Crimson Publishers Publish With Us Reprints e-Books Video articles

Full Text

Novel Research in Sciences

Implementation of a Multimodal Rehabilitation Program in an Esophago-Gastric, Hepatobiliar and Pancreatic Surgery Unit

Fulthon-Frank Vela*, Alfredo Escartín and Jorge-Juan Olsina

General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Spain

*Corresponding author:Fulthon- Frank Vela, General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Spain

Submission: January 16, 2023;Published: January 27, 2023

DOI: 10.31031/NRS.2023.13.000812

Volume13 Issue3
January , 2023


Multimodal Rehabilitation (MMR) in oncological surgery is a novel concept whose core focus is perioperative patient care, based on the evidence generated in the last 3 decades in relation to the Early Recovery After Surgery (ERAS), which has evolved after the implementation of pre, intra and postoperative interventions; In this way, its purpose is to reduce postoperative morbidity and mortality as well as reduce hospital stay. There is still a lack of evidence in relation to the intervention of MMR in Esophageal-Gastric, Hepatobiliary and Pancreatic Oncological Surgery. In the present series of cases, we proceed to evaluate the clinical characteristics, degree of compliance and post-operative results after the implementation of an MMR program in EG and HPB oncological surgery.

Keywords: Multimodal rehabilitation


The Fast-Track in surgery or ERAS; are a series of measures taken in order to reduce surgical stress, which covers different arms, among which minimally invasive procedures with less tissue damage and as a consequence less morbidity and mortality are relevant [1]. The implementation of guidelines and measures in this line, since the 90’s have greatly revolutionized the classic management of post-operative patients. Likewise, in the last dècade, new interventions have been added to the classic fast-track, implementing a set of recommendations that are grouped under the so-called multi-modal rehabilitation. Appraisal of nourishment, physical activity, pain and stress management are the fundamental pillars. All these measures have been implemented in recent decades, in relation to scientific evidence, in different studies and meta-analyses. Furthermore, these have made it possible to endorse its importance and performance in reducing morbidity and mortality in patients undergoing surgery [2]. Despite this, even with the current evidence, it is difficult to implement these novel interventions, mainly due to inherited customs in the field of surgery. The recommendations in this sense are to adapt them progressively so that they will be accepted by the most skeptical [3,4].

Case Series

The present case series were taken from our hospital, the data collection was retrospective, observational and descriptive. The pre, per, and postoperative measures designed in the MMR Protocol of the EG and HPB Surgery Unit were applied. This protocol was standardized to be used in all patients with oncological pathology requiring surgery, the analysis includes all patients since its implementation during the first quarter of 2022. Forty-five patients were included in the MMR case series. We present the descriptive analysis of the MMR implementation in the following table 1.

Table 1:


In the last 3 decades, a new concept of perioperative patient care in different types of surgical procedures have been developed and evaluated [5,6]. These interventions have been named as “Fast Track Surgery”, ERAS and recently MMR, all of them with the only purpose of reducing the impact of surgical stress, postoperative complications, and readmission rates, without interfering with the surgical process [7,8]. Most studies have focused on patients who underwent colonic surgery [9], therefore there is less evidence in patients with upper GI (EG-HPB) oncological pathology.

Liver Resection

A recent systematic review and modified Delphi consensus [10], has drawn up a series of recommendations based on the evidence available up to the year 2020. Of these, 9 with a high level of evidence: Pre-operative measures: Cessation of alcohol intake and smoking, evaluation and improvement of nutritional status. Peroperative interventions: early nutrition, Tap-block (analgesia), avoiding the use of a nasogastric tube and intra-abdominal drains, correct glycemic control, medication to prevent postoperative nausea and vomiting, and strict control of fluid therapy.

Pancreatic Resection

The systematic review carried out by Melloul E et al. [11] describes, in relation to the literature and expert consensus, 5 recommendations with the highest level of evidence: Avoid hypothermia, use of catheters in the wound (analgesia) as an alternative to epidural analgesia, use of antithrombotic, antimicrobial and nutritional prophylaxis protocols. In this way, it concludes that the implementation of these measures could reduce complications, costs and hospital stay.

Gastric Resection

Mortensen and the ERAS Society working group have established a series of recommendations: Among them, 6 with a high level of evidence: Pre-operative fasting for fluids of 2 hours, use of the thromboprophylaxis and perioperative antibiotic therapy protocols, avoid hypothermia, strict management of fluid therapy, removal of urinary catheters on the first postoperative day [12].


The present case series, show us a high prevalence of oncological patients who underwent surgery with high nutritional and surgical risk and non-negligible frailty. The degree of compliance with the MMR protocol in this series has improved over time, reaching 100% in more than half of the cases. Morbimortality was within the expected ranges. The results of this study demonstrate the feasibility of implementing a MMR program in EG-HPB oncological surgery. The current evidence on MMR in EG and HPB surgery is scarce and lacks standardization, it is necessary to generate evidence and provide studies in relation to this field of surgery. The degree of compliance with the MMR is essential and auditing is fundamental to generate future clinically useful contributions.


  1. Slim K (2011) Fast-track surgery: The next revolution in surgical care following laparoscopy. Colorectal Dis 13(5): 478-480.
  2. Rodgers A, Walker N, Schug S, Kehlet H, Zundert AV, et al. (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ 321(7275): 1493.
  3. Salvans S, Gil-Egea MJ, Martínez-Serrano MA, Elionor B, Pérez S, et al. (2010) Multimodal (fast-track) rehabilitation in elective colorectal surgery: Evaluation of the learning curve with 300 patients. Cir Esp 88(2): 85-91.
  4. Roig JV, García-Fadrique A, Armengol JG, Villalba FL, Bruna M, et al. (2008) Use of nasogastric tubes and drains after colorectal surgery. Have attitudes changed in the last 10 years? Cir Esp 83(2): 78-84.
  5. Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248(2): 189-198.
  6. Kehlet H (2011) Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg 396(5): 585-590.
  7. Kehlet H (2009) Multimodal approach to postoperative recovery. Curr Opin Crit Care 15(4): 355-358.
  8. Olsén MF, Wennberg E (2011) Fast-track concepts in major open upper abdominal and thoracoabdominal surgery: A review. World J Surg 35(12): 2586–2593.
  9. Kehlet H (2008) Fast-track colorectal surgery. Lancet 371(9615): 791-793.
  10. Joliat GR, Kobayashi K, Hasegawa K, Thomson JE, Padbury R, et al. (2023) Guidelines for perioperative care for liver surgery: Enhanced Recovery After Surgery (ERAS) society recommendations 2022. World J Surg 47(1): 11-34.
  11. Melloul E, Lassen K, Roulin D, Grass F, Perinel J, et al. (2020) Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg 44(7): 2056-2084.
  12. Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, et al. (2014) Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 101(10): 1209-1229.

© 2023 Fulthon-Frank Vela. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.