Current Opinion in Obstetrics & Gynecology:
GYNECOLOGIC CANCER: Edited by Anne O. Rodriguez
Perioperative care in gynecologic oncology
Kushnir, Christina L.; Díaz-Montes, Teresa P.
The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Correspondence to Teresa P. Díaz-Montes, MD, MPH, The Kelly Gynecologic Oncology Service, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Phipps #281, Baltimore, MD 21287, USA. Tel: +1 410 955 8240; fax: +1 410 614 8718; e-mail: email@example.com
Purpose of review: To review perioperative care in gynecologic oncology with special emphasis on areas of controversy.
Recent findings: Major gynecologic surgery still represents the cornerstone of management among women diagnosed with gynecologic malignancies. The implementation of clinical guidelines can significantly impact perioperative morbidity and mortality. Preoperative evaluation and preparation allows the surgeon to identify patient risks and develop risk factor modification strategies decreasing delays in preparation and cost and improving patient safety. Preoperative areas of controversy include preoperative testing and evaluation, use of mechanical bowel preparation, prophylactic antibiotics, and use of anticoagulants, and the timing of postoperative feeding.
Summary: In healthy women undergoing gynecologic cancer surgery preoperative evaluation requirements will be minimal. For women with extensive comorbid conditions a more detailed evaluation will be required to decrease perioperative morbidity and mortality. Mechanical bowel preparations should not be required preoperatively. Preoperative administration of antibiotics and anticoagulants should be provided to all patients undergoing major gynecologic cancer surgery.
Approximately, 88 750 women will be diagnosed with a gynecologic malignancy and 29 520 will die in the United States during 2012 . The majority of those women will undergo surgery as management of their disease. Perioperative morbidity and mortality is a significant public health issue due to the impact on, not only the patient's short-term and long-term survival, but also the utilization of healthcare resources. Perioperative complications after major gynecologic surgery occur in 3.7–24% of patients [2▪,3,4,5]. Accurate risk assessment and stratification would facilitate informed patient consent, and identify those individuals who may benefit from specific perioperative interventions [6▪▪]. As radical surgery remains a cornerstone of therapy for gynecologic oncology, accepting and implementing clinical recommendations for perioperative management can significantly impact patient care, patient safety, and ultimately patient outcome .
PREOPERATIVE EVALUATION AND PREPARATION
The preoperative evaluation allows the gynecologic oncology surgeon to stratify patients’ risk, and risk factor modification. These measures will reduce delays in the preparation phase, enhance patient safety, recognize and treat complex medical problems, reduce evaluation costs, and minimize case delays and cancellations. Despite the inclination to ‘over assess’ the patient preoperatively with the thought of potentially diagnosing a silent disease, there is an overwhelming body of literature that suggests that the majority of preoperative testing is unnecessary . The likelihood of finding a meaningful abnormality is low, or that would change surgical management is extremely rare. Unnecessary preoperative testing is associated with undue stress and anxiety in patients prior to surgery, and is linked to a substantial cost burden on the healthcare system. It has been estimated that approximately US$ 3 billion per year is spent on preoperative laboratory testing alone . In the face of numerous sets of perioperative guidelines that have been developed over the years for clinicians, it appears that gynecologic surgeons have poor compliance with evidence-based recommendations for preoperative testing .
The preoperative evaluation includes a history and physical examination, review of clinic and hospital medical records, appropriate laboratory studies, electrocardiography with potential additional cardiopulmonary evaluation, and imaging studies . The purpose of the preoperative evaluation is to assess preexisting medical conditions and identify new conditions. Second, it allows for the surgeon to prepare accordingly for any issues that could potentially develop secondary to the patients’ medical condition. Lastly, the preoperative evaluation establishes a baseline to which later issues can be compared [8–10].
