By Chanchal Cabrera, Msc, FNIMH, RH(AHG)

Enhanced Recovery After Surgery (ERAS) is a patient-centered perioperative protocol credited to Henrik Kehlet, a Danish doctor who has specialized in managing supportive care for surgery. In the early 1990s, he proposed an innovative program for recovery that was functional and proactive rather than symptomatic and reactive. 

The principle is to bring about an accelerated recovery by preparing the body in advance and supporting the recuperation phase. Key benefits include lessening of perioperative neuroendocrine stress response, maintenance of organ function, and an accelerated return of gut function. 

The proactive and preventive pre-operative protocol—referred to as “prehabilitation”—includes movement, nutritional supplementation, and health education (eg, alcohol cessation for one to two months prior to major surgery). 

Prehabilitation and subsequent postsurgical rehabilitation is the medical ideal, addressing lifestyle, any chronic diseases, and overall wellness in advance of a significant stressor, and following up in a custom plan for recuperation. This is a great opportunity for herbal and nutritional medicine to be put front and center of the plan. Ultimately, the healthier and stronger the person is before undergoing surgery, the better the recovery.  

One to Two Months Before Surgery

Supplement with milk thistle. The flavano-lignan complex called silymarin protects the liver, inhibiting oxidative stress and supporting toxin clearance. According to herbalist Kerry Bone, based on many years of clinical experience, 200 mg of silymarin three times daily is recommended for two weeks before and two to four weeks after surgery, with higher doses and longer duration of use after longer surgeries (approximately two weeks of use for every hour of anesthesia). 

Boost nonspecific immune function. Immune tonics such as astragalus, echinacea, cat’s claw, taheebo, pokeroot, and medicinal mushrooms can be taken several times per week, and daily in the last two weeks before surgery. Immune-boosting medicinal mushrooms include Agaricus (Agaricus blazei), cordyceps (Cordyceps sinensis), maitake (Grifola frondose), reishi (Ganoderma lucidum), and turkey tail (Trametes versicolor). 

Restore bowel health and boost microbiome. Signing up for surgery often comes with a raft of pharmaceuticals that are recommended, if not required. Muscle relaxants and opioids for pain can contribute to flaccid constipation, hospital food is generally lacking in fiber and micronutrients required for proper digestive function, and antibiotics are routinely prescribed as a prophylactic. For all these reasons it may be useful, both before and after surgery, to work to optimize microbiome health and bowel function.

Maximize nutrition. Pre- and post-surgical nutrition is key for preserving muscle mass, strength, and functionality, particularly after orthopedic surgery. Plus, nutrient-rich foods and beverages can help shorten recovery time and give your body the fuel it needs to heal.

In fact, nutritional status has been shown to be a strong predictor of postoperative outcomes and is well-accepted as an important component of surgical recovery programs. 

Post Surgery Blood Clot Prevention

After surgery, it’s important to take steps to prevent blood clots. Your doctor may recommend the use of an intermittent pneumatic compression device—a set of inflatable sleeves for your legs—and compression stockings to encourage lymph flow. Additionally, physical therapy and other rehabilitation measures (eg, horticulture therapy) can improve circulation and help prevent the formation of postsurgical blood clots. 

In terms of supplementation, the following antithrombotic enzymes can help thin the blood post-surgery: 

Papain and bromelain. These enzymes are plant-derived, mild, and very safe. Studies, including randomized, controlled double-blind clinical trials, show that proteolytic enzymes can help enhance wound healing, reduce swelling, and offer pain relief following surgery or physical injuries.  

Serrapeptase and nattokinase. Serrapeptase is a proteolytic enzyme from silkworms, and nattokinase is from fermented soy and fish paste. Both are useful in cases of impaired circulation to the arms and hands or the legs and feet (peripheral ischemia) or in managing acute inflammation after injury.

Lumbrokinase. This proteolytic enzyme from earthworms acts as a potent fibrinolytic (clot-busting) agent and can be used to treat phlebitis (inflammation of veins). Specifically, lumbrokinase targets excess clot material (fibrin) and can be safely used for dissolving clots, lowering whole blood viscosity, and reducing platelet aggregation (clumping or clotting). 

Pausing Supplements Prior to Surgery

While none of the following supplements are expected to cause notable bleeding, out of an abundance of caution it is still prudent to stop taking any herbs or supplements that may possibly thin the blood or prevent clotting. 

Stop taking the following supplements four days before surgery and recommence four days after surgery: 

• Cayenne
• Chamomile
• Cranberry
• Curcumin
• Dong Quai
• Evening primrose oil
• Flaxseeds
• Garlic
• Ginger
• Ginkgo
• Grapefruit
• Green tea
• Cod liver oil
• Proteolytic enzymes
• St John’s wort
• Turmeric
• Vitamin E (including tocopherols and tocotrienols)

Herbal Remedies for the Prevention of Postoperative Cognitive Impairment 

Many patients exhibit cognitive impairment following surgery and anesthesia. Called postoperative cognitive impairment (POCI), this condition may affect orientation, attention, perception, memory, and judgment. 

Estimates suggest that some degree of postsurgical POCI is seen in more than thirty-five percent of young adults and more than forty percent of elderly patients at hospital discharge and in six percent of young adults and thirteen percent of elderly patients at three months after surgery. 

Symptoms of POCI may persist for weeks and are correlated to the duration of anesthesia (the longer you’re under anesthesia, the greater your chances of developing POCI).

