progression of the tumor.278,279Bowel Preparation for SurgeryIn gastrointestinal surgery, the method of “purgation and offen-sive precipitation” is used in preparation for the operation. Either Large Chengqi decoction or Seasoning Chengqi decoc-tion significantly increases the gastrointestinal motility and washes the gastrointestinal stagnation to prepare the bowel for surgery. These decoctions also improve visceral blood flow and peritoneal absorption, promote early recovery of postoperative bowel function, and prevent superimposed infection of the intes-tine and the effect of endotoxin.280,281Preoperative Optimization During Sepsis and InfectionDue to infection, endotoxemia, blood loss, and other factors, many critically ill patients will deteriorate or progress to shock. Initial surgery during profound shock may be counterproductive until adequate resuscitation is achieved. In


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Surgery_Schwartz. and other factors, many critically ill patients will deteriorate or progress to shock. Initial surgery during profound shock may be counterproductive until adequate resuscitation is achieved. In addition to resuscita-tion, blood transfusion, and antimicrobial treatment if indicated for sepsis, the traditional Chinese medicine treatment based on dialectics can help to create a favorable condition for surgery, if indicated.9Brunicardi_Ch50_p2113-p2136.indd 212601/03/19 9:39 AM 2127OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50For traumatic shock and anaphylactic shock patients, the use of flavored pure ginseng decoction supplemented by blood transfusion and other comprehensive antishock measures, can rapidly raise blood pressure and provide a more optimal set-ting for surgical treatment.282 Qingdan decoction and Qingyi decoction, which are composed of herbs to clear away heat and toxins, remove stasis, purge the bowel, and are used to treat acute


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Surgery_Schwartz. set-ting for surgical treatment.282 Qingdan decoction and Qingyi decoction, which are composed of herbs to clear away heat and toxins, remove stasis, purge the bowel, and are used to treat acute obstructive suppurative cholangitis and hemorrhagic and/or necrotizing pancreatitis.283-285Perioperative Pain ManagementThe application of traditional Chinese medicine in perioperative pain management is has become more prevalent in recent years. Research of acupuncture for analgesia began in the 1950s in China and has developed into a combined acupuncture and medicine anesthesia that is currently recognized by the medical field.286 During surgery, the combined anesthesia is composed of acupuncture and opioid drugs. Experimental data show that the combined acupuncture anesthesia could reduce the dose of opioid by 50%.287 Acupuncture also helps the management of postoperative pain by enhancing the level of the endogenous opioid, encephalin. Encephalin restrains the pain signal from being


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Surgery_Schwartz. the dose of opioid by 50%.287 Acupuncture also helps the management of postoperative pain by enhancing the level of the endogenous opioid, encephalin. Encephalin restrains the pain signal from being transmitted to the central nervous system, blocks the body’s reaction to pain, and increases the pain threshold accord-ingly.288 In several clinical trials, the needed doses of opioid at 8, 24, and 72 hours postoperatively were reduced in acupuncture groups compared to control groups.289 In addition, electroacu-puncture has been demonstrated to be effective at alleviating postoperative pain and assisting in recovery. One randomized controlled trial shows electroacupuncture significantly reduced the dose of fentanyl used, improved the quality of recovery and decreased the incidence of anesthesia related side effects for patients undergoing surgery.290 Postoperative Nausea and Vomiting PreventionPONV is a common complication after surgery. Acupuncture and herbs can be applied to prevent and


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Surgery_Schwartz. related side effects for patients undergoing surgery.290 Postoperative Nausea and Vomiting PreventionPONV is a common complication after surgery. Acupuncture and herbs can be applied to prevent and treat PONV. Acupunc-ture or transcutaneous electroacupuncture improves stress-induced impairment in gastric motility functions, significantly inhibits the frequency of transient lower esophageal sphincter relaxations in response to gastric distention, and suppresses retrograde peristaltic contraction.291-293 In clinical trials, intra-operative P6 acupuncture point (Neiguan acupoint) stimulation during surgery significantly reduces the incidence of PONV over 24 hours, and the efficacy of P6 stimulation is similar to that of commonly used antiemetic drugs in the prevention of PONV.294 Furthermore, electroacupuncture restrains the release of gastrointestinal peptides and consequently relieves PONV with an efficacy comparable to ondansetron.295 Moreover, a randomized, prospective,


