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JBJS.D.02035

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[52] Galanopoulos I, Ilias A, Karliaftis K, Papadopoulos D, Ashwood N. The impact of re-tear on the clinical outcome after rotator cuff repair using open or arthroscopic techniques: A systematic review. The Open Orthopaedics Journal. 2017;**11**(Suppl 1):95-107. DOI: 10.2174/1874325001711010095.M4

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[55] Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? The Journal of Bone and Joint Surgery. American Volume. 2005;**87**(6):1229-1240. DOI: 10.2106/ JBJS.D.02035

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[60] Millett PJ, Warth RJ, Dornan GJ. Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: A systematic review and meta-analysis of level I randomized clinical trials. Journal of Shoulder and Elbow Surgery. 2014;**23**:586-597

[61] Hantes ME, Ono Y, Raoulis VA, Doxariotis N, Venouzioy A, Zibis A, et al. Arthroscopic single-row versus double-row suture bridge technique for rotator cuff tears in patients younger than 55 years: A prospective comparative study. The American Journal of Sports Medicine. 2018;**46**(1):116-121. DOI: 10.1177/0363546517728718

[62] Cho NS, Rhee YG. The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder. Clinics in Orthopedic Surgery. 2009;**1**:96-104. DOI: 10.4055/cios.2<IP_ADDRESS>

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[66] Genuario JW, Donegan RP, Hamman D. The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair. The Journal of Bone and Joint Surgery. 2012;**94**(15):1369-1377. DOI: 10.2106/ JBJS.J.01876

[67] Huang AL, Thavorn K, van Katwyk S, MacDonald P, Lapner P. Double-row arthroscopic rotator cuff repair is more cost-effective than singlerow repair. Journal of Bone and Joint Surgery. 2017;**99**(20):1730-1736. DOI: 10.2106/JBJS.16. 01044

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**47**

*Single-Row Versus Double-Row Repair in Rotator Cuff Tears*

arthroscopic single-row and doublerow suture anchor repair for rotator cuff tears: A randomized controlled trial. American Journal of Sports Medicine. 2007;**35**(8):1254-1260. DOI:

[83] Barber FA. Triple-loaded single-row versus suture-bridge double-row rotator cuff tendon repair with platelet-rich plasma fibrin membrane: A randomized controlled trial. Orthopaedic Journal of Sports Medicine. 2016;**32**(5):753-761. DOI: 10.1016/j.arthro.2015.11.020

[84] Sobhy MH, Khater AH, Hassan MR, El Shazly O. Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and metaanalysis study. European Journal of Orthopaedic Surgery and Traumatology. 2018;**28**(4):593-605. DOI: 10.1007/

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Medicine. 2017;**45**(3):733-741

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Medicine. 2006;**34**(3):407-414

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10.1177/0363546507302218

s00590-018-2145-7

*DOI: http://dx.doi.org/10.5772/intechopen.89693*

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[78] Carbonel I, Martinez AA, Calvo A, Ripalda J, Herrera A. Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: A prospective randomized clinical study. International Orthopaedics. 2012;**36**(9):1877-1883. DOI: 10.1007/

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functional outcomes after triple-loaded

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[76] Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl UJ. Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: A systematic review and meta-analysis of level I randomized clinical trials. The Journal of Shoulder and Elbow Surgery. 2014;**23**(4):586-597. DOI: 10.1016/j. jse.2013.10.006

*Surgical Recovery*

v6.i2.211

integrity of arthroscopically repaired rotator cuff tears of the shoulder. Clinics in Orthopedic Surgery. 2009;**1**:96-104.

tears: The effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002;**18**:519-526

Bayer M. Repair of the rotator cuff: End-result study of factors influencing reconstruction. The Journal of Bone and Joint Surgery. American Volume.

[71] Burks RT, Crim J, Brown N, Fink B, Greis PE. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: Magnetic resonance imaging and early clinical evaluation. The American Journal of Sports Medicine.

[72] Aydin N, Kocaoglu B, Guven O. Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears. Journal of Shoulder and Elbow Surgery. 2010;**19**(5):722-725. DOI: 10.1016/j.

[73] Koh KH, Kang KC, Lim TK, Shon MS, Yoo JC. Prospective randomized clinical trial of singleversus double-row suture anchor repair in 2- to 4-cm rotator cuff tears: Clinical and magnetic resonance imaging results. Arthroscopy. 2011;**27**:453-462

[74] Lapner PLC, Sabri E, Rakhra K, et al. A multicenter

randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. The Journal of Bone and Joint Surgery. American Volume. 2012;**94**(14): 1249-1257. DOI: 10.2106/JBJS.K.00999

[75] Nicholas SJ, Lee SJ, Mullaney MJ, et al. Functional outcomes after doublerow versus single-row rotator cuff repair: A prospective randomized trial. Orthopaedic Journal of Sports Medicine. 2016;**4**(10). DOI:

10.1177/2325967116667398

[70] Ellman H, Hanker G,

1986;**68**:1136-1144

2009;**37**:674-682

jse.2009.11.053

Tashjian RZ. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopedics. 2015;**6**:211-220. DOI: 10.5312/wjo.

[64] Chung SW, Oh JH, Gong HS, Kim JY, Kim SH. Factors affecting rotator cuff healing after arthroscopic

repair: Osteoporosis as one of the independent risk factors. The American Journal of Sports Medicine. 2011;**39**:2099-2107. DOI:

10.1177/0363546511415659

s00167-012-2338-2

JBJS.J.01876

[66] Genuario JW, Donegan RP, Hamman D. The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair. The Journal of Bone and Joint Surgery. 2012;**94**(15):1369-1377. DOI: 10.2106/

[67] Huang AL, Thavorn K, van Katwyk S, MacDonald P, Lapner P. Double-row arthroscopic rotator cuff repair is more cost-effective than singlerow repair. Journal of Bone and Joint Surgery. 2017;**99**(20):1730-1736. DOI:

[68] Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. Journal of Shoulder and Elbow Surgery.

Fitzgibbons PG, Warner JJ. Rotator cuff

[69] Apreleva M, Ozbaydar M,

10.2106/JBJS.16. 01044

1994;**3**:347-352

[65] Bisson L, Zivaljevic N, Sanders S. A cost analysis of single-row versus double-row and suture bridge rotator cuff repair methods. Knee Surgery Sports Traumatology, Arthroscopy. 2015;**23**:487-493. DOI: 10.1007/

DOI: 10.4055/cios.2<IP_ADDRESS>

[63] Abtahi AM, Granger EK,

**46**

[77] Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and doublerow repairs in rotator cuff tears. The American Journal of Sports Medicine. 2008;**36**:1310-1316

[78] Carbonel I, Martinez AA, Calvo A, Ripalda J, Herrera A. Single-row versus double-row arthroscopic repair in the treatment of rotator cuff tears: A prospective randomized clinical study. International Orthopaedics. 2012;**36**(9):1877-1883. DOI: 10.1007/ s00264-012-1559-9

[79] Ma H-L, Chiang E-R, H-TH W, et al. Clinical outcome and imaging of arthroscopic single-row and doublerow rotator cuff repair: A prospective randomized trial. Arthroscopy. 2012;**28**(1):16-24. DOI: 10.1016/j. arthro.2011.07.003

[80] Saridakis P, Jones G. Outcomes of single-row and double-row arthroscopic rotator cuff repair: A systematic review. The Journal of Bone and Joint Surgery. American Volume. 2010;**92**(3):732-742. DOI: 10.2106/JBJS.I.01295

[81] Tashjian RZ, Granger EK, Chalmers PN. Healing rates and functional outcomes after triple-loaded single-row versus transosseousequivalent double-row rotator cuff tendon repair. Orthopaedic Journal of Sports Medicine. 2018;**6**(11):2325967118805365

[82] Franceschi F, Ruzzini L, Longo UG, Martina FM, Zobel BB, Maffulli N, et al. Equivalent clinical results of

arthroscopic single-row and doublerow suture anchor repair for rotator cuff tears: A randomized controlled trial. American Journal of Sports Medicine. 2007;**35**(8):1254-1260. DOI: 10.1177/0363546507302218

[83] Barber FA. Triple-loaded single-row versus suture-bridge double-row rotator cuff tendon repair with platelet-rich plasma fibrin membrane: A randomized controlled trial. Orthopaedic Journal of Sports Medicine. 2016;**32**(5):753-761. DOI: 10.1016/j.arthro.2015.11.020

[84] Sobhy MH, Khater AH, Hassan MR, El Shazly O. Do functional outcomes and cuff integrity correlate after single- versus double-row rotator cuff repair? A systematic review and metaanalysis study. European Journal of Orthopaedic Surgery and Traumatology. 2018;**28**(4):593-605. DOI: 10.1007/ s00590-018-2145-7

[85] Chen M, Xu W, Dong Q, Huang Q, Xie Z, Mao Y. Outcomes of single-row versus double-row arthroscopic rotator cuff repair: A systematic review and meta-analysis of current evidence. Orthopedics. 2013;**29**(8):1437-1449. DOI: 10.1016/j.arthro.2013.03.076

[86] Yang J, Robbins M, Reilly J, Maerz T, Anderson K. The clinical effect of a rotator cuff retear: A meta-analysis of arthroscopic single-row and double-row repairs. The American Journal of Sports Medicine. 2017;**45**(3):733-741

[87] Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA, Arciero RA. Arthroscopic single-row versus double-row suture anchor rotator cuff repair. The American Journal of Sports Medicine. 2005;**33**(12):1861-1868

[88] Kim DH, ElAttrache NS, Tibone JE, et al. Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair. The American Journal of Sports Medicine. 2006;**34**(3):407-414

[89] Baums MH, Spahn G, Buchhorn GH, Schultz W, Hofmann L, Klinger H-M. Biomechanical and magnetic resonance imaging evaluation of a single- and double-row rotator cuff repair in an in vivo sheep model. Arthroscopy. 2012;**28**(6):769-777

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[92] Christoforetti JJ, Krupp RJ, Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. Journal of Shoulder and Elbow Surgery. 2012;**21**(4):523-530

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[94] Hayashida K, Tanaka M, Koizumi K, Kakiuchi M. Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic doublerow rotator cuff repair. Arthroscopy. 2012;**28**(4):458-464

[95] Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: Single-row versus suture bridge technique. The American Journal of Sports Medicine. 2010;**38**(4):664-671

[96] Lee KW, Seo DW, Bae KW, Choy WS. Clinical and radiological evaluation after arthroscopic rotator cuff repair using suture bridge technique. Clinics in Orthopedic Surgery. 2013;**5**(4):306

[97] Kim KC, Shin HD, Cha SM, Park JY. Comparisons of retear patterns for 3 arthroscopic rotator cuff repair methods. The American Journal of Sports Medicine. 2014;**42**(3):558-565

**49**

**Chapter 4**

**Abstract**

Fast Recovery in Esthetic Body

*Héctor Durán, Lazaro Cardenas Camarena, Jorge Bayter,*

Body contouring surgery is worldwide accepted as one of the most successful esthetic surgeries. Lipectomy, liposuction, and buttock fat infiltration are among the most frequent procedures realized, but also, they are not free of complications as any other surgery. A strategy to overcome these complications is to provide the patient with a good perioperative care, to improve every aspect of recovery. The areas to be improved are nutrition, immunology, pain and inflammation, hemodynamics, early mobilization, patient education and communication, and leadership to evaluate if it is correctly been done. The implementation of these fast recovery strategies is the best approach for our patients, with cost-efficiency optimization, a better experience, and a high overall satisfaction during the whole process. It constitutes a paradigm shift from the traditional steps around the well-being of the patient. If all the areas are covered and improved, the patient should have a fast recovery and a good experience of the surgery.