Lobelia (Lobelia Inflata)

Lobelia may be helpful during the postoperative period to reduce the risk of POCI. One of the most active and highly researched constituents, lobeline, acts on the parasympathetic nervous system in much the same way nicotine does to induce feelings of calm. In fact, lobelia has been used by herbalists to support people quitting smoking, and additionally as a smooth and skeletal muscle relaxant, both topically (by poultice, infused oil, or tincture) and internally. 

It is prescribed for respiratory deficiencies such as asthma and chronic obstructive pulmonary disease (COPD), where it acts as a bronchodilator to deepen breathing and increase gaseous exchange capacity. After surgery, this improved blood flow—and increased flow of oxygen to the brain—can boost cognitive functioning and prevent POCI. 

The root of Lobelia inflata was historically used by the Iroquois to treat ulcers and leg sores, and the leaves were mashed and applied as a poultice to treat abscesses. The Cherokee mashed the roots of lobelia and used them as a poultice for body aches, and the leaves were rubbed on sores, aches, and stiff necks. 

Topical application in the form of a poultice or liniment is the traditional way to use lobelia. If you have access to the fresh herb, make a poultice of mashed stems, leaves, and flowers folded into a piece of cheesecloth. With a hot water bottle or a heating pad on top, it will penetrate deeply into a cramped muscle and ease spasming. 

If the fresh herb is not available, the dried herb can be moistened with hot water and applied in the same way. A liniment may be easier to apply and more practical. If used internally, the dose-limiting factor with lobelia is the emesis (vomiting) it causes. This is unlikely to be an issue with topical use, although hands should be washed after application. Tinctures should be taken in drop doses until individual tolerance is established.

Periwinkle (Vinca major, Vinca minor) 

The periwinkle extract is used to increase the uptake of oxygen and glucose in the brain and is prescribed by herbalists for attention-deficit/hyperactivity disorder, dizziness, memory loss, senility, head trauma recovery, stroke recovery, cognitive decline, depression, and POCI. All these applications make it an ideal herb for an ERAS protocol. 

The astringent herb is also traditionally used in mouthwash for bleeding gums, mouth ulcers, or sore throats. Leaves can be taken internally to help with bowel looseness or bleeding (colitis or diarrhea) and for heavy uterine bleeding (menorrhagia or metrorrhagia).  

In terms of contraindications, isolated vincamine alkaloids from periwinkle are not recommended in cases of cerebral tumors with intracranial hypertension and should be avoided in people with cardiac arrhythmia. This is unlikely to be a concern in whole herb extracts taken in formulas.

Rosemary (Rosmarinus officinalis) 

Rosemary, with its beautiful blue flowers and singular scent, is one of the most recognizable Mediterranean herbs both in the kitchen and medicine cabinet. 

Due to its effect of directing blood to the head, rosemary is known as an herb for memory and recall, and even Shakespeare referenced these properties in Hamlet, in which the character Ophelia speaks of rosemary “for remembrance.” 

Rosemary is a gentle, cooling, bitter herb, and a notable antioxidant and antibacterial that is helpful in treating a variety of conditions, including gastroesophageal disease (GERD) and acid reflux, gallbladder insufficiency and chronic indigestion, and small intestine bacterial overgrowth (SIBO). 

Of note, rosemary may occasionally be overstimulating to the heart so avoid combining it with rhodiola; also avoid rosemary if you have high blood pressure.

Huperzia (Huperzia serrata) 

Research suggests that huperzine A—a key component of the fir clubmoss Huperzia serrata—protects the brain cells from toxins and improves memory. In a double-blind study on the effectiveness of huperzine A capsules on memory and learning performance in adolescent students, a dose of 100 mcg of huperzine A twice daily significantly enhanced memory and learning performance with no side effects.

Huperzia serrata prevents cognitive dysfunction through its inhibitory effects on an enzyme called acetylcholinesterase, which allows prolonged bioavailability of acetylcholine—the major neurotransmitter of the parasympathetic nervous system. Mice treated with Huperzia serrata at an oral dose of 100 mg/kg showed improved cognitive functions and decreased lipid peroxidation in the brain.

Huperzine A in pure form has shown efficacy at doses of 0.2 to 0.4 mg/day for Alzheimer’s disease. In one study of people with schizophrenia, 0.3 mg/day for twelve weeks was used with no adverse effects. 

Other Useful Agents for Postoperative Recovery

• Rescue Remedy (Bach Flower Remedy) for shock
• Arnica cream for bruising and soreness
• Peppermint or ginger tea and/or acupressure wristbands for nausea
• Chamomile and skullcap for anxiety
• Silica to heal connective tissue
• Judicious sunlight exposure accelerates wound healing through the production of vitamin D in the skin.

—

Chanchal Cabrera, MSc, FNIMH, RH(AHG), is a medical herbalist who specializes in integrative oncology and is a longtime member of the National Institute of Medical Herbalists. She publishes widely in professional journals and lectures internationally on medical herbalism, nutrition, and health. For more than a decade, she was the faculty chair of botanical medicine at the Boucher Institute of Naturopathic Medicine in British Columbia.

Well Being Journal adapted the above excerpt from Holistic Cancer Care by Chanchal Cabrera, copyright © 2023 by Chanchal Cabrera. Used with permission from Storey Publishing, a division of Workman Publishing Co., Inc. a subsidiary of Hachette Book Group, Inc.