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Surgery_Schwartz. Furthermore, electroacupuncture restrains the release of gastrointestinal peptides and consequently relieves PONV with an efficacy comparable to ondansetron.295 Moreover, a randomized, prospective, double-blinded clinical trial shows that auricular acupressure within 24 hours postoperatively has a similar effect to prevent PONV.296Additionally, some Chinese herb decoctions, such as Liu Jun Zi decoction and Cheng Qi decoction, administrated periop-eratively, show possible effectiveness to reduce the severity of PONV and to relieve abdominal distension.297,298Early Nutrition and Postoperative Ileus PreventionIn traditional Chinese medicine, acupuncture and decoctions have a role in the prevention of postoperative ileus. For example, early acupuncture on Zusanli, Shangjuxu, and Xijuxu acupoints, combined with early enteral nutrition, can effectively improve gastrointestinal function and shorten the length of stay after sur-gery.299 In addition, Dachengqi decoction applied to patients


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Surgery_Schwartz. combined with early enteral nutrition, can effectively improve gastrointestinal function and shorten the length of stay after sur-gery.299 In addition, Dachengqi decoction applied to patients after laparotomy improves gastric dysrhythmia, promotes intestinal peristalsis, and enhances gastrointestinal motility.300,301 Further-more, in one randomized trial, the combination of Simo decoc-tion and acupuncture reduces the incidence of postoperative ileus and shortens hospital stay for patient undergoing abdominal sur-gery when compared to the perioperative use of chewing gum.302 Other traditional Chinese medicine methods such as electroacu-puncture combined with Evodia hot compress, confers benefit in postoperative recovery of gastrointestinal function of patients who have undergone abdominal surgery.303Traditional Chinese Medicine in Common Surgical ConditionsColon Surgery. Several traditional Chinese medicine decoc-tions can assist in bowel preparation prior to surgery. For exam-ple,


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Surgery_Schwartz. surgery.303Traditional Chinese Medicine in Common Surgical ConditionsColon Surgery. Several traditional Chinese medicine decoc-tions can assist in bowel preparation prior to surgery. For exam-ple, during the bowel cleansing before surgery, Dachengqi decoction can be used to promote bowel peristalsis and evacua-tion, thus preventing contamination during surgery and reducing the risk of postoperative complications of infection. Addition-ally, after colon surgery, traditional Chinese medicine therapies such as acupuncture and decoctions prevent postoperative ileus, reduce the incidence of PONV, and promote the recovery of colon function. As a result, traditional Chinese medicine can shorten the hospital stay after colon surgery.Appendicitis. In general, patients suffering from acute appen-dicitis will undergo appendectomy. Exceptionally, when a case of acute simple appendicitis or a periappendiceal abscess is encountered, Chinese herbs together with antibiotics can serve as an


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Surgery_Schwartz. appen-dicitis will undergo appendectomy. Exceptionally, when a case of acute simple appendicitis or a periappendiceal abscess is encountered, Chinese herbs together with antibiotics can serve as an alternative treatment. In early acute simple appendicitis, oral Qinghua decoction can help the appendix infection resolve without surgical management.304 This nonsurgical treatment also can be applied to patients with periappendiceal abscess that is unsuitable for surgery. These Chinese medicine herbs activate blood flow, dissolve stasis, clear heat, and remove toxicity.Biliary Disease. Cholelithiasis is a common disease of the biliary tract that can result in cholecystitis and the possible need for cholecystectomy. Several traditional Chinese medicine herbs can relieve the symptoms of acute cholecystitis and delay the progression of the disease, possibly preventing the need for cholecystectomy. These Chinese medicine herbs are composed of herbs for clearing heat and secreting bile (Qing Re


