Page 60 - Read Online

Page 2 of 15 Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27

INTRODUCTION
Protocols to expedite patient recovery after surgery were first pioneered in the late 1990s by colorectal and
cardiothoracic surgeons looking to reduce length of hospital stay and postoperative complications.
Conventional postsurgical care for these populations frequently involved a hospital stay of five to ten days
and significant postoperative complications, such as prolonged ileus, loss of physical mobility, and poor
[1-4]
wound healing . Surprisingly, innovations in surgical technique, such as the advent of laparoscopy over
open abdominal surgery, had a limited impact on patient recovery; thoughtful standardization of pre-,
intra-, and post-operative care, however, was shown to improve outcomes and enhance recovery after
surgery significantly. A paper by Kehlet et al. , “Multimodal strategies to improve surgical outcome”, is
[5]
often credited as the first systematic review to compile and evaluate many of these perioperative
interventions. From this paper and others, Enhanced Recovery After Surgery (ERAS) was developed and
gave way to the significant developments in this field over the last decade.

The foundational concept of ERAS is that major surgery incites a significant biologic stress response in the
patient. Length of stay and severity of postoperative complications correlate with the magnitude of this
stress and how it is managed. Interventions aimed at reducing the magnitude of this stress response are
paramount and are performed in the following ways :
[6-8]
• A multidisciplinary team working together to reduce the impact of surgery;
• A multimodal approach to resolving issues that delay recovery and cause complications;
• A standardized, evidence-based approach to all phases of perioperative care;
• Changes in management using interactive and continuous audits.

Some reviews in multiple surgical fields have been performed on this subject in efforts to compile the most
compelling interventions for readers to learn from and implement in their own institutions. Our research
team has published previously on this topic, specifically highlighting interventions applicable to head and
[8]
neck surgery and its patient population . This review builds upon and emphasizes that work while also
focusing on compelling perioperative interventions that have not yet reached universal acceptance despite
convincing evidence and thus have not been discussed much elsewhere. While certain well-established
interventions, such as perioperative antibiotics and deep vein thrombosis prophylaxis, often have the
strongest data to support their use, we have included these established practices only for completeness in the
final section on “accepted practices”. We hope to focus the attention of our readership on the interventions
that may not currently be in practice at their respective institutions in the hopes of future widespread
investigation and implementation [Figure 1].

ERAS for major head and neck surgery
ERAS protocols have become increasingly popular in the field of head and neck surgery over the last
decade [9-11] . The ERAS Society, a nonprofit medical society, was formed in 2010 to promote and develop
ERAS programs and build on foundational work in enhanced recovery in colorectal and thoracic surgery
from the beginning of the century. The official ERAS society recommendations for head and neck surgery
were published in 2017, setting off a slew of research both to report outcomes of the implementation of
these protocols as well as to trial new interventions that build off the tenets of ERAS .
[12]
While the composition of interventions comprising an ERAS protocol has differed amongst the many head
and neck institutions reporting results of their ERAS implementation, the results of these implementations
are often similar. In particular, implementation studies have demonstrated that, compared to control groups
treated with conventional perioperative care, ERAS patient cohorts experience reduced ICU and hospital
stays, reduced delay between surgery and adjuvant radiotherapy, diminished narcotic use in the first 24-72 h