Advance in diagnosis & treatment of cancers has led to high cure rate & longer survival.
Nearly 1 in 12 cases detected before 40 years age.
Survivors have to face infertility or early menopause.
Advance in diagnosis & treatment of cancers has led to high cure rate & longer survival.
Nearly 1 in 12 cases detected before 40 years age.
Survivors have to face infertility or early menopause.
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
SHARE Presentation: Having Children after Cancerbkling
Dr. Diana Chavkin, Reproductive Endocrinology and Infertility (REI) specialist at Genesis Fertility and Reproductive Medicine, made this presentation at SHARE about fertility preservation options before and after cancer treatment.
If you'd like to hear the audio, visit www.sharecancersupport.org/chavkin
The information in this presentation is not intended to be a substitute for professional medical advice, diagnosis or treatment. The presentation was given on May 15, 2014.
Poly-ADP-ribose polymerase inhibitors (PARPis) are the most active and interesting therapies approved for the treatment of epithelial ovarian cancer. They have changed the clinical management of a disease characterized, in almost half of cases, by extreme genetic complexity and alteration of DNA damage repair pathways, particularly homologous recombination (HR) deficiency. It is causing a paradigm shift in the first-line treatment of patients with advanced ovarian cancer
Fertility preservation in Cancer patientsArunSharma10
The need for fertility preservation
Chemotherapeutic drugs according to gonadotoxicity level
Fertility preservation: subject of continuous review by experts
Non-oncological conditions requiring fertility preservation
Delayed childbearing
AVAILABLE PROCEDURES FOR FP
Embryo and oocyte cryopreservation
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
In gynecologic cancers, fertility preservation strategies include fertility-sparing surgical approaches and assisted reproductive technologies (ART). Fertility preservation can be considered in women with early stage I epithelial ovarian cancer and most borderline tumors, stages I–III
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface MalignanciesMary Ondinee Manalo Igot
The prognosis of most peritoneal surface malignancies were previously dismal. However, with the incorporation of HIPEC to standard of care, we have been seeing doubling of survival for select malignancies. Appropriate patient selection is crucial.
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
SHARE Presentation: Having Children after Cancerbkling
Dr. Diana Chavkin, Reproductive Endocrinology and Infertility (REI) specialist at Genesis Fertility and Reproductive Medicine, made this presentation at SHARE about fertility preservation options before and after cancer treatment.
If you'd like to hear the audio, visit www.sharecancersupport.org/chavkin
The information in this presentation is not intended to be a substitute for professional medical advice, diagnosis or treatment. The presentation was given on May 15, 2014.
Poly-ADP-ribose polymerase inhibitors (PARPis) are the most active and interesting therapies approved for the treatment of epithelial ovarian cancer. They have changed the clinical management of a disease characterized, in almost half of cases, by extreme genetic complexity and alteration of DNA damage repair pathways, particularly homologous recombination (HR) deficiency. It is causing a paradigm shift in the first-line treatment of patients with advanced ovarian cancer
Fertility preservation in Cancer patientsArunSharma10
The need for fertility preservation
Chemotherapeutic drugs according to gonadotoxicity level
Fertility preservation: subject of continuous review by experts
Non-oncological conditions requiring fertility preservation
Delayed childbearing
AVAILABLE PROCEDURES FOR FP
Embryo and oocyte cryopreservation
Enhanced Recovery after Surgery its relevance - Evidence BasedDeep Goel
Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery
In gynecologic cancers, fertility preservation strategies include fertility-sparing surgical approaches and assisted reproductive technologies (ART). Fertility preservation can be considered in women with early stage I epithelial ovarian cancer and most borderline tumors, stages I–III
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Enhanced recovery care pathways: a better journey for patients seven days a week and a better deal for the NHS - presentation from the Health and Care Innovation Expo 2014 - Sue Cottle, Amy Kerr and Neil Betteridge
Contents lists available at ScienceDirectApplied Nursing RAlleneMcclendon878
Contents lists available at ScienceDirect
Applied Nursing Research
journal homepage: www.elsevier.com/locate/apnr
Original article
Optimize patient outcomes among females undergoing gynecological
surgery: A randomized controlled trial
Kari Johnson (PhD, RN, ACNS-BC, Hartford Scholar)⁎, Sherry Razo (M.A.-L., BSN, RN, NEA-BC),
Jeannie Smith (BSN, CMSRN), Alex Cain (RN), Kathi Soper (BSN, RN-BC)
Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ 85255, United States
A R T I C L E I N F O
Keywords:
Gynecological surgery
Enhanced Recovery After Surgery (ERAS)
Hysterectomy
Bundle components
Institute of Healthcare Improvement
Length of stay
30 day readmission
Patient satisfaction
Randomized controlled trial
A B S T R A C T
Background: Optimizing early education in gynecological procedures utilizing an Enhanced Recovery after
Surgery (ERAS) program and a bundle concept may optimize patient outcomes after surgery.