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Surgery_Schwartz. and delay the progression of the disease, possibly preventing the need for cholecystectomy. These Chinese medicine herbs are composed of herbs for clearing heat and secreting bile (Qing Re Li Dan), herbs for promoting circulation of Qi and relieving pain (Xing Qi Zhi Tong), and herbs for clearing heat and promoting diure-sis (Qing Re Li Shi). According to different Chinese medicine therapies, the use of these herbs can also be applied to patients postoperatively from abdominal or biliary surgery to adjust bili-ary excretion and/or prevent cholestasis.Unfortunately, severe cholecystitis or cholangitis may progress to liver abscess. When a liver abscess develops, per-cutaneous catheter drainage and Chinese medicine herbs are applied in Chinese medicine practice.305 Generally, in the early stage of abscess, Chinese medicine herbs are used for clearing heat and removing toxicity (Qing Re Jie Du) and for promoting blood circulation and removing blood stasis (Huo Xue Hua Yu). When abscess


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Surgery_Schwartz. stage of abscess, Chinese medicine herbs are used for clearing heat and removing toxicity (Qing Re Jie Du) and for promoting blood circulation and removing blood stasis (Huo Xue Hua Yu). When abscess is evident, Chinese medicine herbs for clearing heat and cooling blood are added.305 The main function of these Chinese medicine herbs is to relieve infection, reduce inflam-mation, and activate intestinal motility in order to evacuate the 10Brunicardi_Ch50_p2113-p2136.indd 212701/03/19 9:39 AM 2128SPECIFIC CONSIDERATIONSPART IItoxicity, reduce the inflammatory response, and thus hasten recovery.Pancreas Surgery. In recent years, the early use of traditional Chinese medicine and enteral nutrition treatment in patients after pancreaticoduodenectomy, can help to hasten recovery in gastrointestinal function, improve nutritional status and immune function, and also reduce postoperative complications. The combined use of total parenteral nutrition and Astragalus injection can improve the


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Surgery_Schwartz. function, improve nutritional status and immune function, and also reduce postoperative complications. The combined use of total parenteral nutrition and Astragalus injection can improve the nutrition status of patients with obstructive jaundice and improve the immune function of these patients.306 All Nourishing (Shiquan Dabu) decoction has the role of increasing the level of plasma albumin and hemoglobin, which can be used as a recipe in surgical nutrition therapy.307Intestinal Obstruction. Adhesive ileus is the most com-mon type of small intestinal obstruction and also is the kind to which traditional Chinese medicine therapies apply widely. The methods of traditional Chinese medicine treatment include acupuncture, Chinese herbal enema, and gastrointestinal intuba-tion. Acupuncture or transcutaneous electroacupuncture applied to acupoints such as Zusanli point, Neiguan point, Zhongwan point, and Tianshu point has remarkable regulatory effects on gastrointestinal function and can


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Surgery_Schwartz. transcutaneous electroacupuncture applied to acupoints such as Zusanli point, Neiguan point, Zhongwan point, and Tianshu point has remarkable regulatory effects on gastrointestinal function and can promote relief of obstruction.308 Dachengqi decoction combined with the Chinese medicine herbs for clearing heat and removing toxicity (Qing Re Jie Du), and for promoting blood circulation and removing blood stasis (Huo Xue Hua Yu), can enhance gastrointestinal motility, improve blood circulation of the intestine, reduce intestinal capillary perme-ability, protect the barrier function of the intestinal mucosa, and help inflammatory edema to resolve.309 Additionally, acupunc-ture, Chinese herbal enema, and gastrointestinal intubation can shorten the time of the obstructive event and reduce the length of stay in patients suffering from adhesive intestinal obstruction.310 These methods of traditional Chinese medicine treatment can also be applied to the treatment of postoperative