**Keywords:** body contouring surgery, fast recovery, enhanced recovery in esthetic

in order to obtain a greater good. In cosmetic surgery, the objective of this controlled damage is to obtain greater beauty. But for this to happen, the damage will have to be controlled so that the body can recover. These procedures are usually performed on patients who must have optimal medical conditions. Therefore, recovery should be quick and smooth and is very desirable in all surgeries, especially in body

A surgery is an intervention that generates damage in an area of the human body

• share strategies to provide high quality indications, innovating in perioperative

• reduce the risk and frequency of complications from body contouring surgery

Contouring Surgery

*and Alejandro López Echaury*

surgery, esthetic body contouring

contouring surgery. The goals of this work are to:

• provide guidelines for a patient's rapid recovery;

• reduce hospitalization costs through a fast recovery.

**1. Introduction**

care [1];

[2]; and

*Juan Carlos Zambrano, Marcelo Uriarte*

### **Chapter 4**

*Surgical Recovery*

2012;**28**(6):769-777

2006;**88**(2):403

[90] Burkhart SS, Adams CR, Burkhart SS, Schoolfield JD. A

[89] Baums MH, Spahn G, Buchhorn GH, Schultz W, Hofmann L, Klinger H-M. Biomechanical and magnetic resonance imaging evaluation of a single- and double-row rotator cuff repair in an in vivo sheep model. Arthroscopy.

[96] Lee KW, Seo DW, Bae KW, Choy WS. Clinical and radiological evaluation after arthroscopic rotator cuff repair using suture bridge technique. Clinics in Orthopedic

[97] Kim KC, Shin HD, Cha SM,

Park JY. Comparisons of retear patterns for 3 arthroscopic rotator cuff repair methods. The American Journal of Sports Medicine. 2014;**42**(3):558-565

Surgery. 2013;**5**(4):306

biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: The SwiveLock-FiberChain construct versus standard double-row repair. Arthroscopy. 2009;**25**(3):274-281

[91] Ma CB, Comerford L, Wilson J, Puttlitz CM. Biomechanical evaluation of arthroscopic rotator cuff repairs: Double-row compared with singlerow fixation. The Journal of Bone and Joint Surgery. American Volume.

[92] Christoforetti JJ, Krupp RJ,

transosseus equivalent fixation of rotator cuff tendon preserves

[93] Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: Is the repair integrity actually maintained. The American Journal of Sports Medicine.

2011;**39**(10):2108-2116

2012;**28**(4):458-464

2010;**38**(4):664-671

Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge

intratendinous blood flow at the time of initial fixation. Journal of Shoulder and Elbow Surgery. 2012;**21**(4):523-530

[94] Hayashida K, Tanaka M, Koizumi K, Kakiuchi M. Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic doublerow rotator cuff repair. Arthroscopy.

[95] Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: Single-row versus suture bridge technique. The American Journal of Sports Medicine.

**48**

## Fast Recovery in Esthetic Body Contouring Surgery

*Héctor Durán, Lazaro Cardenas Camarena, Jorge Bayter, Juan Carlos Zambrano, Marcelo Uriarte and Alejandro López Echaury*

### **Abstract**

Body contouring surgery is worldwide accepted as one of the most successful esthetic surgeries. Lipectomy, liposuction, and buttock fat infiltration are among the most frequent procedures realized, but also, they are not free of complications as any other surgery. A strategy to overcome these complications is to provide the patient with a good perioperative care, to improve every aspect of recovery. The areas to be improved are nutrition, immunology, pain and inflammation, hemodynamics, early mobilization, patient education and communication, and leadership to evaluate if it is correctly been done. The implementation of these fast recovery strategies is the best approach for our patients, with cost-efficiency optimization, a better experience, and a high overall satisfaction during the whole process. It constitutes a paradigm shift from the traditional steps around the well-being of the patient. If all the areas are covered and improved, the patient should have a fast recovery and a good experience of the surgery.

**Keywords:** body contouring surgery, fast recovery, enhanced recovery in esthetic surgery, esthetic body contouring

#### **1. Introduction**

A surgery is an intervention that generates damage in an area of the human body in order to obtain a greater good. In cosmetic surgery, the objective of this controlled damage is to obtain greater beauty. But for this to happen, the damage will have to be controlled so that the body can recover. These procedures are usually performed on patients who must have optimal medical conditions. Therefore, recovery should be quick and smooth and is very desirable in all surgeries, especially in body contouring surgery. The goals of this work are to:

#### **2. Main text**

According to ISAPS latest global report, body contouring surgeries (BCS) are among the top four procedures worldwide [3], with a tendency to increase every year; different techniques and technologies have been implemented to optimize the surgical act and improve the patient's esthetic outcome [4]. We recently searched for literature and realized that we could not find anything specific about optimizing the perioperative management in BCS, although we found some for breast augmentation and microvascular reconstruction [5, 6]. Therefore, we must first understand the problems and complications derived from BCS (mainly lipectomy and liposuction with buttock fat infiltration). By knowing the complications, we can develop strategies to prevent, mitigate, or avoid these complications. Fortunately, there are well-defined strategies for other surgery protocols, which can be used since they present similar complications [7].

The principles we used to select these strategies were that they could be grouped by systems (to facilitate their management), have a defined objective and scientific support, without interacting with the other recommendations, are cost-effective, and are easy to understand for patients. Based on the above principles, we consider that some points are highly relevant to achieve this rapid recovery, and we identified the following seven areas:

	- An excellent preoperative diet and a quick restart
	- An adequate immunological function to decrease infections
	- Avoiding pain with strategies that promote comfort and mobility
	- Hydration and response to bleeding, preventing thrombosis
	- To avoid complications and rapid reintegration
	- Adequate patient education for active participation
	- Effective decision making and re-evaluation for improvement

#### **3. Nutrition**

Body contouring surgeries sometimes require more than 3 hours of surgical time, management of large surgical areas, and a large exchange of fluids (as in the

**51**

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

**3.1 Preoperative management**

• perioperative nutrition;

• fast to solid food; and

**3.2 Perioperative nutrition**

mass indexes below 30 kg/m<sup>2</sup>

**3.3 Preoperative fasting**

improve our patient's behaviors and bad habits.

• fluid and carbohydrate loading.

case of liposculpture). Therefore, it is important to consider the management of perioperative nutrition as a fundamental pillar for a good recovery, as well as the multimodal management [2, 5–8]. Some of the possible benefits of adequate perioperative nutrition management such as decreased perioperative anxiety and thirst, controlled nausea and vomiting, decreased morbidity and mortality, and shortened

In order to properly apply the recommendations, a patient undergoing body contouring surgery must be selected according to specific parameters [4] and preferably without comorbidities. Increased metabolic stress and insulin resistance are closely associated with fasting long periods [10], which may result in nausea, vomiting, and increased morbidity and mortality, including prolonged hospital stay and longer recovery period [1]; there are several perioperative guidelines and protocols published in order to avoid them [5, 6, 8]. In the case of body contouring

The patient who undergoes elective body contouring surgeries must comply with the specific indications to improve his postoperative period, optimize recovery times, provide optimal conditions for healing, and prevent possible complications. Obese patients can also be malnourished; we suggest a complete nutritional evaluation, and the patient follows the appropriate and specific indications before surgery [9]. It is important to work on the patient's good eating habits and physical activity, since obesity is undoubtedly a factor that increases perioperative morbidity and mortality, wound dehiscence and infections, venous thromboembolism, and other complications. We would even recommend the surgeon to postpone surgery if the patient's weight is not adequate, seeking to perform elective surgeries on body

professionals that includes a nutritionist and a psychologist, working together to

Alcoholic beverages should also be avoided. An intake of five or more alcoholic beverages in 1 day or five or more days in the last 30 days is considered high consumption and should be recommended to be suspended 1 month before surgery, since it is considered a risk factor frequently associated with wound infection [11]. Adequate preoperative intake should be monitored, and foods rich in protein and energy can be recommended 7 to 10 days before surgery [13, 14]. Supplements rich in arginine, fatty acids, and nucleotides have been shown to be effective in improving tissue oxygenation by promoting healing and overall recovery [13].

Preoperative fasting is intended to prevent perioperative bronchoaspiration, which has a relatively low incidence but high mortality [15]. But fasting along with surgery can trigger increased insulin resistance and catabolic stress. Catabolic stress produces

ideally [11, 12]. It is important to integrate a group of

hospital stay have been reported in different protocols [2, 5, 7, 9].

surgeries, they are particularly useful and can be divided into:

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

case of liposculpture). Therefore, it is important to consider the management of perioperative nutrition as a fundamental pillar for a good recovery, as well as the multimodal management [2, 5–8]. Some of the possible benefits of adequate perioperative nutrition management such as decreased perioperative anxiety and thirst, controlled nausea and vomiting, decreased morbidity and mortality, and shortened hospital stay have been reported in different protocols [2, 5, 7, 9].

