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Perioperative- post op- reduces post operative complications and length of hospital stay

Reducing post-operative complications and length of hospital stay 

Thoracic Surgery

ERAS programs have been well established in specialities such as colorectal surgery, and a meta-analysis of 38 studies – many based in colorectal surgery – found ERAS pathways to be effective in reducing hospital LOS and post-operative complication rates (3). The positive impact of ERAS on such clinical outcomes in thoracic surgery has been more recently recognised (4-7).

Although ERAS protocols consist of many elements, early mobilisation is an integral aspect. Bed rest can lead to reduced muscle mass, physical deconditioning, increased risk of VTE and possible respiratory complications such as pneumonia (3). Two systematic reviews failed to demonstrate any post-operative benefit from early mobilisation following thoracic surgery (8-9). However, the quality of the studies included were poor and treatment protocols varied widely precluding comparison.

A prospective cohort study addressed the impact of a standardised, 15-element ERAS protocol on 30-day morbidity and length of stay in 422 patients undergoing lung resection for primary lung cancer between 2012 and 2014. While increased adherence to the ERAS pathway leads to improved clinical outcomes after surgery, early mobilisation was one of only two protocol elements that were predictive of reduced morbidity or LOS (4).*

In their aim to standardise peri-operative care, the Enhanced Recovery after Surgery Society and the European Society for Thoracic surgery conducted a systematic review of meta-analyses, randomised controlled trials, large non-randomised studies and reviews for each element of the ERAS protocol. Although there is a need for further evidence, early mobilisation is strongly recommended in their consensus document (3).

A systematic review and meta-analysis of the effects of early mobilisation therapy on post-operative outcomes in cardiac surgery is currently being conducted (10). A previous similar systematic review of 9 trials concluded that avoiding bed rest and early mobilisation is integral to preventing post-operative complications and reducing LOS (11). This particular study did not include a meta-analysis however.

Quality of Evidence:

Grade B (Moderate quality). Combination of systematic reviews and cohort studies. 

Strength of Recommendation:

Grade 2. Weak recommendation.


There is sufficient evidence that early mobilisation in the post-operative period can improve surgical outcomes.

*Minor morbidity was defined as the occurrence of a Clavien-Dindo grade I or II complication, and major morbidity was defined as the occurrence of a grade III or IV complication.


1.         Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-8.

2.         Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019;154(8):755-66.

3.         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). Eur J Cardiothorac Surg. 2019;55(1):91-115.

4.         Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ, et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155(4):1843-52.

5.         Medbery RL, Fernandez FG, Khullar OV. ERAS and patient reported outcomes in thoracic surgery: a review of current data. J Thorac Dis. 2019;11(Suppl 7):S976-s86.

6.         Li S, Zhou K, Che G, Yang M, Su J, Shen C, et al. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res. 2017;9:657-70.

7.         Khandhar SJ, Schatz CL, Collins DT, Graling PR, Rosner CM, Mahajan AK, et al. Thoracic enhanced recovery with ambulation after surgery: a 6-year experience. Eur J Cardiothorac Surg. 2018;53(6):1192-8.

8.         Castelino T, Fiore JF, Jr., Niculiseanu P, Landry T, Augustin B, Feldman LS. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Surgery. 2016;159(4):991-1003.

9.         Mainini C, Rebelo PF, Bardelli R, Kopliku B, Tenconi S, Costi S, et al. Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence? SAGE Open Med. 2016;4:2050312116673855.

10.       Chen B, You X, Lin Y, Dong D, Xie X, Zheng X, et al. A systematic review and meta-analysis of the effects of early mobilization therapy in patients after cardiac surgery: A protocol for systematic review. Medicine (Baltimore). 2020;99(4):e18843.

11.       Ramos Dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon Suster É, de Moraes Paisani D, Dias Chiavegato L. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103(1):1-12.

12.       Chang NW, Lin KC, Lee SC, Chan JY, Lee YH, Wang KY. Effects of an early postoperative walking exercise programme on health status in lung cancer patients recovering from lung lobectomy. J Clin Nurs. 2014;23(23-24):3391-402.

13.       Messaggi-Sartor M, Marco E, Martínez-Téllez E, Rodriguez-Fuster A, Palomares C, Chiarella S, et al. Combined aerobic exercise and high-intensity respiratory muscle training in patients surgically treated for non-small cell lung cancer: a pilot randomized clinical trial. Eur J Phys Rehabil Med. 2019;55(1):113-22.

14.       Cavalheri V, Burtin C, Formico VR, Nonoyama ML, Jenkins S, Spruit MA, et al. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2019;6(6):Cd009955.

