Evidence-based decision support

Protocol development in integrative medicine is not typically a simple process. Individuals require individualized care, and what works for one patient may not work for another.

To establish these protocols, we first developed a Rating Scale that could be used to discern the rigor of evidence supporting a specific nutrient’s therapeutic effect.

The following protocols were developed using only A through C-quality evidence.
weight management protocol table

Ingredients for postoperative care

Physiological responses to surgical procedures impact various outcomes such as length of hospital stay and risk of postoperative complications. (6)(12)(18) Targeting mechanisms that help regulate inflammation and immune function is key to an integrative treatment plan. 

Regulation of post-surgical immune function and inflammation may be achieved through decreasing pro-inflammatory cytokines, such as tumor necrosis factor (TNFα) and interleukins. (9)(24)(19) It is hypothesized that gene expressions of TNF and interleukin-6 (IL-6) are correlated with the gene expression of suppressor of cytokine stimulation-3 (SOCS3), providing insight into the possible mechanism through which decreased inflammation is achieved. (6)

Decreasing oxidative stress may also improve the inflammatory response. Focusing on maintaining adequate plasma and RBC glutathione levels, as well as a favorable glutathione to glutathione disulfide ratio, assists in the attenuated loss of antioxidants. (4) Additionally, interventions aimed at improving neutrophil phagocytosis show potential in upregulating immune function post-operatively. (1)

The ingredients presented in the protocol below reflect research findings that demonstrate the efficacy of dietary supplements when used to support physiological function following surgical interventions.


Probiotics

Specific probiotics strains may reduce the incidence of common postoperative complications such as infection. However, outcomes are dependent on type of surgery, demographic, strain, and dosing. Listed below are three possible strain combinations with associated outcomes. (2)(7)(10)(24)

Strain combination 1

30 billion CFU of Bifidobacterium bifidum, Bifidobacterium infantis, Bifidobacterium longum, Lactobacillus acidophilus, Lactobacillus casei subsp, Lactobacillus lactis, twice per month, 6 months beginning 4 weeks post-surgery

Scenario: postoperative complications in colorectal cancer

  • Reduced inflammation, demonstrated by decreased serum levels of TNFα and interleukins IL-6, IL-10, IL-12, IL-17A, IL-17C, and IL-22 when compared to placebo (24)

Strain combination 2

5.5 billion CFU probiotic containing Lactobacillus acidophilus, Lactobacillus plantarum, Bifidobacterium lactis, and Saccharomyces boulardii, once per day, 14 days starting on the day of surgery

Scenario: postoperative complications in colorectal cancer (6)

  • Decreased rate of colorectal surgery complications by 20.2%, including the rate of postoperative pneumonia by 8.9%, surgical site infection by 12.9%, and anastomotic leakage by 7.6% when compared to placebo
    Length of hospital stay shortened by two days in patients receiving probiotics
  • Length of hospital stay shortened by two days in patients receiving probiotics


Strain combination 3

4 billion CFU probiotic containing Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus casei, Bifidobacterium bifidum and 100 mg of fructooligosaccharides, twice a day, 14 days perioperatively

Scenario: postoperative complications in periampullary neoplasm (18)

  • Reduced the rate of postoperative infection incidence by 43.5% when compared to placebo
  • Decreased mean length of hospital stay from 23 days to 12 days
  • Reduced postoperative mortality; no occurrences of death were experienced in the probiotic group when compared to 6 deaths recorded in the placebo group


Magnesium

800 mg magnesium oxide (240 mg elemental magnesium), once per day, from admission to discharge, or 2 g (or 5-50 mg/kg) of intravenous magnesium in the form of levulinate, gluconate, sulfate, or chloride, on day of surgery (3)(8)(11)(12)

  • Incidences of hypomagnesemia, associated with high occurrences in cardiac surgery, were decreased by 29.3% in oral magnesium oxide supplementation, demonstrating an overall decrease in postoperative complications; additionally, reduced gastrointestinal incidences of nausea, vomiting, and constipation in postoperative coronary artery bypass graft surgery when compared to control (12)
  • Decreased postoperative ventricular dysrhythmias, ventilatory support, and increased stroke volume in postoperative cardiac patients treated with intravenous magnesium chloride (3)
  • Systematic review of 14 randomized trials found perioperative magnesium supplementation decreased the risk of postoperative shivering (11)
  • Meta-analysis of 5 randomized controlled trials found magnesium supplementation in pediatric patients undergoing cardiopulmonary bypass decreased incidence of arrhythmia postoperatively (8)

Support postoperative care with the evidence-based ingredients in this protocol. 