#### **3.1 Preoperative management**

*Surgical Recovery*

**2. Main text**

the following seven areas:

○ An excellent preoperative diet and a quick restart

○ An adequate immunological function to decrease infections

○ Hydration and response to bleeding, preventing thrombosis

○ To avoid complications and rapid reintegration

○ Adequate patient education for active participation

○ Effective decision making and re-evaluation for improvement

Body contouring surgeries sometimes require more than 3 hours of surgical time, management of large surgical areas, and a large exchange of fluids (as in the

○ Avoiding pain with strategies that promote comfort and mobility

• Nutrition

• Immunology

• Hemodynamics

• Early mobilization

• Leadership

**3. Nutrition**

• Education and communication

• Pain and inflammation

According to ISAPS latest global report, body contouring surgeries (BCS) are among the top four procedures worldwide [3], with a tendency to increase every year; different techniques and technologies have been implemented to optimize the surgical act and improve the patient's esthetic outcome [4]. We recently searched for literature and realized that we could not find anything specific about optimizing the perioperative management in BCS, although we found some for breast augmentation and microvascular reconstruction [5, 6]. Therefore, we must first understand the problems and complications derived from BCS (mainly lipectomy and liposuction with buttock fat infiltration). By knowing the complications, we can develop strategies to prevent, mitigate, or avoid these complications. Fortunately, there are well-defined strategies for other surgery protocols, which can be used since they present similar complications [7]. The principles we used to select these strategies were that they could be grouped by systems (to facilitate their management), have a defined objective and scientific support, without interacting with the other recommendations, are cost-effective, and are easy to understand for patients. Based on the above principles, we consider that some points are highly relevant to achieve this rapid recovery, and we identified

**50**

In order to properly apply the recommendations, a patient undergoing body contouring surgery must be selected according to specific parameters [4] and preferably without comorbidities. Increased metabolic stress and insulin resistance are closely associated with fasting long periods [10], which may result in nausea, vomiting, and increased morbidity and mortality, including prolonged hospital stay and longer recovery period [1]; there are several perioperative guidelines and protocols published in order to avoid them [5, 6, 8]. In the case of body contouring surgeries, they are particularly useful and can be divided into:

#### **3.2 Perioperative nutrition**

The patient who undergoes elective body contouring surgeries must comply with the specific indications to improve his postoperative period, optimize recovery times, provide optimal conditions for healing, and prevent possible complications. Obese patients can also be malnourished; we suggest a complete nutritional evaluation, and the patient follows the appropriate and specific indications before surgery [9]. It is important to work on the patient's good eating habits and physical activity, since obesity is undoubtedly a factor that increases perioperative morbidity and mortality, wound dehiscence and infections, venous thromboembolism, and other complications. We would even recommend the surgeon to postpone surgery if the patient's weight is not adequate, seeking to perform elective surgeries on body mass indexes below 30 kg/m<sup>2</sup> ideally [11, 12]. It is important to integrate a group of professionals that includes a nutritionist and a psychologist, working together to improve our patient's behaviors and bad habits.

Alcoholic beverages should also be avoided. An intake of five or more alcoholic beverages in 1 day or five or more days in the last 30 days is considered high consumption and should be recommended to be suspended 1 month before surgery, since it is considered a risk factor frequently associated with wound infection [11].

Adequate preoperative intake should be monitored, and foods rich in protein and energy can be recommended 7 to 10 days before surgery [13, 14]. Supplements rich in arginine, fatty acids, and nucleotides have been shown to be effective in improving tissue oxygenation by promoting healing and overall recovery [13].

#### **3.3 Preoperative fasting**

Preoperative fasting is intended to prevent perioperative bronchoaspiration, which has a relatively low incidence but high mortality [15]. But fasting along with surgery can trigger increased insulin resistance and catabolic stress. Catabolic stress produces

#### *Surgical Recovery*

homeostasis alterations leading to an increase in the occurrence of nausea, vomiting, pain, and general postoperative discomfort that prolongs hospital stay [5, 13].

To avoid this, we recommend patients with BCS, a 6-hour fast for solid foods may be considered. Patients with underlying gastroduodenal pathology [5, 13, 14] and with evidence of delayed gastric emptying will need an 8-hour fast or an overnight fast.

Preoperative administration of carbohydrates (loading) is an option that should be considered 2 hours before the procedure and may be administered in clear liquids (maltodextrin, 12.5%, 285 mOsm/kg, 800 ml the evening before surgery and 400 ml 2–3 hours before induction of anesthesia) [5, 8, 9, 14]. In patients with delayed gastric emptying, carbohydrate loading should be avoided. These measures have been reported to decrease preoperative anxiety, in addition to suppressing thirst and postoperative discomfort [13, 14].

#### **3.4 Postoperative nutritional management**

Resuming an early oral intake after major surgery has shown many benefits, such as decreased nausea, faster return of bowel motility, and shorter hospital stay. It is generally recommended to start 4 hours after surgery, preferably with a low-residue diet. The addition of high-calorie and high-protein supplements will compensate for post-metabolic surgical stress [14].

Undoubtedly, nutrition is an important factor in improving critical postoperative aspects such as wound healing and infection prevention [5, 8, 13, 16]. Once the patient is at home, it is important to start a diet with supplementation of amino acids such as arginine and glutamine in addition to fatty acids, antioxidants, and nucleotides, since these are the most necessary nutrients for the body's metabolic response to surgical stress.

Several studies attribute benefits to arginine supplementation, which is associated with an improvement in vasodilation and oxygenation, in addition to normalizing T-lymphocyte function in tissues, enhancing the body's immune response, and accelerating biological recovery processes [13, 14].

Consuming protein-rich supplements has also been observed to reduce infection rate and hospital stay [13]. Similarly, supplementation with protein, iron, and vitamin B12 and supplementation with vitamin A, C, as well as zinc, calcium, and magnesium should be considered [17].

#### **3.5 Reactivation of intestinal function**

The consumption of coffee when started orally and gum (three times a day for 1 hour) has been widely studied to quickly reactivate the intestinal function, being these measures inexpensive and available in any recovery environment. Attempts have also been made to counteract the effect of opiates on intestinal motility by using alvimopan for its antagonistic effect on u-blockers in the gastrointestinal tract, as well as mosapride and its serotonin agonist action to enhance recovery from ileus [5, 13].

#### **4. Immunology**

#### **4.1 Antimicrobial prophylaxis**

It is important to note that surgical infections are rare in body contouring procedures [11, 18, 19], but adequate prophylaxis covering both aerobic and anaerobic bacteria is mandatory [20].

**53**

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

**4.2 Surgical area decontamination**

**5.1 Prevention and treatment of pain**

povidone-iodine [11].

procedure [11, 21].

recommended [25, 26].

7 days (**Table 1**) [26].

**5. Pain**

wide coverage, low cost, and low allergenic potential [20–22].

The appropriate time for antibiotic administration, according to current guidelines, is intravenous administration 60 minutes before the surgical procedure. The use of first-generation cephalosporins (Cefazolin 1 g) is preferred because of its

The administration of oral antibiotics in the subsequent postoperative period lacks scientific support to demonstrate its efficacy in preventing infections, and its

It is recommended to clean the skin with alcohol and chlorhexidine solutions to eliminate the bacterial flora. Its use decreases the presence of surgical site infection by up to 40%. Studies have shown that they are more effective compared to

Preoperative bathing with chlorhexidine-based soaps remains questionable [20]; however, it can be considered useful as BCS works in large surgical areas, and this theoretically allows for more adequate preparation before the surgical

One of the pillars of the comprehensive approach to surgical patient recovery is the management of analgesia. With this in mind, the first step is precisely to establish an appropriate analgesia management scheme even before the procedure. There is evidence that reducing pain during the intraoperative and postoperative processes will allow patients to have a faster nutritional, psychological, and motor recovery [23]. Among the results, a significant decrease in postoperative pain from day 0 to day 3 has been found. Another reason within rapid recovery protocols is to limit the use of opiates, thereby achieving the goal without increasing complications. On the other hand, opioids reduction is also part of the postoperative strategy to limit nausea and vomiting and avoid postural hypotension.  Among the recommendations for postoperative analgesia, treatment with ketorolac and then with paracetamol, nonsteroidal anti-inflammatory drugs, and gabapentin are

Multimodal management is chosen to act on the different pain mechanisms and thus reduce them in the postoperative period [25]. As preoperative planning, celecoxib (200–400 mg), gabapentin (300–600 mg), and ondansetron (8 mg) are started as premedication one night before surgery and the surgery morning. Intraoperatively, dexamethasone (8 mg) and promethazine (25 mg) are added after induction, either intravenously or in suppository [26], in addition to fentanyl and propofol per kilogram of weight [23]. In breast surgery, the protocols also include regional anesthesia by paravertebral blocks [25] and in abdominoplasty the use of liposomal bupivacaine [27] (0.25–0.5%) below the rectus abdominis sheath [25] or transverse abdominal plane block. Ropivacaine as a pain control measure within the breast pocket in breast surgeries has also been reported efficiently by Durán-Vega [28]. In all cases, 1 g of paracetamol is applied intravenously at the end of surgery and just before extubation. In the recovery area, gabapentin can be used before discharge or during the hospital stay. For outpatient management, celecoxib and gabapentin are indicated for 5 to

role in eliminating intestinal bacterial flora can be questioned [11, 20, 22].

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

The appropriate time for antibiotic administration, according to current guidelines, is intravenous administration 60 minutes before the surgical procedure. The use of first-generation cephalosporins (Cefazolin 1 g) is preferred because of its wide coverage, low cost, and low allergenic potential [20–22].

The administration of oral antibiotics in the subsequent postoperative period lacks scientific support to demonstrate its efficacy in preventing infections, and its role in eliminating intestinal bacterial flora can be questioned [11, 20, 22].

#### **4.2 Surgical area decontamination**

It is recommended to clean the skin with alcohol and chlorhexidine solutions to eliminate the bacterial flora. Its use decreases the presence of surgical site infection by up to 40%. Studies have shown that they are more effective compared to povidone-iodine [11].

Preoperative bathing with chlorhexidine-based soaps remains questionable [20]; however, it can be considered useful as BCS works in large surgical areas, and this theoretically allows for more adequate preparation before the surgical procedure [11, 21].

