Surgically Significant Supplements
The Naturopathic Perspective
Michael Traub ND
For our patients undergoing surgery, we generally make recommendations for the use or discontinuance of certain natural medicines. These protocols have not been subjected to rigorous study. I was recently asked to provide information on this subject to the medical staff at North Hawaii Community Hospital. I decided to examine the evidence, or lack thereof, behind the common suggestions that we make.
My search revealed only one clinical trial on PubMed for a peri-operative program incorporating nutrition and specific vitamin and herbal medications. This study was conducted on total hip arthroplasty (THA) and total knee arthroplasty (TKA) at Ohio State University (Berend, KR et al. Surg Technol Int. 2004;13:329-47). A retrospective review of 168 consecutive THA’s and 195 TKA’s during a six month period was compared to control groups of 128 THA’s and 185 TKA’s performed by the same orthopedic practice during a 6 month period prior to implementation of the “rapid recovery program.” Both treatment groups had significantly decreased length of stays, improvements in implant fixation, bearing surface longevity, and component life span, as well as superior pain relief, improved function and quality of life. The interventions included a pre-operative nutritional supplement formula containing erythropoietin, L-arginine, organic germanium, a multivitamin, additional vitamins C and E, zinc, L-glutamine, ornithine alpha-ketoglutarate and beta-1, 3-1, 6 glycan (a medicinal mushroom extract). Omega-3 fatty acids were discontinued in the treatment groups due to their potential for increasing bleeding. A smoking-cessation program was another component of the protocol.
The only other article I discovered which considered this topic in a comprehensive manner was a well-referenced review article published in 1996 (Petry JJ. Plast Reconstr Surg. 1996 Jan;97(1):233-40). This was not an exhaustive review, however, of all surgically significant nutritional supplements that patients may be taking or that physicians may be recommending.
There are two main points that I would emphasize after my review of this literature.
First, it is important to remember that our patients are individuals and that a one-protocol-fits-all patients is ill-advised. For optimal outcomes, we must tailor our recommendations to the individual’s condition, their biochemical individuality and the particular procedure they are undergoing,
Secondly, there exist many misconceptions about the relative safety, risk and efficacy in regards to surgically significant medications, for drugs as well as nutritional supplements. A good example is the herb Ginkgo biloba. Most physicians believe that due to the reported ability of this medicine to inhibit platelet-activating factor, it should be avoided prior to surgery. Despite several well-publicized case reports linking the use of Ginkgo to episodes of severe bleeding, this herb does not appear to increase the risk of bleeding (Bal Dit Sollier, C, et al. Clin. Lab. Haem. 2003;25:251–3).
As more studies elucidate the mechanisms of natural medicines, it becomes increasingly apparent that their safe and efficacious use demands a sophisticated understanding of them on the same level as prescription medications. This is a far cry from the simple and general concepts that have been historically applied to vitamins, minerals and traditional herbal preparations.
Vitamin E is another good example that there is no simple answer to whether or not to use it for surgical support. Patients requiring antiplatelet agents should not take vitamin E preoperatively. Healthy patients taking supplemental vitamin E show no decrease in platelet aggregation but do show a decrease in platelet adherence and should not take vitamin E preoperatively. Diabetic patients have abnormal platelets and may benefit from stopping vitamin E prior to surgery but resuming it afterwards to avoid increased platelet aggregation caused by cumulative effects of surgery and their disease. Patients undergoing tendon repairs and other procedures requiring strong collagen repairs should avoid vitamin E before and after surgery (Petry JJ. Plast Reconstr Surg. 1996 Jan;97(1):233-40). There is no evidence that topical vitamin E speeds wound healing or improves cosmetic outcome of burns and other wounds. It may actually be detrimental to the cosmetic appearance of a scar and has a high incidence of causing contact dermatitis. (Baumann LS, et al. Dermatol Surg. 1999 Apr;(4):311-5).
Vitamin A should be given preoperatively, especially to steroid-treated patients and those with decreased immunity. It is especially indicated for surgical patients with sepsis, fractures, tendon damage, gastrointestinal dysfunction, bowel anastomoses and trauma. It should be used cautiously in patients for whom the anti-inflammatory effects of steroids is needed (e.g., rheumatoid arthritis), since this will be inhibited somewhat by vitamin A. The recommended dosage is 25,000 iu daily, except in pregnant women, where it should be limited to 5,000 iu daily.
Bromelain significantly increases the resorption rate of hematomas, as demonstrated in a well-designed placebo-controlled trial in 1965. (Woolf, RM et al. J Trauma 1965. 5:491)
Bromelain has been studied as well for its effect on blood-clotting mechanisms. Forty-seven patients with various disorders having edema and inflammation were given bromelain for one week. Bleeding, coagulation, and prothrombin times were determined immediately before and after therapy. Changes in these values were very slight and without practical significance. (Cirelli MG, Smyth, RD. J Clin Pharmacol 1963: 3;37-39). The recommended dose is 500 mg qid on an empty stomach beginning 3 days prior to surgery and for at least 3 days postoperatively.
Vitamin C is needed to make collagen and to ensure proper wound healing. Severe injury appears to increase vitamin C requirements and vitamin C deficiency causes delayed healing. Preliminary human studies suggest that vitamin C supplementation in non-deficient people can speed healing of various types of wounds and trauma, including surgery, minor injuries, herniated intervertebral discs and skin ulcers (Mazzotta MY. J Am Podiatr Med Assoc 1994;84:456–62). A combination of 1–3 grams per day of vitamin C and 200–900 mg per day of pantothenic acid has produced minor improvements in the strength of healing skin tissue (Vaxman F, et al. Eur Surg Res 1996;28:306–14).
Zinc is a component of many enzymes, including some that are needed to repair wounds. Even a mild deficiency of zinc can interfere with optimal recovery from everyday tissue damage, as well as from more serious trauma. One controlled trial found the healing time of a surgical wound was reduced by 43% with oral supplementation of 50 mg of zinc tid (Pories WJ, et al. Ann Surg 1967;165:432–6).
A partial list of medicines and supplements to be avoided due to their potential for anticoagulant effects include aspirin, borage seed oil, curcumin, evening primrose oil, flaxseed oil, fish oil, garlic, ginger, ginseng, and green tea.
Fractionated citrus pectin is advisable during biopsy of suspected malignancies and in cancer surgery. By binding to galactin 3 receptors, these pectin fractions have significantly reduced the aggregation of cancer cells and the adhesion of breast, prostate and melanoma cells to healthy epithelium. Dosage is 6 gm bid for 3 days prior to the procedure and for up to 6 months afterwards.
Arnica montana is a homeopathic medicine that is routinely prescribed by homeopaths to alleviate the soft tissue trauma from surgery, to reduce bleeding, bruising, pain and swelling, and prevent infection. Studies have been mixed and further research is needed to draw firm conclusions. (Jaggi R, et al. Inflamm Res 2004;53(4):150-157; Ernst E, Pittler MH. Arch Surg 1998;133(11):1187-1190; Petry JJ. Arnica and homeopathy. Plast Reconstr Surg 2004;May, 113(6):1867-1868).
The most frequently used nutritional supplements and those potentially most detrimental or most beneficial for surgical patients have been chosen for review of pertinent effects. It is essential to ask patients specifically about supplements or unusual dietary habits that may affect their surgical outcome prior to their procedure and to keep in mind the supplements that may improve their outcome.