Patient age, disease diagnosis, procedure risk class, and prevalence of associated disease states, coupled with a careful and detailed history and physical examination, determine the need for specific preoperative testing. Johnson and Porter  define low-risk gynecologic procedures as those that include laparoscopic procedures not requiring hospital admission. These procedures carry a less than 1% combined morbidity and mortality. Intermediate-risk procedures include major intraperitoneal surgery with a cardiac risk of 1–5%. High-risk procedures are those surgeries that will be prolonged and involve large fluid shifts. Once the risk of the surgery has been estimated, the functional status of the patient is assessed by calculating the number of metabolic equivalents of task (METs) the patient is able to perform. A MET is a unit equal to the metabolic equivalent of oxygen uptake while seated. Four METs has been defined as a normal level of activity and functional status, which is equivalent to walking on a flat surface, or climbing a flight of stairs. If a patient can perform four METs of activity or more without shortness of breath, chest pain, or fatigue, the physician and patient can move forward with intermediate-risk surgery without further testing. However, if the patient's functional status is less than four, she will require further evaluation prior to surgery.
St. Clair et al. retrospectively reviewed the compliance of physicians in using evidence-based guidelines in requesting preoperative testing in women undergoing gynecologic surgery. The guidelines used were developed by the National Institute for Health and Clinical Excellence (NICE)  in 2003 for the use of routine preoperative tests in elective surgery. The NICE criteria were used as the standard for which tests were determined to be indicated or not. The guidelines use the patient's age, type of surgery, comorbidities, and American Society of Anesthesiologists grade for anesthetic risk to determine if testing is indicated. In this study, 95% were found to have had testing that was in accordance with the guidelines. Ninety percent of the patients had at least one preoperative test that was not indicated. Of the chest radiographs that were ordered, 99% were ordered without an indication. St. Clair et al. estimated that more than US$ 418 000.00 in direct costs was spent secondary to inappropriately ordered perioperative tests. Additionally, of the inappropriate tests ordered, the abnormalities that were found rarely led to a change in management or a delay in surgery.
Normal healthy women undergoing minor procedures may be seen by both the surgeon and anesthesia personnel on the day of surgery in the preoperative holding area. However, women with significant medical conditions should be seen at least 1 week before surgery to allow time for risk assessment, specialty consultation, and patient preparation. Many medical conditions can change or occur within a few weeks, days, or hours after the preoperative evaluation. These complicated patients and their conditions require additional evaluation or treatment before surgery is performed.
PREOPERATIVE BOWEL PREPARATION
In 1887, Sir William Halsted proposed the use of mechanical bowel preparation (MBP) to decrease infectious complications and anastomotic breakdown in elective colorectal surgery, and has since been the surgical dogma despite this practice not being based on evidence-based medicine [12,13▪▪].
In minimally invasive surgery (laparoscopic and robotic), gynecologic surgeons routinely use MBP based on the arguments that visualization is improved, the procedure is easier to perform, to decrease peritoneal contamination if bowel injury occurs, and to facilitate handling of the bowel itself [14▪,15▪,16,17▪,18]. Although the literature available specifically discussing MBP and endoscopic surgery is scant, those studies that do exist have not found that MBP improves endoscopic outcomes [14▪,15▪,16,17▪,18].
Guenaga et al. reviewed 13 prospective randomized trials of patients who underwent large bowel resection. The rate of anastomotic leak in the patients who underwent preoperative MBP was 4% as compared with 3% in those patients who did not have a bowel preparation (P = 0.15). There was no difference in wound infection rates among groups (P = 0.09). The authors concluded that the recommendation to routinely use preoperative MBP should be revisited.
Seven trials [20–26] evaluated the clinical benefit and the use of different types of MBP, as compared with those who did not undergo MBP. All seven failed to detect a benefit. A meta-analysis of these studies conducted by Slim et al. found more anastomotic leakages after MBP than those who did not undergo MBP (5.6 versus 3.2%, P = 0.03). Wound infections, septic and nonseptic complications were not statistically different between those who did and did not have MBP prior to surgery.