#### **5. Pain**

*Surgical Recovery*

night fast.

homeostasis alterations leading to an increase in the occurrence of nausea, vomiting, pain, and general postoperative discomfort that prolongs hospital stay [5, 13]. To avoid this, we recommend patients with BCS, a 6-hour fast for solid foods may be considered. Patients with underlying gastroduodenal pathology [5, 13, 14] and with evidence of delayed gastric emptying will need an 8-hour fast or an over-

Preoperative administration of carbohydrates (loading) is an option that should

Resuming an early oral intake after major surgery has shown many benefits, such as decreased nausea, faster return of bowel motility, and shorter hospital stay. It is generally recommended to start 4 hours after surgery, preferably with a low-residue diet. The addition of high-calorie and high-protein supplements will

Undoubtedly, nutrition is an important factor in improving critical postoperative aspects such as wound healing and infection prevention [5, 8, 13, 16]. Once the patient is at home, it is important to start a diet with supplementation of amino acids such as arginine and glutamine in addition to fatty acids, antioxidants, and nucleotides, since these are the most necessary nutrients for the body's metabolic

Several studies attribute benefits to arginine supplementation, which is associated with an improvement in vasodilation and oxygenation, in addition to normalizing T-lymphocyte function in tissues, enhancing the body's immune response, and

Consuming protein-rich supplements has also been observed to reduce infection rate and hospital stay [13]. Similarly, supplementation with protein, iron, and vitamin B12 and supplementation with vitamin A, C, as well as zinc, calcium, and

The consumption of coffee when started orally and gum (three times a day for 1 hour) has been widely studied to quickly reactivate the intestinal function, being these measures inexpensive and available in any recovery environment. Attempts have also been made to counteract the effect of opiates on intestinal motility by using alvimopan for its antagonistic effect on u-blockers in the gastrointestinal tract, as well as mosapride and its serotonin agonist action to enhance recovery from ileus [5, 13].

It is important to note that surgical infections are rare in body contouring procedures [11, 18, 19], but adequate prophylaxis covering both aerobic and anaerobic

be considered 2 hours before the procedure and may be administered in clear liquids (maltodextrin, 12.5%, 285 mOsm/kg, 800 ml the evening before surgery and 400 ml 2–3 hours before induction of anesthesia) [5, 8, 9, 14]. In patients with delayed gastric emptying, carbohydrate loading should be avoided. These measures have been reported to decrease preoperative anxiety, in addition to suppressing

thirst and postoperative discomfort [13, 14].

**3.4 Postoperative nutritional management**

compensate for post-metabolic surgical stress [14].

accelerating biological recovery processes [13, 14].

magnesium should be considered [17].

**3.5 Reactivation of intestinal function**

response to surgical stress.

**52**

**4. Immunology**

**4.1 Antimicrobial prophylaxis**

bacteria is mandatory [20].

#### **5.1 Prevention and treatment of pain**

One of the pillars of the comprehensive approach to surgical patient recovery is the management of analgesia. With this in mind, the first step is precisely to establish an appropriate analgesia management scheme even before the procedure. There is evidence that reducing pain during the intraoperative and postoperative processes will allow patients to have a faster nutritional, psychological, and motor recovery [23]. Among the results, a significant decrease in postoperative pain from day 0 to day 3 has been found. Another reason within rapid recovery protocols is to limit the use of opiates, thereby achieving the goal without increasing complications. On the other hand, opioids reduction is also part of the postoperative strategy to limit nausea and vomiting and avoid postural hypotension.  Among the recommendations for postoperative analgesia, treatment with ketorolac and then with paracetamol, nonsteroidal anti-inflammatory drugs, and gabapentin are recommended [25, 26].

Multimodal management is chosen to act on the different pain mechanisms and thus reduce them in the postoperative period [25]. As preoperative planning, celecoxib (200–400 mg), gabapentin (300–600 mg), and ondansetron (8 mg) are started as premedication one night before surgery and the surgery morning. Intraoperatively, dexamethasone (8 mg) and promethazine (25 mg) are added after induction, either intravenously or in suppository [26], in addition to fentanyl and propofol per kilogram of weight [23]. In breast surgery, the protocols also include regional anesthesia by paravertebral blocks [25] and in abdominoplasty the use of liposomal bupivacaine [27] (0.25–0.5%) below the rectus abdominis sheath [25] or transverse abdominal plane block. Ropivacaine as a pain control measure within the breast pocket in breast surgeries has also been reported efficiently by Durán-Vega [28]. In all cases, 1 g of paracetamol is applied intravenously at the end of surgery and just before extubation. In the recovery area, gabapentin can be used before discharge or during the hospital stay. For outpatient management, celecoxib and gabapentin are indicated for 5 to 7 days (**Table 1**) [26].

**Table 1.**

*Options for pain management.*

#### **6. Hemodynamics**

The accelerated recovery protocol after surgery originated in the 1990s after findings from major research groups in elective surgery [29] demonstrated improved hydration, reduced incidence of bleeding, transfusions, and complications of thrombosis [1].

The strategies carried out in the perioperative period emphasize the application of management in the different stages of surgery, and one of the main objectives is to avoid the non-rational use of fluids to avoid water overload [30]. It has been shown that water overload is one of the main risk factors that increase morbidity and mortality. Inadequate use of intravenous fluids in quality and quantity favors tissue edema, increased body weight, and fluid leakage into the third space. This also translates into cardiorespiratory complications and, at abdominal level, into a delay in the recovery of adequate peristalsis, since it favors the presence of mesenteric edema and ascites.

Fluid restriction and the use of adequate intravenous fluids have resulted in less interstitial and visceral edema; however, the beneficial effects of such water restriction have not been fully demonstrated through various studies. Some meta-analyses even concluded that there is no decrease in complications or hospital stay [31]. Other randomized controlled studies report a decrease of up to 59% in complications in abdominal surgeries [32]. Optimizing water balance begins with the intake of clear liquids up to 2 hours before surgery [32]. Regarding solid food, it is recommended to be 6 hours before surgery.

But what is the volume that they consider ml/kg/hour within the (non-standardized) definition of water restriction? The range is from 4 to 9 ml/kg/hour compared to non-restriction of 18 ml/kg/hour. It is also important to consider the type and

**55**

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

quality of the liquids used for a proper hydroelectrolyte balance ideally with balanced crystalloid solutions instead of saline solutions. Most of the studies are still inconclusive in this topic. Some multicenters report a 20% decrease in postoperative complications and others report a 40% decrease. However, a key element in the success of trans- and postsurgical care continue being continuous hemodynamic monitoring, including surveillance of variables as simple as urine volume per hour, being a very effective and minimally invasive tool. Hydration must always adjust the insensitive losses and the blood losses with crystalloids in each surgical procedure. It is recommended to keep IV fluids at a rate of 6 to 8 ml/kg/hour, the mean arterial pressure above 60 mmHg and the urinary output greater than 0.5 ml/kg/hour. Patients treated with target-administered fluid therapy (TAFT) has shown in meta-analysis significantly lower morbidity (p = 0.002); therefore, the decrease in hospital stay, hospital costs, as well as lower mortality specifically due to major cardiovascular complications, in this case without being statistically significant (p = 0.370). It was demonstrated in all cases that managed with TAFT globally, less intraoperative fluids were administered compared to their controls [33]. We all recognize the need to replace water in surgery; however, the exact amount for a given procedure remains unknown, and the ideal volume should be identified in an attempt to avoid postoperative complications. Optimal management using conventional heart rate, blood pressure, and urine output parameters is difficult; so, TAFT was proposed; however, the beneficial effect is inconsistent. Nevertheless, TAFT is currently recommended in the context of protocols to improve postoperative recovery. The use of vasopressors is recommended to support fluid management

and has no negative effect in the case of free flap surgery [12].

some previously unidentified disorder [36].

selected, among others [37].

anesthesiologist [38].

Regarding bleeding, studies by Zakhaleva and others, relate the use of less fluid,

Every patient will prove to be a different challenge in relation to bleeding. This can be related to factors like age, sex, medical history, comorbidities, type and duration of surgery, intraoperative and especially postoperative bleeding, drains use, etc. Also, anesthesia-related factors will have to be analyzed, such as hemodynamic monitoring technique, hemodynamic optimization, and fluid infusion solutions

with less surgical morbidity [34]. Hemoglobin before surgery should ideally be greater than 13 g/dl [35] in an attempt to decrease morbidity and mortality from bleeding in our elective surgeries. In the case of anemia identified preoperatively, it should be corrected regardless of whether the cause is due to iron deficiency or

The protocolization of the approach to fluid management will result in adequate perioperative water management, which will reduce costs, morbidity, and mortality, as well as the prompt recovery of our patients, avoiding high rates of postoperative morbidity and mortality dependent on water management by the

A fundamental element for the prevention of complications and an adequate perioperative evolution is venous thromboembolism prophylaxis. This becomes more relevant when the surgery includes abdominoplasty, a surgery that is usually known to have a higher risk of deep vein thrombosis and pulmonary embolism [18]. In these cases, it is essential to carry out a risk scale from the first contact in the office before elective surgery. There are several scales, and each team must determine which is the most appropriate to work with, although the best known is the scale of Caprini and Davidson [39]. The use of low-molecular-weight heparins is recommended in high-risk patients, unless the procedure is contraindicated and there is a high risk of postoperative bleeding. Among prophylactic measures, the use of graduated compression stockings, as well as intermittent mechanical pneumatic compression devices until the patient's discharge, is confirmed in different

#### *Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

*Surgical Recovery*

**Moment Drug** Night before surgery Celecoxib

Morning of surgery Celecoxib

Induction Dexamethasone

Intraoperative Acetaminophen

Recovery Gabapentin Postoperative Acetaminophen

**6. Hemodynamics**

*Options for pain management.*

**Table 1.**

tions of thrombosis [1].

teric edema and ascites.

mended to be 6 hours before surgery.