Glutamine

 0.18-0.4 g/kg, once per day, 1-7 days subsequent to surgery (1)(16)(22)

  • Improved immune function as demonstrated by increased neutrophil phagocytosis, as well as maintained muscular protein synthesis as measured by muscular ribosomal concentration, which is typically reduced following surgical trauma in postoperative colorectal cancer patients (1)
  • Increased T-cell DNA synthesis, indicating enhancement of T-cell function in postoperative colorectal resection (16)
  • Improved immunodepression and nutrition response as well as decreased inflammation in gastrointestinal surgery (22)
  • Attenuated loss of antioxidants, demonstrated by maintenance of plasma and RBC glutathione levels and glutathione to glutathione disulfide ratio in patients undergoing elective abdominal surgery; additionally, length of hospital stay decreased (4)


Omega-3 fatty acids 

0.1-0.2 g/kg once per day of omega-3 fatty acids, seven days subsequent to surgery (1)(9)

Note: Changes in blood flow or coagulation related to altered levels of fibrinogen, factor V, and triglycerides may occur in select populations (13)(14)(20)

  • Neutrophil phagocytosis increased for postoperative colorectal cancer patients whose standard total parenteral nutrition was supplemented with omega-3 fatty acids
  • Postoperative immune function improved and inflammation as indicated by lower levels of IL-6, TNFα, and C-reactive protein in postoperative colorectal cancer patients who had a radical resection; additionally, length of hospital stay decreased (9)
  • Meta-analysis of 16 randomized controlled trials found omega-3 fatty acid emulsion improved immune function, inflammation, and postoperative curative effect in postoperative gastrointestinal cancer (25)
  • Decreased risk of olfactory loss in patients undergoing endoscopic resection for sellar or parasellar tumors (21)


Branched-chain amino acids

4.74-5.56 g branched-chain amino acids (BCAAs), 2-3 times per day, starting two weeks prior to surgery, and continued for three to six months subsequent to surgery (5)(15)

  • Compared to a control group, individuals receiving BCAA supplementation demonstrated anti-catabolic effects leading to improved metabolic status, which was indicated by improved BCAA-to-tyrosine ratio and favorable levels of retinol-binding protein (23)
  • Decreased mean length of hospital stays from 19 days to 17 days and overall incidence of postoperative complications by 26.9% when compared to placebo (15)(17)
  • Events of hepatic recurrence were decreased by 17.5% postoperatively and decreased morbidity after liver resection for hepatocellular carcinoma; additionally, hospital stay decreased (17)
  • Ameliorated mental stress and decreased risk of intrahepatic recurrence and complications after radiofrequency ablation for hepatocellular carcinoma (15)
  • Decreased recurrence of hepatic resection and decreased tumor markers AFP and PIVKA-II compared to control after hepatic resection in patients with hepatocellular carcinoma (5)

Reviewed by

Christopher Knee, ND, MSc

Medical Education Manager

Dr. Christopher Knee is a naturopathic doctor, clinical researcher, and natural health and wellness expert from Ottawa, Canada. As the research and education manager for Fullscript’s Integrative Medical Advisory team, he oversees research projects and the development of medical education content for practitioners and patients across North America. He completed Bachelor's and Master's degrees from the University of Guelph in human kinetics and human biology and nutritional sciences, respectively, and naturopathic training at the Canadian College of Naturopathic Medicine. He's passionate about evidence-informed practice, patient education, health services research, and natural medicines. He has almost 15 years of academic, industry, and advisory experience, having worked with various organizations, including The Ottawa Hospital, the Ottawa Police Service, the University of Ottawa Heart Institute, the Ontario Association of Naturopathic Doctors, the Canadian College of Naturopathic Medicine, Valeant Pharmaceuticals, Nordion, and Pfizer.

References

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  2. Bajramagic, S., Hodzic, E., Mulabdic, A., Holjan, S., Smajlovic, S. V., & Rovcanin, A. (2019). Usage of Probiotics and its Clinical Significance at Surgically Treated Patients Sufferig from Colorectal Carcinoma. Medieval Archaeology, 73(5), 316–320. https://pubmed.ncbi.nlm.nih.gov/31819304/ (C)
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  12. Moradian, S. T., Ghiasi, M. S., Mohamadpour, A., & Siavash, Y. (2017). Oral magnesium supplementation reduces the incidence of gastrointestinal complications following cardiac surgery: a randomized clinical trial. Magnesium Research: Official Organ of the International Society for the Development of Research on Magnesium, 30(1), 28–34. https://pubmed.ncbi.nlm.nih.gov/28417897/ (C)
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Disclaimer

This site is intended solely as an informational reference tool for practicing healthcare professionals. The content provided is not intended to be for medical diagnosis or treatment, is not a substitute for your professional judgment, and is not meant to provide you with medical or professional advice. You should evaluate and independently confirm the appropriateness of the content provided, and you should rely on your experience and judgment and other available resources when applying the provided content to an actual patient care situation. While content has been obtained from sources believed to be reliable, we cannot and do not guarantee the accuracy, validity, timeliness, or completeness of the content.