Recently, Wells et al.[14▪] reviewed practice patterns of gynecologic oncologists belonging to the Society of Gynecologic Oncologists of Canada, reviewed the literature about MBP use in gynecologic oncology, and form recommendations specific to gynecologic oncology. Of those that participated, 48% ordered bowel preparation despite acknowledging that the literature does not support this practice. MBP was used for all cancer sites, but was most commonly ordered in ovarian and endometrial cancer procedures (53 and 32%, respectively). The most common reasons for using MBP was to decrease risk of anastomotic leak, and to improve visualization. As a direct result of this study, the use of MBP over the last 5 years decreased in 77% of those who participated. The use of MBP demonstrated statistically higher rates of nausea, vomiting, weakness, abdominal distension, insomnia, and overall discomfort. It was suggested that MBP was associated with an increased incidence of urinary tract infections and Clostridium difficile colitis. The authors concluded that first, MBP should not be recommended for gynecologic oncology surgery even if bowel surgery might be a possibility. Second, a diverting colostomy is not necessary for unplanned bowel surgery, or unintentional bowel injury. Third, the use of oral and/or rectal MBP should be ordered with caution because their use is not benign.
USE OF PREOPERATIVE ANTIBIOTICS
Preoperative antibiotics are used to eradicate or retard the growth of endogenous microorganisms that may case surgical site infection (SSI). Postoperative complications, including wound, vaginal cuff, and urinary tract infections are common after hysterectomy [28▪]. The infection rate after abdominal hysterectomy has been reported to be 15–24% without the use of antibiotics. With the use of antibiotic prophylaxis the rate of infection has decreased to 10–11% [29▪▪]. SSI accounts for approximately 500 000 infections annually [30▪]. This accounts for nearly 4 million excess hospital days per year, and US$ 2 billion in increased healthcare costs. Risk factors for developing SSI are advanced age, comorbidities, preexisting infections, change in vaginal flora (bacterial vaginosis), extensive surgery, excessive blood loss (greater than 1000cc), and use of drains and catheters . The Institute for Healthcare Improvement (IHI) estimated that misuse, overuse, under use, and improper timing of antibiotics occurs in 25–50% of operations in the United States .
Van Eyk et al.[31▪▪] performed a literature search of published articles found in Medline and the Cochrane library between 1978 and 2011 on the topic of antibiotic prophylaxis in gynecologic surgery to evaluate the necessity and effectiveness of antibiotics in preventing infections in gynecologic procedures. They concluded that all women undergoing abdominal hysterectomy should receive antibiotic prophylaxis 15–60 min prior to the skin incision. The first-line antibiotics for hysterectomy are cephalosporins (cefazolin 1 or 2 g, cefoxitin 1 to 2 g, cefotetan 1 to 2 g). Phoolcharoen et al.[29▪▪] compared ceftriaxone with cefazolin for antibiotic prophylaxis in abdominal hysterectomy. The overall incidence of infection after total abdominal hysterectomy was 13.8%. No difference in infection rates was noted between the two antibiotics. In gynecologic oncology cases wherein bowel surgery is anticipated cefoxitn or cefotetan should be used. For patients that are allergic to β-lactams options include: clindamycin with ciprofloxaxin, levofloxacin, or aztreonam is a reasonable option. A single dose of antibiotic is all that is necessary. In situations of excessive blood loss (>1500 cc), or in procedures with a duration greater than 3 h, an additional dose of antibiotic is needed. Additionally, in those patients with class II obesity (>35 kg/m2) it is reasonable to consider doubling the dose of antibiotic. There is no need to continue prophylaxis postoperatively, as they do not confer additional benefit.
PREVENTION OF VENOUS THROMBOEMBOLISM
Venous thromboembolism (VTE) has been deemed the number one preventable complication by the Agency for Healthcare Research and Quality. According to the Centers for Disease Control and Prevention, there are between 200 000 and 400 000 cases of deep vein thrombosis (DVT) diagnosed per year in the United States [32▪]. Without DVT prophylaxis, approximately 38% of gynecologic oncology patients would develop a thrombotic event. With prophylaxis, up to 15% of gynecologic cancer patients still develop DVTs [32▪,33▪▪,34▪]. As it stands, the overall risk of DVT in patients undergoing gynecologic surgery is 7–45%, with 1% of these patients dying from a pulmonary embolism [7,33▪▪,35]. The presence of malignancy creates almost a four-fold increase in the incidence of VTE following gynecologic surgery [35,36▪]. Risk factors for developing thrombosis include the malignancy itself, old age, prolonged postoperative immobilization, previous history of DVT, central venous catheter, vascular compression by a pelvic mass, chemotherapy, previous radiation therapy, vascular injury, operative time more than 3 h, obesity, and the type of cancer and stage of disease [7,32▪,34▪,36▪].