GI surgery

Reducing post-operative complications and length of hospital stay 

There has been a paradigm shift in the peri-operative care of surgical patients with the development of Enhanced Recovery After Surgery (ERAS) evidence-based programs (1).  ERAS, a multimodal, multidisciplinary approach to the care of the surgical patient, emphasises the importance of early mobilisation and has become well established in specialities such as colorectal surgery (2).

There is an abundance of evidence to suggest that ERAS pathways reduce length of hospital stay and complications after major elective open colorectal surgery without compromising patient safety. However, many of the RCTs included in meta-analyses do not directly look at the impact of early mobilisation, but rather ERAS as a whole – of which early mobilisation if one of many elements (2).

Similarly, 12 out of 13 RCTs evaluating the effect of an ERAS program in laparoscopic colorectal cancer surgery compared with traditional perioperative care (TC) revealed shorter post-operative length of stays in the ERAS groups (p=0.00) (3). All of the studies in the meta-analysis assessed complication rates as a primary outcome; postoperative complications occurred in 17.84% of ERAS patients, compared to 27.01% of TC patients (p<0.01) (3). Although the quality of evidence is high, it is difficult to assess the strength of recommendation for early post-operative exercise/mobilisation as the benefits of early mobilisation alone cannot be established. Interestingly, levels of IL-6 and CRP on post-operative days 1,3 and 5, were lower than in the TC group.

There are many similar examples in the literature (4-7).

Gat et al., conducted an RCT where 39 patients awaiting colorectal surgery were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. Part of this optimization package included an aggressive structured mobilisation plan (4). Optimization decreased the length of hospital stay without any measurable increase in morbidity or mortality. With regards to safety, review at 1 month after surgery revealed no increase in complication or re-admission rates associated with optimization, and patients in the optimized group did not require more visits to the GP (4).

A prospective cohort study looking at the effects of different adherence levels to ERAS pathways and the effect of various ERAS elements on outcomes following major colorectal surgery in 953 patients was conducted by Gustafsson et al. (5). Early mobilisation – one of the key elements – was defined as spending more than 6 hours out of bed after the first day of surgery. Those patients with a high adherence to the ERAS protocol had a 25% lower risk of postoperative complications and a nearly 50% lower risk of postoperative symptoms delaying discharge. Almost all of the individual ERAS elements had a positive outcome on surgical outcomes (including early mobilisation), however there was no statistical significance in multivariate analyses adjusting for confounding (5).

However, a multivariate analysis of specific ERAS elements identified that early mobilisation of patients was independently associated with a significant decrease in moderate to severe post-operative complications in a moderate quality multi-centre, prospective cohort study of 2084 adults undergoing elective colorectal surgery with or without ERAS protocols (8). 20% of patients undergoing early mobilisation post-operatively experienced moderate to severe complications compared to 32.52% of those that did not (p=0.01). Complications were defined and graded as mild, moderate, and severe based upon the European Perioperative Clinical Outcome definitions (8).

A handful of mixed-quality papers focussing solely on the impact of exercise post-gastrointestinal surgery were identified (9-12).

Ahn et al., conducted an RCT looking at the effectiveness of a twice-daily 15 min supervised exercise programme in 31 patients undergoing colectomy for stage I-III colon cancer performed until discharge from hospital (9). They found that the mean length of hospital stay was 7.82±1.07 days in the exercise group, compared with 9.86±2.66 days in the control group (p=0.005). The group concluded that an inpatient exercise programme including stretching, core, balance, and low-intensity resistance exercises significantly reduced the length of hospital stay (9). A moderate quality prospective RCT comparing a traditional post-operative programme to a controlled rehabilitation with early ambulation and diet after laparotomy and intestinal resection in 64 patients identified that the length of hospital stay was significantly reduced (p=0.02) in the group that had early ambulation (10).

A moderate to high quality prospective case control study revealed a 50% reduction in the rate of postoperative respiratory tract infection (RTI) and postoperative hospital stay after complex abdominal surgery in patients undergoing early aerobic exercise with a pedal exerciser (11). The pedal exerciser was implemented on day 2 post-op or whenever the patient was able to sit independently – whichever came first (11).

Quality of Evidence:

Grade A-B (moderate to high quality): Combination of meta-analyses, RCTs, and observational studies.

Strength of Recommendation:

Grade 1: Strong recommendation


There is high quality evidence supporting the use of ERAS pathways to improve post-operative outcomes. Evidence that early mobilisation of patients is independently associated with reduced post-operative complications and length of hospital stay cannot often be established. However, there is sufficient evidence that early mobilisation and supervised exercise post-operatively can have significant benefits without an increased risk of adverse effects.


1.         Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-8.

2.         Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434-40.

3.         Ni X, Jia D, Chen Y, Wang L, Suo J. Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg. 2019;23(7):1502-12.