The accelerated recovery protocol after surgery originated in the 1990s after

Celecoxib Gabapentin Methylprednisolone Tramadol (rescue)

Gabapentin Ondansetron

Gabapentin Ondansetron

Promethazine (suppository)

(Duran's technique) [28]

Bupivacaine injection or ropivacaine pocket irrigation site

The strategies carried out in the perioperative period emphasize the application of management in the different stages of surgery, and one of the main objectives is to avoid the non-rational use of fluids to avoid water overload [30]. It has been shown that water overload is one of the main risk factors that increase morbidity and mortality. Inadequate use of intravenous fluids in quality and quantity favors tissue edema, increased body weight, and fluid leakage into the third space. This also translates into cardiorespiratory complications and, at abdominal level, into a delay in the recovery of adequate peristalsis, since it favors the presence of mesen-

Fluid restriction and the use of adequate intravenous fluids have resulted in less interstitial and visceral edema; however, the beneficial effects of such water restriction have not been fully demonstrated through various studies. Some meta-analyses even concluded that there is no decrease in complications or hospital stay [31]. Other randomized controlled studies report a decrease of up to 59% in complications in abdominal surgeries [32]. Optimizing water balance begins with the intake of clear liquids up to 2 hours before surgery [32]. Regarding solid food, it is recom-

But what is the volume that they consider ml/kg/hour within the (non-standardized) definition of water restriction? The range is from 4 to 9 ml/kg/hour compared to non-restriction of 18 ml/kg/hour. It is also important to consider the type and

findings from major research groups in elective surgery [29] demonstrated improved hydration, reduced incidence of bleeding, transfusions, and complica-

**54**

quality of the liquids used for a proper hydroelectrolyte balance ideally with balanced crystalloid solutions instead of saline solutions. Most of the studies are still inconclusive in this topic. Some multicenters report a 20% decrease in postoperative complications and others report a 40% decrease. However, a key element in the success of trans- and postsurgical care continue being continuous hemodynamic monitoring, including surveillance of variables as simple as urine volume per hour, being a very effective and minimally invasive tool. Hydration must always adjust the insensitive losses and the blood losses with crystalloids in each surgical procedure. It is recommended to keep IV fluids at a rate of 6 to 8 ml/kg/hour, the mean arterial pressure above 60 mmHg and the urinary output greater than 0.5 ml/kg/hour.

Patients treated with target-administered fluid therapy (TAFT) has shown in meta-analysis significantly lower morbidity (p = 0.002); therefore, the decrease in hospital stay, hospital costs, as well as lower mortality specifically due to major cardiovascular complications, in this case without being statistically significant (p = 0.370). It was demonstrated in all cases that managed with TAFT globally, less intraoperative fluids were administered compared to their controls [33]. We all recognize the need to replace water in surgery; however, the exact amount for a given procedure remains unknown, and the ideal volume should be identified in an attempt to avoid postoperative complications. Optimal management using conventional heart rate, blood pressure, and urine output parameters is difficult; so, TAFT was proposed; however, the beneficial effect is inconsistent. Nevertheless, TAFT is currently recommended in the context of protocols to improve postoperative recovery. The use of vasopressors is recommended to support fluid management and has no negative effect in the case of free flap surgery [12].

Regarding bleeding, studies by Zakhaleva and others, relate the use of less fluid, with less surgical morbidity [34]. Hemoglobin before surgery should ideally be greater than 13 g/dl [35] in an attempt to decrease morbidity and mortality from bleeding in our elective surgeries. In the case of anemia identified preoperatively, it should be corrected regardless of whether the cause is due to iron deficiency or some previously unidentified disorder [36].

Every patient will prove to be a different challenge in relation to bleeding. This can be related to factors like age, sex, medical history, comorbidities, type and duration of surgery, intraoperative and especially postoperative bleeding, drains use, etc. Also, anesthesia-related factors will have to be analyzed, such as hemodynamic monitoring technique, hemodynamic optimization, and fluid infusion solutions selected, among others [37].

The protocolization of the approach to fluid management will result in adequate perioperative water management, which will reduce costs, morbidity, and mortality, as well as the prompt recovery of our patients, avoiding high rates of postoperative morbidity and mortality dependent on water management by the anesthesiologist [38].

A fundamental element for the prevention of complications and an adequate perioperative evolution is venous thromboembolism prophylaxis. This becomes more relevant when the surgery includes abdominoplasty, a surgery that is usually known to have a higher risk of deep vein thrombosis and pulmonary embolism [18]. In these cases, it is essential to carry out a risk scale from the first contact in the office before elective surgery. There are several scales, and each team must determine which is the most appropriate to work with, although the best known is the scale of Caprini and Davidson [39]. The use of low-molecular-weight heparins is recommended in high-risk patients, unless the procedure is contraindicated and there is a high risk of postoperative bleeding. Among prophylactic measures, the use of graduated compression stockings, as well as intermittent mechanical pneumatic compression devices until the patient's discharge, is confirmed in different

meta-analyses. Early ambulation is undoubtedly one of the main objectives of the rapid recovery process. Mobilization within the first 24 hours after the end of surgery is imperative.

#### **7. Early mobilization**

Early mobilization after any surgery is the key to rapid recovery from any surgery. This is desirable even in those surgeries where such mobilization would normally be thought to be contraindicated (for example, in the case of skin grafting) [40]; but in the case of body contouring surgery, mobilization is highly indicated. It is considered the most important general care measure in postoperative care to avoid complications [41]. Early mobilization also reduces hospital stay and hospitalization costs and improves the psychological well-being of patients; it promotes circulation, improves muscle tone, adds coordination and independence, improves bowel and urinary functions, and reduces the risk of pulmonary embolism and pneumonia. We owe this knowledge to Dr. Canavarro since World War II, who made the wounded walk from day 1, reporting a 50% reduction in complications in general [40].

Complications from not having early mobilization include muscle weakness, predisposition to lower extremity thrombosis and embolism, and impaired lung function [42]. For this reason, it is always desirable for the patient to move quickly. Also, mobilization is in full relation with the rest of the indications. For example, if anesthesia does not result in adequate recovery, the patient will not be able to mobilize properly. Or if the patient is in a lot of pain, mobilization will be extremely restricted. Similarly, nausea, cold, and other factors may prevent early mobilization.

One of the fears any doctor may have after surgery is that early mobilization will cause more bleeding. However, studies have shown that it is possible and indicated after surgeries even though when the risk of bleeding is thought to be higher. Southwell showed that there was neither any difference in graft integration nor was it necessarily associated with a higher risk of bruising, bleeding, infection, or slower integration [40]. Similarly, Yang after reconstructions [43] with maxillofacial free flap, considered mobilization as safe and that it could even have a better impact on patient comfort and sleep. Shakil [44] after orthopedic surgeries demonstrated that mobilization is not only desirable but also necessary, as it significantly reduces the rate of wound infection. Miyamoto [45] showed that early mobilization is possible after free anastomosis of the lower limbs. And Krauss [46] mentioned that in patients after hip arthroplasty surgery, it is possible to use tranexamic acid as an adjuvant to prevent bleeding and promote early mobilization.

#### **8. Education and communication**

A very important element is the adequate communication and information of patients through education and counseling of patients throughout the perioperative process. Human, physical, and digital resources can be used for this purpose. Knowing the complete perioperative procedure will help the patient to make the best decisions and to prepare physically and mentally in an adequate way for the surgery, as well as to know the process that will be presented during the recovery phase that starts from the postoperative recovery area.

Within this information, it is fundamental to inform the aspects that can interfere in the evolution and the result of the surgery, as well as those elements and factors that can increase the risk of some complications. The patient must change

**57**

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

surgery and at least 4 weeks after surgery [11].

therapy, and postoperative rehabilitation.

impediment to timely treatment.

**9. Team leader and follow-up**

team [27].

scenarios.

departments [50].

mobility and improve patient self-confidence [48].

absence of complications requiring hospitalization [27].

or suspend some behaviors like the habit of smoking, suggesting the complete abstinence from tobacco, both actively and passively, 4 weeks before the date of the

to collaborate with behaviors and attitudes that seek early recovery and the best outcome, since they will understand in detail the key elements that can prevent complications. The patient must know the importance of immediate ambulation (within the first 24 hours after surgery), the need and procedure for physical

Education and information about the perioperative process will allow the patient

Immediate postoperative follow-up with clear and precise indications and recommendations promotes early physical and emotional recovery. Adequate follow-up have been shown to promote better mobility, decrease pain scales, and promote the overall quality of life in the recovery process [47]. Appropriate follow-up includes supervised physical activation programs and other care and support initiatives to be implemented after discharge, which have been shown to accelerate recovery and

The central objective of educating a patient about the process he will face in surgery will be to have a proactive patient who understands what is happening. This patient will be able to differentiate between what is normal and what is not and will know the alarm data so that he can communicate with the surgeon on time in case of any eventuality. This will allow the surgeon to avoid or treat complications in a timely manner thanks to the cooperation of the patient, eliminating ignorance as an

For the correct application of these protocols, it is essential to establish a lead director of the indications, who within his functions will also ensure the socialization and compliance with the steps, and will monitor and establish the improvements or changes necessary for each group. Therefore, it is of great importance that the processes and successes are audited by a professional and multidisciplinary

As a major milestone, it is proposed that the patient can be discharged when the following conditions are met: oral fluid and solid tolerance, audible peristalsis, controllable pain with oral medications, assisted or independent mobilization, and

Rapid recovery protocols after surgery have shown that, even with variable surgeries and different populations, perioperative care determines outcome and success more than the surgical procedure itself [18]. The principles of these practices allow shorter stays and early mobility without increased morbidity [27]. Despite the numerous reports and solid literature on the benefits of rapid recovery protocols, differences in populations and access to resources and elements described above, patient comorbidities [27] involving behavioral changes among so many other variables should be identified by the team leader who should be sensitive to these differences and seek a solution for the different usual

Lack of willingness to implement changes, non-standardization of processes and the execution without inspectors [49] are barriers that prevent the proper implementation of these strategies. For this reason, it is very important to be a leader who can work with barriers, such as general resistance to change, lack of time and team availability, and poor communication, collaboration, and coordination between

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

*Surgical Recovery*

mobilization.

surgery is imperative.