The American Society of Clinical Oncology considers any cancer patient that is having major surgery, defined as laparotomy, laparoscopy, or thoracotomy lasting longer than 30 min, at high risk for the development of VTE . Furthermore, those patients with cancer who are hospitalized are candidates for prophylaxis with anticoagulation. Routine prophylaxis with anticoagulation for ambulatory cancer patients is not recommended at this time . The risk of VTE after minimally invasive surgery is uncertain. Some studies have reported no VTE after laparoscopic procedures [34▪].
All cancer patients undergoing major surgery should receive some form of anticoagulation unless contraindicated. Pharmacologic therapy should be started preoperatively, 2 h prior to surgery [32▪,34▪] or as early in the postoperative period as possible, 6–8 h after the procedure [32▪,34▪], and continued for 7–10 days in low-risk patients, and up to 4 weeks in high-risk patients (age 60 years and older, those with residual cancer, those with a history of DVT, or obese patients) [7,33▪▪,35,36▪]. Extended prophylaxis is recommended because it has been found to have a 60% relative-risk reduction, and a 7.2% absolute-risk reduction in those patients undergoing laparotomy . In those patients in whom a VTE is diagnosed prior to surgery, the decision to anticoagulate and to proceed with surgery is a difficult decision. In these patients, it is reasonable to consider placement of an inferior vena cava filter prior to surgery to protect the renal and pulmonary vasculature. Anticoagulation is still recommended in the perioperative period in these patients as with all cancer patients [7,38▪].
Whitworth et al.[32▪] performed a multiinstitutional chart review of gynecologic oncology patients who underwent preoperative, double prophylaxis with sequential compression devices (SCD) and thromboprophylaxis for DVT prior to laparotomy. There was a statistically significant difference in DVT incidence in the dual prophylaxis group as compared with the mechanical prophylaxis only group. There were fewer DVT-attributable deaths in the dual prophylaxis group than the mechanical prophylaxis group alone (P < 0.001). There was no statistical difference in postoperative hematocrit and number of blood transfusions between the groups. The authors concluded that preoperative use of anticoagulation decreases the incidence of DVTs in this population, and decreases the number of DVT-attributable deaths. Furthermore, the addition of anticoagulation prior to radical gynecologic surgery does not increase the patients’ risk for hemorrhage.
TIMING OF POSTOPERATIVE ORAL FEEDING
Early oral feeding (EOF) is defined as resumption of solid meals prior to postoperative resumption of intestinal activity [7,39,40]. EOF has resulted in decreased length of stay, increased patient satisfaction, a reduction in infective postoperative complications , faster resolution of postoperative ileus, and an earlier first passage of stool . There was no statistical difference found between EOF and traditional feeding as it pertains to nausea and vomiting. EOF should be initiated in the routine postoperative care of gynecologic cancer patients, even those who underwent radical cytoreductive surgery .
Satisfactory perioperative management is crucial to decrease patient distress and improve patient safety and the quality of life of women with gynecologic cancer who are undergoing surgery. A growing body of literature suggests that adherence to evidence-based guidelines for perioperative testing and management by gynecologic oncologists is poor. As radical surgery remains a cornerstone of therapy for gynecologic oncology, accepting and implementing clinical recommendations for perioperative management can significantly impact patient care, significantly decrease healthcare costs, and ultimately improve patient outcome. More research is needed to evaluate areas of decreased compliance with guidelines in order to develop strategies to improve adherence to evidence-based medicine practices.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 83–84).
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antibiotic prophylaxis; deep venous thrombosis prophylaxis; gynecologic cancer surgery; mechanical bowel preparation; perioperative care
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