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Surgery_Schwartz. reduce the length of stay in patients suffering from adhesive intestinal obstruction.310 These methods of traditional Chinese medicine treatment can also be applied to the treatment of postoperative ileus.REFERENCESEntries highlighted in bright blue are key references. 1. Bardram L, Funch-Jensen P, Jensen P, et al. Recovery after lap-aroscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet. 1995;345:763-764. 2. Kehlet H. Multimodal approach to control postopera-tive pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606-617. 3. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86:227-230. 4. Delaney CP, Fazio VW, Senagore AJ, et al. “Fast track” post-operative management protocol for patients with high co-mor-bidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533-1538. 5. Nicholson A, Lowe MC, Parker J, et al.


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Surgery_Schwartz. preoperative evaluation clinic in a teaching hospital. Anesthe-siology. 1996;85:196-206. 10. van Klei WA, Moons KG, Rutten CL, et al. The effect of out-patient preoperative evaluation of hospital inpatients on can-cellation of surgery and length of hospital stay. Anesth Analg. 2002;94:644-649. 11. Gibby GL. How preoperative assessment programs can be justified financially to hospital administrators. Int Anesthesiol Clin. 2002;40:17-30. 12. Ferschl MB, Tung A, Sweitzer B, et al. Preoperative clinic visits reduce operating room cancellations and delays. Anes-thesiology. 2005;103:855-859. 13. Blitz JD, Kendale SM, Jain SK, et al. preoperative evalua-tion clinic visit is associated with decreased risk of in-hospital postoperative mortality. Anesthesiology. 2016;125:280-294. 14. Costa MJ. The lived perioperative experience of ambula-tory surgery patients. AORN J. 2001;74:874-881. 15. Kruzik N. Benefits of preoperative education for adult elective surgery patients. AORN J.


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Surgery_Schwartz. IL, et al. Exercise and physi-cal activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clini-cal Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107:3109-3116. 25. Belardinelli R, Georgiou D, Cianci G, et al. Randomized, con-trolled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999;99:1173-1182. 26. Mandic S, Myers J, Selig SE, et al. Resistance versus aerobic exercise training in chronic heart failure. Curr Heart Fail Rep. 2012;9:57-64. 27. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450. 28. Cornelissen VA, Buys R, Smart NA. Endurance


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Surgery_Schwartz. al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450. 28. Cornelissen VA, Buys R, Smart NA. Endurance exercise bene-ficially affects ambulatory blood pressure: a systematic review and meta-analysis. J Hypertens. 2013;31:639-648.Brunicardi_Ch50_p2113-p2136.indd 212801/03/19 9:39 AM 2129OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50 29. Cornelissen VA, Smart NA. Exercise training for blood pres-sure: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2:e004473. 30. Hayashino Y, Jackson JL, Fukumori N, et al. Effects of supervised exercise on lipid profiles and blood pressure con-trol in people with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. Diabetes Res Clin Pract. 2012;98:349-360. 31. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;CD002968. 32. Waschki


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Surgery_Schwartz. controlled trials. Diabetes Res Clin Pract. 2012;98:349-360. 31. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;CD002968. 32. Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. 2011 140:331-342. 33. Cooney GM, Dwan K, Greig CA, et al. Exercise for depres-sion. Cochrane Database Syst Rev. 2013;CD004366. 34. Forbes D, Thiessen EJ, Blake CM, et al. Exercise programs for people with dementia. Cochrane Database Syst Rev. 2013:CD006489. 35. Saunders DH, Sanderson M, Brazzelli M, et al. Physical fit-ness training for stroke patients. Cochrane Database Syst Rev. 2013:CD003316. 36. Des Guetz G, Uzzan B, Bouillet T, et al. Impact of physical activity on cancer-specific and overall survival of patients with colorectal cancer. Gastroenterol Res Pract. 2013:340851. 37. Hoogeboom TJ, Dronkers JJ, Hulzebos EH, et al. Merits of


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