**7. Early mobilization**

meta-analyses. Early ambulation is undoubtedly one of the main objectives of the rapid recovery process. Mobilization within the first 24 hours after the end of

Early mobilization after any surgery is the key to rapid recovery from any surgery. This is desirable even in those surgeries where such mobilization would normally be thought to be contraindicated (for example, in the case of skin grafting) [40]; but in the case of body contouring surgery, mobilization is highly indicated. It is considered the most important general care measure in postoperative care to avoid complications [41]. Early mobilization also reduces hospital stay and hospitalization costs and improves the psychological well-being of patients; it promotes circulation, improves muscle tone, adds coordination and independence, improves bowel and urinary functions, and reduces the risk of pulmonary embolism and pneumonia. We owe this knowledge to Dr. Canavarro since World War II, who made the wounded walk from day 1, reporting a 50% reduction in complications in general [40]. Complications from not having early mobilization include muscle weakness, predisposition to lower extremity thrombosis and embolism, and impaired lung function [42]. For this reason, it is always desirable for the patient to move quickly. Also, mobilization is in full relation with the rest of the indications. For example, if anesthesia does not result in adequate recovery, the patient will not be able to mobilize properly. Or if the patient is in a lot of pain, mobilization will be extremely restricted. Similarly, nausea, cold, and other factors may prevent early

One of the fears any doctor may have after surgery is that early mobilization will cause more bleeding. However, studies have shown that it is possible and indicated after surgeries even though when the risk of bleeding is thought to be higher. Southwell showed that there was neither any difference in graft integration nor was it necessarily associated with a higher risk of bruising, bleeding, infection, or slower integration [40]. Similarly, Yang after reconstructions [43] with maxillofacial free flap, considered mobilization as safe and that it could even have a better impact on patient comfort and sleep. Shakil [44] after orthopedic surgeries demonstrated that mobilization is not only desirable but also necessary, as it significantly reduces the rate of wound infection. Miyamoto [45] showed that early mobilization is possible after free anastomosis of the lower limbs. And Krauss [46] mentioned that in patients after hip arthroplasty surgery, it is possible to use tranexamic acid as an

A very important element is the adequate communication and information of patients through education and counseling of patients throughout the perioperative process. Human, physical, and digital resources can be used for this purpose. Knowing the complete perioperative procedure will help the patient to make the best decisions and to prepare physically and mentally in an adequate way for the surgery, as well as to know the process that will be presented during the recovery

Within this information, it is fundamental to inform the aspects that can interfere in the evolution and the result of the surgery, as well as those elements and factors that can increase the risk of some complications. The patient must change

adjuvant to prevent bleeding and promote early mobilization.

phase that starts from the postoperative recovery area.

**8. Education and communication**

**56**

or suspend some behaviors like the habit of smoking, suggesting the complete abstinence from tobacco, both actively and passively, 4 weeks before the date of the surgery and at least 4 weeks after surgery [11].

Education and information about the perioperative process will allow the patient to collaborate with behaviors and attitudes that seek early recovery and the best outcome, since they will understand in detail the key elements that can prevent complications. The patient must know the importance of immediate ambulation (within the first 24 hours after surgery), the need and procedure for physical therapy, and postoperative rehabilitation.

Immediate postoperative follow-up with clear and precise indications and recommendations promotes early physical and emotional recovery. Adequate follow-up have been shown to promote better mobility, decrease pain scales, and promote the overall quality of life in the recovery process [47]. Appropriate follow-up includes supervised physical activation programs and other care and support initiatives to be implemented after discharge, which have been shown to accelerate recovery and mobility and improve patient self-confidence [48].

The central objective of educating a patient about the process he will face in surgery will be to have a proactive patient who understands what is happening. This patient will be able to differentiate between what is normal and what is not and will know the alarm data so that he can communicate with the surgeon on time in case of any eventuality. This will allow the surgeon to avoid or treat complications in a timely manner thanks to the cooperation of the patient, eliminating ignorance as an impediment to timely treatment.

#### **9. Team leader and follow-up**

For the correct application of these protocols, it is essential to establish a lead director of the indications, who within his functions will also ensure the socialization and compliance with the steps, and will monitor and establish the improvements or changes necessary for each group. Therefore, it is of great importance that the processes and successes are audited by a professional and multidisciplinary team [27].

As a major milestone, it is proposed that the patient can be discharged when the following conditions are met: oral fluid and solid tolerance, audible peristalsis, controllable pain with oral medications, assisted or independent mobilization, and absence of complications requiring hospitalization [27].

Rapid recovery protocols after surgery have shown that, even with variable surgeries and different populations, perioperative care determines outcome and success more than the surgical procedure itself [18]. The principles of these practices allow shorter stays and early mobility without increased morbidity [27]. Despite the numerous reports and solid literature on the benefits of rapid recovery protocols, differences in populations and access to resources and elements described above, patient comorbidities [27] involving behavioral changes among so many other variables should be identified by the team leader who should be sensitive to these differences and seek a solution for the different usual scenarios.

Lack of willingness to implement changes, non-standardization of processes and the execution without inspectors [49] are barriers that prevent the proper implementation of these strategies. For this reason, it is very important to be a leader who can work with barriers, such as general resistance to change, lack of time and team availability, and poor communication, collaboration, and coordination between departments [50].

#### **10. Conclusion**

The implementation of these fast recovery strategies is the best approach for our patients, with cost-efficiency optimization, a better experience, and a high overall satisfaction during the whole process [27]. It constitutes a paradigm shift from the traditional steps [24] around the well-being of the patient. It is possible to develop a management protocol that, although standardized, can be adapted to the different surgical groups performing BCS. In the area of nutrition, appropriate support should be sought to adequately nourish the patient so that the patient can have the least amount of fasting and a rapid tolerance to food. In the area of immunology, care must be taken to ensure that the patient has adequate immunological competence to keep inflammation under control and reduce infectious complications. Maintaining and taking care of an adequate hemodynamic function will help to avoid problems of postural hypotension, besides taking care of hemorrhage and adequate hydration, without it being minor or major. In the area of pain, try to make the patient feel as little discomfort as possible so that he or she can move and recover. Early mobilization will bring immediate benefits to the entire body. Proper patient education will help you understand the challenges you will face and communicate properly with the team to achieve a rapid response and avoid complications. And having a team leader who monitors the processes and implements the changes needed to make them truly effective will give the patient success for rapid recovery after BCS.

#### **Acknowledgements**

We would like to acknowledge Dra. Diana Cecilia Popoca for the translation of this document.

**59**

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

Héctor Durán1,2,3,4,5,6\*, Lazaro Cardenas Camarena1,2,3,4,6, Jorge Bayter6,7,8,9,10,11, Juan Carlos Zambrano5,12, Marcelo Uriarte13,14 and Alejandro López Echaury2,3,4

3 AMCPER – Asociación Mexicana de Cirugía plástica estetica y reconstructive,

4 FILACP – Federación Ibero Latino Americana de Cirugía Plástica, Panama City,

6 LATAM Safety Task Force is a Mexico-Colombia Union 14 FACS is Fellow of

8 Reanimation Critical and Intensive Care, Universidad la Sabana in Bucaramanga,

10 Colombian Society of Anesthesia and Reanimation (SCARE), Bogota, Colombia

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

9 Society of Ambulatory Anesthesia (SAMBA), Overland Park, Kansas

12 Pontificia Universidad Javeriana, Bogota, DC, Colombia

\*Address all correspondence to<EMAIL_ADDRESS>
1 ASAPS – American Society for Aesthetic Plastic Surgery, New York, USA

2 ASPS – American Society of Plastic Surgeons, Illinois, USA

5 SAPS – South American Plastic Surgery, Bogota, Colombia

American College of Surgeons, USA

11 Clínica "EL Pinar", Colombia

13 Uriarte Aesthetics, La Paz, Bolivia

provided the original work is properly cited.

7 Universidad Industrial de Santander, Colombia

**Author details**

Mexico

Panama

Colombia

14 FACS

#### **Conflict of interest**

None of the authors declare any conflict of interest.

### **Author details**

*Surgical Recovery*

**10. Conclusion**

after BCS.

**Acknowledgements**

**Conflict of interest**

this document.

The implementation of these fast recovery strategies is the best approach for our patients, with cost-efficiency optimization, a better experience, and a high overall satisfaction during the whole process [27]. It constitutes a paradigm shift from the traditional steps [24] around the well-being of the patient. It is possible to develop a management protocol that, although standardized, can be adapted to the different surgical groups performing BCS. In the area of nutrition, appropriate support should be sought to adequately nourish the patient so that the patient can have the least amount of fasting and a rapid tolerance to food. In the area of immunology, care must be taken to ensure that the patient has adequate immunological competence to keep inflammation under control and reduce infectious complications. Maintaining and taking care of an adequate hemodynamic function will help to avoid problems of postural hypotension, besides taking care of hemorrhage and adequate hydration, without it being minor or major. In the area of pain, try to make the patient feel as little discomfort as possible so that he or she can move and recover. Early mobilization will bring immediate benefits to the entire body. Proper patient education will help you understand the challenges you will face and communicate properly with the team to achieve a rapid response and avoid complications. And having a team leader who monitors the processes and implements the changes needed to make them truly effective will give the patient success for rapid recovery

We would like to acknowledge Dra. Diana Cecilia Popoca for the translation of

None of the authors declare any conflict of interest.

**58**

Héctor Durán1,2,3,4,5,6\*, Lazaro Cardenas Camarena1,2,3,4,6, Jorge Bayter6,7,8,9,10,11, Juan Carlos Zambrano5,12, Marcelo Uriarte13,14 and Alejandro López Echaury2,3,4

1 ASAPS – American Society for Aesthetic Plastic Surgery, New York, USA

2 ASPS – American Society of Plastic Surgeons, Illinois, USA

3 AMCPER – Asociación Mexicana de Cirugía plástica estetica y reconstructive, Mexico

4 FILACP – Federación Ibero Latino Americana de Cirugía Plástica, Panama City, Panama

5 SAPS – South American Plastic Surgery, Bogota, Colombia

6 LATAM Safety Task Force is a Mexico-Colombia Union 14 FACS is Fellow of American College of Surgeons, USA

7 Universidad Industrial de Santander, Colombia

8 Reanimation Critical and Intensive Care, Universidad la Sabana in Bucaramanga, Colombia

9 Society of Ambulatory Anesthesia (SAMBA), Overland Park, Kansas

10 Colombian Society of Anesthesia and Reanimation (SCARE), Bogota, Colombia

11 Clínica "EL Pinar", Colombia

12 Pontificia Universidad Javeriana, Bogota, DC, Colombia

13 Uriarte Aesthetics, La Paz, Bolivia

14 FACS

\*Address all correspondence to<EMAIL_ADDRESS>
© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[24] Offodile AC, Gu C, Boukovalas S, et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: Systematic review and meta-analysis of the literature. Breast Cancer Research and Treatment. 2019;**173**(1):65-77. DOI: 10.1007/ s10549-018-4991-8

[25] Parikh RP, Myckatyn TM. Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: Patient selection and perspectives. Journal of Pain Research. 2018;**11**:1567-1581. DOI: 10.2147/JPR.S148544

