Enhanced Recovery After Surgery Protocols in Functional Endoscopic Sinus Surgery for Patients With Chronic Rhinosinusitis With Nasal Polyps: A Randomized Clinical Trial
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory condition characterized by persistent nasal congestion, headache, hyposmia, and rhinorrhea. Functional endoscopic sinus surgery (FESS) remains the primary intervention when conservative treatments fail. However, traditional perioperative practices often involve prolonged fasting, delayed mobilization, and inadequate pain management, contributing to patient discomfort, systemic stress, and extended hospitalization. Enhanced recovery after surgery (ERAS) protocols, initially developed for colorectal and major surgical procedures, aim to minimize physiological stress, accelerate recovery, and improve outcomes through evidence-based perioperative interventions. This study evaluates the implementation of ERAS protocols in FESS for CRSwNP, focusing on psychological well-being, postoperative pain, inflammation, sleep quality, hospitalization metrics, and safety.
Study Design and Methodology
A single-center randomized clinical trial enrolled 102 CRSwNP patients scheduled for FESS between January and April 2018. Participants were stratified into ERAS (n=52) and control (n=50) groups using a random number table. The ERAS protocol integrated multidisciplinary strategies across preoperative, intraoperative, and postoperative phases:
Preoperative Phase
- Patient Education: Detailed counseling on ERAS components to alleviate anxiety.
- Fasting and Carbohydrate Loading: Solid fasting for 8 hours and fluid fasting for 2 hours preoperatively, followed by a 300 mL carbohydrate drink (Outfast®) 2 hours before surgery.
- Preemptive Analgesia: Oral loxoprofen (80 mg) administered the night before surgery.
Intraoperative Phase
- Anesthesia Management: Short-acting sedatives (e.g., propofol) and opioids (e.g., remifentanil) combined with nasal mucosal anesthesia (tetracaine and lidocaine).
- Hemostasis and Fluid Management: Degradable nasal packing (Nasopore®) and restricted crystalloid infusion to maintain euvolemia.
- Thermoregulation: Active warming to prevent intraoperative hypothermia (<36°C).
Postoperative Phase
- Early Mobilization and Nutrition: Out-of-bed activities and oral intake resumed 2 hours postoperatively.
- Multimodal Analgesia: Intravenous flurbiprofen axetil (50 mg) at 2 and 12 hours post-surgery.
- Discharge Criteria: Resumption of regular diet, completion of nasal cavity cleaning, absence of complications, and independent mobility.
The control group adhered to traditional protocols: prolonged fasting (≥8 hours), delayed postoperative feeding (6 hours), non-degradable nasal packing (Merocel®), and reactive pain management.
Outcomes and Key Findings
Psychological Well-Being
The Self-Rating Anxiety Scale (SAS) assessed preoperative anxiety, with scores ≤35 indicating mild anxiety. The ERAS group demonstrated significantly lower SAS scores (28 [24, 35]) compared to controls (43 [42, 47]; Z = 5.968, P < 0.001), highlighting reduced psychological stress through targeted counseling and ERAS education.
Postoperative Pain Management
Pain severity was quantified using a 10-point Visual Analogue Scale (VAS). ERAS patients reported markedly lower rhinalgia and headache scores:
- Rhinalgia: 1 (0–1) vs. 3 (3–4) at 2 hours; 1 (0–1) vs. 2 (2–3) at 24 hours; 0 (0–1) vs. 2 (1–2) at 48 hours (P < 0.001 for all).
- Headache: 1 (0–1) vs. 2 (2–3) at 2 hours; 1 (0–1) vs. 2 (1–2) at 24 hours; 0 (0–1) vs. 1 (1–2) at 48 hours (P < 0.001 for all).
Preemptive NSAIDs and localized anesthesia minimized nociceptive stimuli, enabling early mobilization without compromising recovery.
Sleep Quality and Comfort
The Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba General Comfort Questionnaire (GCQ) evaluated postoperative recovery. ERAS patients achieved superior MOS-SS scores (43 [42, 49] vs. 28 [22, 35]; Z = 7.071, P < 0.001) and higher GCQ scores (76 [68, 87] vs. 64 [50, 75]; Z = 4.806, P < 0.001), reflecting enhanced sleep continuity and overall comfort.
Systemic Inflammation
Serum C-reactive protein (CRP), a biomarker of surgical stress, showed no preoperative intergroup difference (ERAS: 1.3 mg/L [0.6–2.8] vs. control: 0.5 mg/L [0.5–1.2]; P > 0.05). At 24 hours postoperatively, CRP levels in the ERAS group (2.5 mg/L [1.4–3.9]) were significantly lower than controls (6.6 mg/L [3.8–9.0]; Z = 5.027, P < 0.001), underscoring ERAS-driven attenuation of inflammatory responses.
Hospitalization Metrics and Safety
ERAS implementation reduced median hospital stay by 3 days (5 [4–5] vs. 8 [8–9]; Z = 8.939, P < 0.001) and lowered costs by $459 (ERAS: $2,670 [2,375–2,740] vs. control: $3,129 [3,116–3,456]; Z = 8.514, P < 0.001). Complication rates, including nausea/emesis (2 vs. 2 cases), hemorrhage (0 vs. 0), and aspiration (0 vs. 0), were comparable (P > 0.05), affirming ERAS safety.
Mechanistic Insights and Clinical Implications
ERAS protocols synergize multimodal strategies to counteract surgical stress. Preoperative carbohydrate loading preserves metabolic homeostasis, mitigating insulin resistance and catabolism. NSAID-based preemptive analgesia dampens cyclooxygenase-2 activity, reducing prostaglandin-mediated hyperalgesia. Early enteral nutrition and mobilization counter postoperative ileus and muscle atrophy, while targeted fluid therapy avoids volume overload, a known trigger for endothelial dysfunction.
In CRSwNP, FESS-induced mucosal trauma activates pro-inflammatory cytokines (e.g., IL-6, TNF-α), amplifying systemic CRP. ERAS-mediated reductions in CRP correlate with attenuated stress responses, possibly via optimized pain control and minimized tissue injury. Shorter hospitalization aligns with ERAS principles of accelerated convalescence, reducing nosocomial infection risks and healthcare burdens.
Limitations and Future Directions
While this trial demonstrates ERAS feasibility in FESS, limitations include single-center design and absence of long-term follow-up. Future studies should assess polyp recurrence rates, olfaction recovery, and quality-of-life metrics beyond the perioperative period. Multicenter validation and cost-effectiveness analyses are warranted to generalize findings.
Conclusion
ERAS protocols significantly enhance recovery in CRSwNP patients undergoing FESS by alleviating preoperative anxiety, reducing postoperative pain and inflammation, improving sleep quality, and shortening hospitalization without elevating complication risks. This paradigm shift from traditional care underscores ERAS adaptability across surgical disciplines, offering a patient-centered framework for sinonasal surgery optimization.
doi.org/10.1097/CM9.0000000000000060
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