4.         Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg. 2005;92(11):1354-62.

5.         Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146(5):571-7.

6.         Raue W, Haase O, Junghans T, Scharfenberg M, Müller JM, Schwenk W. ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc. 2004;18(10):1463-8.

7.         Baird G, Maxson P, Wrobleski D, Luna BS. Fast-track colorectal surgery program reduces hospital length of stay. Clin Nurse Spec. 2010;24(4):202-8.

8.         Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, Aldecoa C, Abad-Motos A, Logroño-Egea M, et al. 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 Surg. 2019;154(8):725-36.

9.         Ahn KY, Hur H, Kim DH, Min J, Jeong DH, Chu SH, et al. The effects of inpatient exercise therapy on the length of hospital stay in stages I-III colon cancer patients: randomized controlled trial. Int J Colorectal Dis. 2013;28(5):643-51.

10.       Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum. 2003;46(7):851-9.

11.       Bhatt NR, Sheridan G, Connolly M, Kelly S, Gillis A, Conlon KC, et al. Postoperative exercise training is associated with reduced respiratory infection rates and early discharge: A case-control study. Surgeon. 2017;15(3):139-46.

12.       Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother. 2007;53(1):47-52.

13.       de Almeida EPM, de Almeida JP, Landoni G, Galas F, Fukushima JT, Fominskiy E, et al. Early mobilization programme improves functional capacity after major abdominal cancer surgery: a randomized controlled trial. Br J Anaesth. 2017;119(5):900-7.

14.       Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ. Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum. 2011;54(1):21-8.

15.       Le H, Khankhanian P, Joshi N, Maa J, Crevensten H. Patients recovering from abdominal surgery who walked with volunteers had improved postoperative recovery profiles during their hospitalization. World J Surg. 2014;38(8):1961-5.

16.       van Zutphen M, Winkels RM, van Duijnhoven FJ, van Harten-Gerritsen SA, Kok DE, van Duijvendijk P, et al. An increase in physical activity after colorectal cancer surgery is associated with improved recovery of physical functioning: a prospective cohort study. BMC Cancer. 2017;17(1):74.

17.       Mascherini G, Ringressi MN, Castizo-Olier J, Badicu G, Irurtia A, Stefani L, et al. Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial. Medicina (Kaunas). 2020;56(2).

Orthopaedic Surgery

Reducing length of stay

Masaracchio et al., conducted a systematic review with meta-analysis of the literature to assess the effect of early rehabilitation on length of stay in patients undergoing hip or knee joint arthroplasty (1). The group identified 17 suitable studies (4 RCTs, 1 quasi-experimental study, 1 cost-effectiveness study, 6 prospective cohort studies and 5 retrospective cohort studies) with a total of 26,614 patients. Early rehabiitation was defined as commencing on either the day of surgery, or day one post-op while standard rehabilitation was defined as commencing day one or day two post-op. One of the included studies implemented delayed rehabilitation which was defined as commencing two weeks after surgery.  Early therapy was found to decrease the LOS (statistically significant) in 10 of the studies, including the 4 RCTs, with no evidence for increased post-operative complications compared to standard care (1).

These results are consistent with an earlier systematic review of 5 RCTs (2). Early mobilisation (sitting out of bed/walking within 24 hours) was found to reduce LOS by 1.8 days in 622 participants following hip or knee joint replacement without an increase in negative outcomes.

Quality of Evidence:

Grade B (moderate quality): Majority of the studies included in Masaracchio et al., were non-randomised clinical trials. Moreover, there was a lack of consistency across studies in terms of dose or type of intervention.

Strength of Recommendation:

Grade 2: Weak recommendation.


There is sufficient evidence to suggest that patients undergoing hip or knee arthroplasty could benefit from early post-operative exercise. Further evidence with standardised methodology is required to more accurately assess whether there is a superior intervention/exercise modality.


1.         Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS One. 2017;12(6):e0178295.

2.         Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844-54.

3.         Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-92.

4.         Sattler LN, Hing WA, Vertullo CJ. What is the evidence to support early supervised exercise therapy after primary total knee replacement? A systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):42.

5.         NIH Consensus Statement on total knee replacement December 8-10, 2003. J Bone Joint Surg Am. 2004;86(6):1328-35.

6.         Petterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstab A, Newcomb W, et al. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum. 2009;61(2):174-83.

7.         Bade MJ, Stevens-Lapsley JE. Early high-intensity rehabilitation following total knee arthroplasty improves outcomes. J Orthop Sports Phys Ther. 2011;41(12):932-41.

8.         Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005;35(7):424-36.

9.         Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord. 2015;16:15.

10.       Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physiother. 2013;59(4):219-26.