[26] Bartlett EL, Zavlin D, Friedman JD, Abdollahi A, Rappaport NH. Enhanced recovery after surgery: The plastic surgery paradigm shift. Aesthetic Surgery Journal. 2018;**38**(6):676-685. DOI: 10.1093/asj/sjx217

[27] Jogerst K, Thomas O, Kosiorek HE, et al. Same-day discharge after mastectomy: Breast cancer surgery in the era of ERAS®. Annals of Surgical Oncology. 2020. DOI: 10.1245/ s10434-020-08386-w

[28] Durán-Vega HC, Ramírez-Montañana A, Galindo OG, Gutierrez AM, González AZ, Galindo EG, et al. Ropivacaine in breast augmentation surgery. Plastic and Reconstructive Surgery. Global Open. 2018;**6**(5):1-4

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[31] Abraham-Nordling M, Hjern F, Pollack J, Prytz M, Borg T, Kressner U. Randomized clinical trial of fluid restriction in colorectal surgery. The British Journal of Surgery. 2012;**99**:186-191

[32] Brandstrup B, Tønnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens. A randomized assessorblinded multicenter trial. Annals of Surgery. 2003;**238**:641-648

[33] Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesthesia and Analgesia. 2011;**112**:1392-1402

[34] Zakhaleva J, Tam J, Denoya PI, Bishawi M, Bergamaschi R. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: A randomized controlled trial. Colorectal Disease. 2013;**15**:892-899

[35] Ripollés-Melchor J. Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: The postoperative outcomes within enhanced recovery after surgery protocol (POWER) study. JAMA Surgery. 2019;**154**(8):725-736

[36] Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of

the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic Surgery. 2019;**55**(1):91-115

[37] ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: Results from an international registry. Annals of Surgery. 2015;**261**:1153-1159

[38] Lagarda-Cuevas J. Terapia de líquidos dirigida por metas en cirugía mayor no cardíaca: metaanálisis y revisión de la literatura. 2018;**41**(2):105-116

[39] Cuenca-Pardo J, Ramos-Gallardo G, Morales Olivera M, Bucio-Duarte J, Caravantes-Cortés I. Stratification of the risk of thrombosis and prophylaxis: What is the best score to stratify the risk of thrombosis in patients of plastic surgery? What is the best prophylaxis? Evidence based medicine. Cirugía Plástica. 2020;**29**(1):32-47

[40] Southwell-Keely J, Vandervord J. Mobilisation versus bed rest after skin grafting pretibial lacerations: A meta-analysis. Plastic Surgery International. 2012;**2012**:1-6. DOI: 10.1155/2012/207452

[41] Morris BA, Benetti M, Marro H, Rosenthal CK. Clinical practice guidelines for early mobilization hours after surgery. Orthopaedic Nursing. 2010;**29**(5):290- 316. DOI: 10.1097/ NOR.0b013e3181ef7a5d

[42] Kitching AJ, O'Neill SS. Fast-track surgery and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2009;**9**(2):39-43. DOI: 10.1093/ bjaceaccp/mkp006

[43] Yang Y, Wu HY, Wei L, Li PJ, Cai ZG, Shan XF. Improvement of the patient early mobilization protocol

**63**

2014;**14**(1):641

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

> [50] Pearsall EA, Meghji Z, Pitzul KB, et al. A qualitative study to understand

implementing an enhanced recovery after surgery programs. Annals of Surgery. 2015;**261**(1):92-96

the barriers and enablers in

after oral and maxillofacial free flap reconstruction surgery. Journal of Cranio-Maxillofacial Surgery. 2020;**48**(1):43-48. DOI: 10.1016/j.

[44] Shakil S, Rehman U, Danish K. The role of early mobilization in the prevention of post operative wound infection after lower extremity orthopedic surgeries. Journal of the Islamic International Medical College.

[45] Miyamoto S, Kayano S, Fujiki M, Chuman H, Kawai A, Sakuraba M. Early mobilization after free-flap transfer to the lower extremities: Preferential use of flow-through anastomosis. Plastic and Reconstructive Surgery Global Open. 2014;**2**(3):1-7. DOI: 10.1097/ GOX.0000000000000080

jcms.2019.11.016

2012;**7**(January):63-66

[46] Krauss ES, Cronin MA,

Suratwala SJ, Enker P, Rosen L, Segal A. Use of intravenous tranexamic acid improves early ambulation after total knee arthroplasty and anterior and posterior total hip arthroplasty. American Journal of Orthopedics (Belle Mead, N.J.). 2017;**46**(5):E314-E319

[47] Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in surgical breast cancer patients: Results of a randomized controlled study. European Journal of Physical and Rehabilitation Medicine.

[48] Cho HS, Davis GC, Paek JE, et al. A randomised trial of nursing interventions supporting recovery of the postmastectomy patient. Journal of Clinical Nursing. 2013;**22**:919-929

[49] Ament SM, Gillissen F, Moser A, et al. Identification of promising strategies to sustain improvements in hospital practice: A qualitative case study. BMC Health Services Research.

2014;**50**:275-284

*Fast Recovery in Esthetic Body Contouring Surgery DOI: http://dx.doi.org/10.5772/intechopen.93266*

after oral and maxillofacial free flap reconstruction surgery. Journal of Cranio-Maxillofacial Surgery. 2020;**48**(1):43-48. DOI: 10.1016/j. jcms.2019.11.016

*Surgical Recovery*

[30] Carrillo-Esper R, de los

2013;**36**(S1):296-301

2012;**99**:186-191

Pollack J, Prytz M, Borg T, Kressner U. Randomized clinical trial of fluid restriction in colorectal surgery. The British Journal of Surgery.

[32] Brandstrup B, Tønnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens. A randomized assessorblinded multicenter trial. Annals of

Surgery. 2003;**238**:641-648

[33] Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesthesia and Analgesia. 2011;**112**:1392-1402

[34] Zakhaleva J, Tam J, Denoya PI, Bishawi M, Bergamaschi R. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: A randomized controlled trial. Colorectal

[35] Ripollés-Melchor J. Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: The postoperative outcomes within enhanced recovery after surgery protocol (POWER) study. JAMA Surgery. 2019;**154**(8):725-736

[36] Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al.

Guidelines for enhanced recovery after lung surgery: Recommendations of

Disease. 2013;**15**:892-899

Monteros-Estrada E, Pérez-Calatayud A. Una nueva propuesta de la medicina perioperatoria. El protocolo ERAS. Revista Mexicana de Anestesiología.

the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic

[37] ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: Results from an international

Surgery. 2019;**55**(1):91-115

registry. Annals of Surgery.

[38] Lagarda-Cuevas J. Terapia de líquidos dirigida por metas en cirugía mayor no cardíaca:

metaanálisis y revisión de la literatura.

[39] Cuenca-Pardo J, Ramos-Gallardo G, Morales Olivera M, Bucio-Duarte J, Caravantes-Cortés I. Stratification of the risk of thrombosis and prophylaxis: What is the best score to stratify the risk of thrombosis in patients of plastic surgery? What is the best prophylaxis? Evidence based medicine. Cirugía

2015;**261**:1153-1159

2018;**41**(2):105-116

Plástica. 2020;**29**(1):32-47

10.1155/2012/207452

316. DOI: 10.1097/ NOR.0b013e3181ef7a5d

bjaceaccp/mkp006

[41] Morris BA, Benetti M, Marro H, Rosenthal CK. Clinical practice guidelines for early mobilization hours after surgery. Orthopaedic Nursing. 2010;**29**(5):290-

[40] Southwell-Keely J, Vandervord J. Mobilisation versus bed rest after skin grafting pretibial lacerations: A meta-analysis. Plastic Surgery International. 2012;**2012**:1-6. DOI:

[42] Kitching AJ, O'Neill SS. Fast-track surgery and anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2009;**9**(2):39-43. DOI: 10.1093/

[43] Yang Y, Wu HY, Wei L, Li PJ, Cai ZG, Shan XF. Improvement of the patient early mobilization protocol

[31] Abraham-Nordling M, Hjern F,

**62**

[44] Shakil S, Rehman U, Danish K. The role of early mobilization in the prevention of post operative wound infection after lower extremity orthopedic surgeries. Journal of the Islamic International Medical College. 2012;**7**(January):63-66

[45] Miyamoto S, Kayano S, Fujiki M, Chuman H, Kawai A, Sakuraba M. Early mobilization after free-flap transfer to the lower extremities: Preferential use of flow-through anastomosis. Plastic and Reconstructive Surgery Global Open. 2014;**2**(3):1-7. DOI: 10.1097/ GOX.0000000000000080

[46] Krauss ES, Cronin MA, Suratwala SJ, Enker P, Rosen L, Segal A. Use of intravenous tranexamic acid improves early ambulation after total knee arthroplasty and anterior and posterior total hip arthroplasty. American Journal of Orthopedics (Belle Mead, N.J.). 2017;**46**(5):E314-E319

[47] Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in surgical breast cancer patients: Results of a randomized controlled study. European Journal of Physical and Rehabilitation Medicine. 2014;**50**:275-284

[48] Cho HS, Davis GC, Paek JE, et al. A randomised trial of nursing interventions supporting recovery of the postmastectomy patient. Journal of Clinical Nursing. 2013;**22**:919-929

[49] Ament SM, Gillissen F, Moser A, et al. Identification of promising strategies to sustain improvements in hospital practice: A qualitative case study. BMC Health Services Research. 2014;**14**(1):641

[50] Pearsall EA, Meghji Z, Pitzul KB, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery programs. Annals of Surgery. 2015;**261**(1):92-96

**65**

**Chapter 5**

**Abstract**

be adjusted and followed closely.

**1. Introduction**

Surgical Recovery of Intestinal

Postoperative Care and How

*Burhan Hakan Kanat, Erhan Eröz, Atakan Saçli,*

**Keywords:** intestinal obstructions, conservative methods, treatment

Intestinal obstruction is a clinical manifestation that occurs since the passage of the intestinal contents, which should be into the distal levels, is prevented in any part of the passage. It is a condition frequently encountered in the emergency department, which gives positive results with early diagnosis and accurate treatment methods but may have negative consequences if it is not managed well. The patients usually present with the complaints of nausea and vomiting, colic abdominal pain, and inability to defecate. Intestinal obstruction accounts for 5–15% of the patients presenting to the emergency department with acute abdomen [1–3].

