Multimodal perioperative management - Combining thoracic epidural analgesia, forced mobilization, and oral nutrition - Reduces hormonal and metabolicstress and improves convalescence after major urologic surgery

We sought in this prospective study to use a multimodal approach to reduce stress and improve recovery in patients undergoing major surgery. During an initial study period, 30 patients were randomly allocated to receive gener al anesthesia (GA; Group 1) or a combination of GA and intraoperative thora cic epidural analgesia (TEA; Group 2) when undergoing radical cystectomy. P arenteral nutrition was provided for 5 days after surgery. During the secon d period, 15 patients were treated with a multimodal approach (Group 3) con sisting of intraoperative GA and TEA, postoperative patient-controlled TEA, early oral nutrition, and enforced mobilization. Data for plasma and urine catecholamines, plasma cortisol, the nitrogen balance, the postoperative i nflammatory nutrition index, pain relief, fatigue, sleep, overnight recover y, recovery of bowel function, and mobilization were recorded up to the fif th postoperative day. Plasma concentrations of catecholamines and cortisol were comparable in all patients, but those in Group 3 had lower levels Of u rinary catecholamine excretion. Protein intake was more effective with pare nteral nutrition. Nitrogen balances were less negative, and the postoperati ve inflammatory nutrition index score increased significantly in the tradit ional groups but not in Group 3. Multimodally treated patients reported les s fatigue and better overnight recovery. Along with improved pain relief, r ecovery of bowel function, and ambulation, there were no differences in the postoperative complication rates among the three groups. The multimodal ap proach reduced stress and improved metabolism and recovery after radical cy stectomy.