Purpose: Evaluate whether an ERAS bundle compared to standard education can affect length of stay, 30 day
readmission, and patient satisfaction among patients undergoing gynecologic surgery.
Design: Prospective, comparative, randomized design
Setting: 28 bed Medical Surgical Unit
Sample/Intervention: 50 patients undergoing hysterectomy, 25 who received post-operative evidence based
bundle/standard education, and 25 who received standard education packet. Bundle components included 1)
early mobilization, 2) early transition to oral pain medication, 3) early feeding, and 4) chewing gum. A follow-up
phone call was made in two to three days following discharge for both groups utilizing teach-back.
Results: 84% (n = 21) patients in the bundle group were discharged in one day. There were no 30 day read-
missions for both groups. Twenty two (88%) participants met the bundle components 100% of the time. For the
indicator “walking helped with recovery” 100% (n = 25) responded “very good to excellent” for bundle group
and 96% (n = 24) responded “very good to excellent” for standard group. Twenty three (92%) of the bundle
group felt that that overall nursing care received was very good to excellent and 24 (96%) of the general group
felt that overall nursing care received was very good to excellent.
Conclusion: Optimizing peri-operative education using a bundle approach to provide evidence based interven-
tions can minimize risk and enhance early recovery for females undergoing gynecological surgery.
1. Introduction
A hysterectomy is a common gynecological surgical procedure with
minimally invasive methods including vaginal or laparoscopic proce-
dures. Studies have shown that preoperative patient education can
improve patient outcomes after surgery, including reduced length of
hospital stay, decreased post-operative complications, and increased
patient satisfaction with the surgical experience (Modesitt et al., 2016;
Steiner & Strand, 2017; Wijk, Franzen, Ljungqvist, & Nilsson, 2014).
Enhanced recovery p ...
Objective: To evaluate the utility of a targeted lecture in improving FP awareness amongst clinicians.
Design: This is a dual institution, prospective survey-based study assessing if an educational lecture can increase the likelihood of FP consideration, discussion, and referral.
Pushing it up the Agenda: Promoting the Importance of Physical Activity amongst Pregnant Women by Smith R Examines in Physical Medicine and Rehabilitation
G112 Ito & Shiromaru (2009). Patients’ coping strategies before and after ab...Takehiko Ito
G112 Ito & Shiromaru (2009). Patients’ coping strategies before and after abdominal surgery: A questionnaire survey. The 1st International Nursing Research Conference of World Academy of Nursing Science, Kobe: Program & Abstracts, 235.
Background: Traditionally, Patients are not given fl uids or food after abdominal surgery until bowel functions returns, as by bowel sounds, passage of flatus or stool, or a feeling of hunger, Early versus Traditional oral hydration have been studied to evaluate prospectively the benefits and safety of early hydration on bowel movement after Cesarean Section.
Aim of the work: To evaluate prospectively the benefits and safety of early hydration on bowel movement after Cesarean Section.
Dr Anna Campbell's keynote speech 'The Importance of Staying Active after a Cancer Diagnosis' at the SCPN's 'Be Active Against Cancer' conference, Tuesday 4th February 2014.
Enhancing the quality of life for palliative care cancer patients in Indonesi...UniversitasGadjahMada
Palliative care in Indonesia is problematic because of cultural and socio-economic factors. Family in Indonesia is an integral part of caregiving process in inpatient and outpatient settings. However, most families are not adequately prepared to deliver basic care for their sick family member. This research is a pilot project aiming to evaluate how basic skills training (BST) given to family caregivers could enhance the quality of life (QoL) of palliative care cancer patients in Indonesia. The study is a prospective quantitative with pre and post-test design. Thirty family caregivers of cancer patients were trained in basic skills including showering, washing hair, assisting for fecal and urinary elimination and oral care, as well as feeding at bedside. Patients’ QoL were measured at baseline and 4 weeks after training using EORTC QLQ C30. Hypothesis testing was done using related samples Wilcoxon Signed Rank. A paired t-test and one-way ANOVA were used to check in which subgroups was the intervention more significant. The intervention showed a significant change in patients’ global health status/QoL, emotional and social functioning, pain, fatigue, dyspnea, insomnia, appetite loss, constipation and financial hardship of the patients. Male patient’s had a significant effect on global health status (qol) (p = 0.030); female patients had a significant effect on dyspnea (p = 0.050) and constipation (p = 0.038). Younger patients had a significant effect in global health status/ QoL (p = 0.002). Patients between 45 and 54 years old had significant effect on financial issue (p = 0.039). Caregivers between 45 and 54 years old had significant effect on patients’ dyspnea (p = 0.031). Thus, it is concluded that basic skills training for family caregivers provided some changes in some aspects of QoL of palliative cancer patients. The intervention showed promises in maintaining the QoL of cancer patients considering socioeconomic
and cultural challenges in the provision of palliative care in Indonesia.