In parallel with the development of medical technology and the increasing experience of us, the surgeons, morbidity and mortality rates due to intestinal obstruction have decreased, but difficulties in diagnosis and treatment remain. Now, the cases may present with more complex conditions, and treatment may become more complicated. Nowadays, when minimally invasive and conservative methods are more popular, there is no doubt that nonoperative approach should be the preferred approach for intestinal obstruction. However, unfortunately, surgery should not

*Nizamettin Kutluer, Mehmet Gençtürk and Selim Sözen*

Although initial data on intestinal obstructions are based on Hippocrates, there is still no consensus on approaches today. However, parallel to the development of medical technology and the increasing experience of us surgeons, morbidity and mortality rates due to intestinal obstruction have decreased. Obstruction can occur at any point in the gastrointestinal tract. The main thing is to make a correct diagnosis and to treat the patient in the most correct way. Intestinal obstructions usually present with colic abdominal pain, nausea, vomiting, and constipation. Intestinal obstructions may be present due to various reasons. Surgeons have an important role in preventive mechanical obstructions due to adhesions. Patients must be hospitalized. If there is no emergency surgical indication, conservative methods can be applied. Patients should be mobilized early, and fluid-electrolyte balance should

Obstructions: Pre- and

Could it Be Prevented?

#### **Chapter 5**

## Surgical Recovery of Intestinal Obstructions: Pre- and Postoperative Care and How Could it Be Prevented?

*Burhan Hakan Kanat, Erhan Eröz, Atakan Saçli, Nizamettin Kutluer, Mehmet Gençtürk and Selim Sözen*

### **Abstract**

Although initial data on intestinal obstructions are based on Hippocrates, there is still no consensus on approaches today. However, parallel to the development of medical technology and the increasing experience of us surgeons, morbidity and mortality rates due to intestinal obstruction have decreased. Obstruction can occur at any point in the gastrointestinal tract. The main thing is to make a correct diagnosis and to treat the patient in the most correct way. Intestinal obstructions usually present with colic abdominal pain, nausea, vomiting, and constipation. Intestinal obstructions may be present due to various reasons. Surgeons have an important role in preventive mechanical obstructions due to adhesions. Patients must be hospitalized. If there is no emergency surgical indication, conservative methods can be applied. Patients should be mobilized early, and fluid-electrolyte balance should be adjusted and followed closely.

**Keywords:** intestinal obstructions, conservative methods, treatment

#### **1. Introduction**

Intestinal obstruction is a clinical manifestation that occurs since the passage of the intestinal contents, which should be into the distal levels, is prevented in any part of the passage. It is a condition frequently encountered in the emergency department, which gives positive results with early diagnosis and accurate treatment methods but may have negative consequences if it is not managed well. The patients usually present with the complaints of nausea and vomiting, colic abdominal pain, and inability to defecate. Intestinal obstruction accounts for 5–15% of the patients presenting to the emergency department with acute abdomen [1–3].

In parallel with the development of medical technology and the increasing experience of us, the surgeons, morbidity and mortality rates due to intestinal obstruction have decreased, but difficulties in diagnosis and treatment remain. Now, the cases may present with more complex conditions, and treatment may become more complicated. Nowadays, when minimally invasive and conservative methods are more popular, there is no doubt that nonoperative approach should be the preferred approach for intestinal obstruction. However, unfortunately, surgery should not

#### *Surgical Recovery*

be delayed, and appropriate intervention should be performed in the presence of a condition that requires absolute surgery in its etiology.

Obstruction can occur at any point in the gastrointestinal tract. Correct diagnosis and appropriate treatment of the patient is essential. Another important point, especially in surgical treatment, is to prevent brid formation which may cause re-obstruction. In addition, absolute oncological principles should be followed in obstructions caused by tumors, etc.

Intestinal obstructions can be due to very simple benign causes that need to be considered or malignant causes where no intervention apart from palliative surgical interventions can be performed [1–6]. Here, we will examine this entity with a wide clinical, treatment, and follow-up margin.

#### **2. Etiology**

Mechanical intestinal obstructions may be present due to various reasons. Etiology should be learned well to be able to determine the appropriate treatment option. The causes of intestinal obstruction can be broadly classified into three categories [3].

Intraluminal causes can be defined as factors causing obstruction by not allowing intestinal passage. These can be exemplified as gallstones, foreign bodies such as bezoar, and solidified ileal content.

Tumors of the small intestine, inflammatory small bowel diseases such as Crohn's disease, intramural hematoma, invagination, and stricture due to radiotherapy can be considered as intramural causes.

This part, which is classified as extrinsic factors, appears more than the sum of the other two parts. We know that adhesions secondary to previous abdominal surgery account for approximately 75% of small intestinal obstructions. In addition, we encounter with a considerable amount of hernias, congenital anomalies, and carcinomatosis due to intra-abdominal tumors [7, 8].

According to the mechanism of formation, there are also paralytic ileus, spastic ileus, and chronic intestinal pseudo-obstruction as well as mechanical intestinal obstruction. While paralytic ileus can be observed as a result of insufficient nerve conduction due to excessive analgesic use or electrolyte imbalance, spastic ileus occurs in cases of increased nerve conduction, such as metal poisoning [2, 7–9].

#### **3. Clinic**

Small intestinal obstructions usually present with colic abdominal pain, nausea, vomiting, and constipation. If obstruction is at proximal levels, vomiting is more prominent, while if it is at distal levels, abdominal distension is more prominent. Although intestinal sounds, by listening, may increase in the early period, they decrease in later periods. Strangulation or ischemia should be considered if there is severe abdominal pain that is not correlated with mild distention, and the diagnosis and treatment should be made without any delay [9].

**67**

**Figure 1.**

*Surgical Recovery of Intestinal Obstructions: Pre- and Postoperative Care and How Could it Be…*

Although it is known by the world of medicine that a good anamnesis is necessary for the diagnosis, it has been shown to be more important in the diagnosis of ileus. The presence of previous abdominal surgery and intra-abdominal disease (Crohn's disease, tumor, etc.) should be questioned in the anamnesis, and the inguinal region should be checked for hernias during the examination.

Plain abdominal radiography in the standing position should be first obtained for the radiological imaging of the patient. Plain radiography is an examination that has been used for about half a century. The radiograph should be checked for enlarged small intestinal loop and air-fluid level. If present, it should be noted whether this is from the small intestine or the large intestine (**Figures 1** and **2**). It should not be forgotten that obstructions proximal to the small intestine may be overlooked as they may not be able to produce air-fluid level on the radiograph. Nevertheless, it is still used as the cheapest, most practical, and easiest diagnostic

Abdominal ultrasonography is an option that may be beneficial in cases where direct radiography is contraindicated such as pregnancy, although it is not in the

Computed tomography has a sensitivity and specificity of approximately 80–90% in detecting small intestinal obstructions. Tomography may show the point causing small intestinal obstruction (transition zone), loss of diameter in large loops proximal to the transition zone and loops distal to the transition zone, and decompression in the colon due to lack of ileal content. Closed loop is visible, if present. Hematoma in the small intestinal wall, tumor, and invagination can also be observed if obstruction is due to an intramural cause. Gallstones, bezoars, and foreign bodies, which are among the intraluminal causes, can also be easily observed

*DOI: http://dx.doi.org/10.5772/intechopen.92748*

method in appropriate patients [3, 10, 11].

first place in practice [3, 12].

by computed tomography [10–12].

*Volvulus view on plain radiography (from the archive of Burhan Hakan Kanat).*

**4. Diagnosis**

*Surgical Recovery of Intestinal Obstructions: Pre- and Postoperative Care and How Could it Be… DOI: http://dx.doi.org/10.5772/intechopen.92748*

#### **4. Diagnosis**

*Surgical Recovery*

**2. Etiology**

categories [3].

1.Intraluminal

2.Intramural

3.Extrinsic factors

bezoar, and solidified ileal content.

therapy can be considered as intramural causes.

carcinomatosis due to intra-abdominal tumors [7, 8].

and treatment should be made without any delay [9].

be delayed, and appropriate intervention should be performed in the presence of a

Obstruction can occur at any point in the gastrointestinal tract. Correct diagnosis and appropriate treatment of the patient is essential. Another important point, especially in surgical treatment, is to prevent brid formation which may cause re-obstruction. In addition, absolute oncological principles should be followed in

Intestinal obstructions can be due to very simple benign causes that need to be considered or malignant causes where no intervention apart from palliative surgical interventions can be performed [1–6]. Here, we will examine this entity with a wide

Mechanical intestinal obstructions may be present due to various reasons. Etiology should be learned well to be able to determine the appropriate treatment option. The causes of intestinal obstruction can be broadly classified into three

Intraluminal causes can be defined as factors causing obstruction by not allowing intestinal passage. These can be exemplified as gallstones, foreign bodies such as

Tumors of the small intestine, inflammatory small bowel diseases such as Crohn's disease, intramural hematoma, invagination, and stricture due to radio-

This part, which is classified as extrinsic factors, appears more than the sum of the other two parts. We know that adhesions secondary to previous abdominal surgery account for approximately 75% of small intestinal obstructions. In addition, we encounter with a considerable amount of hernias, congenital anomalies, and

According to the mechanism of formation, there are also paralytic ileus, spastic ileus, and chronic intestinal pseudo-obstruction as well as mechanical intestinal obstruction. While paralytic ileus can be observed as a result of insufficient nerve conduction due to excessive analgesic use or electrolyte imbalance, spastic ileus occurs in cases of increased nerve conduction, such as metal poisoning [2, 7–9].

Small intestinal obstructions usually present with colic abdominal pain, nausea, vomiting, and constipation. If obstruction is at proximal levels, vomiting is more prominent, while if it is at distal levels, abdominal distension is more prominent. Although intestinal sounds, by listening, may increase in the early period, they decrease in later periods. Strangulation or ischemia should be considered if there is severe abdominal pain that is not correlated with mild distention, and the diagnosis

condition that requires absolute surgery in its etiology.

obstructions caused by tumors, etc.

clinical, treatment, and follow-up margin.

**66**

**3. Clinic**

Although it is known by the world of medicine that a good anamnesis is necessary for the diagnosis, it has been shown to be more important in the diagnosis of ileus. The presence of previous abdominal surgery and intra-abdominal disease (Crohn's disease, tumor, etc.) should be questioned in the anamnesis, and the inguinal region should be checked for hernias during the examination.