Similar to ERAS Gynecologic Oncology (2019).pptx (20)
Experiential Learning through the lens of Communities of Practice (CoP) theoryJibran Mohsin
Individual Presentation on "Experiential Learning through the lens of Communities of Practice (CoP) theory"
Advanced Level Course on Teaching and Learning 1
Master of Health Professions Education
Department for Educational Development
The Aga Khan University
Tuesday, February 07, 2023
Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomized, open-label, phase 3 trial
CURRICULUM ON RESIDENCY PROGRAM FOR FCPS MOLECULAR PATHOLOGYJibran Mohsin
CURRICULUM ON RESIDENCY PROGRAM FOR FCPS MOLECULAR PATHOLOGY (Advanced Level Course on Curriculum Development in Health Professions Education, Department for Educational Development, The Aga Khan University)
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
ERAS Gynecologic Oncology (2019).pptx
1. Shaukat Khanum Memorial Cancer Hospital and Research Centre
Perioperative Care in Gynecologic Oncology:
Enhanced Recovery After Surgery (ERAS)
Society Recommendations – 2019 Update
Iqra Yasin
Fellow Gynecologic Oncology (Department of Surgical Oncology)
2. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Outline
Introduction
Literature Search
ERAS items
Summary
3. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Introduction
ERAS
Global surgical quality improvement initiative
Clinical improvement [1] + cost benefits to the healthcare system [2]
Highest quality evidence + regular updates [3]
ERAS – Gynecologic Oncology
1st Published – February 2016 [4,5]
Update version – 2019
ERAS society + International ERAS Gynecologic Chapters
1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152:292–8.
2. Ljungqvist O, Thanh NX, Nelson G. ERAS-Value based surgery. J Surg Oncol 2017;116:608–12.
3. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations: 2018. World J Surg 2019;43:659–95.
4. Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations--Part I. Gynecol Oncol 2016;140:313–22.
5. Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations--part II. Gynecol Oncol 2016;140:323–32.
4. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Literature Search
1966 – 2018 (Embase, PubMed)
Meta-analysis,
Systemic reviews,
RCT,
Non-RCT, and
Case Series.
5. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
ERAS Items
1. Pre-admission Information, Education, and Counseling
2. Prehabilitation
3. Pre-operative Bowel Preparation
4. Pre-operative Fasting and Carbohydrate Treatment
5. Venous Thromboembolism Prophylaxis
6. Surgical Site Infection (SSI) Reduction Bundles
7. Minimally Invasive Surgery
8. Standard Anesthetic Protocol
6. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
ERAS Items
9. Perioperative Fluid Management/Goal-Directed Fluid Therapy
10. Opioid Sparing Multimodal Post-operative Analgesia
11. Perioperative Nutrition
12. Prevention of Post-operative Ileus
13. Patients Reported Outcomes, Including Functional Recovery
14. Role of ERAS in Pelvic Exenteration and HIPEC
15. ERAS Audit and Reporting
7. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
1. Pre-admission Information, Education,
and Counseling
Reduce fatigue, stress, and anxiety [1,2]
Improve patient satisfaction and early discharge [3]
Reduced pain, nausea and improve well-being [4,5]
RCT: Written > Verbal [6]
All members of the surgery team, anesthetist, dietician, and nurse [7,8]
1. Waller A, Forshaw K, Bryant J, et al. Preparatory education for cancer patients undergoing surgery: a systematic review of volume and quality of research output over time. Patient Educ Couns 2015. doi:10.1016/j.pec.2015.05.008. [Epub ahead of print: 23 May 2015].
2. Powell R, Scott NW, Manyande A, et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev 2016;5.
3. Wang F, Li C-B, Li S, et al. Integrated interventions for improving negative emotions and stress reactions of young women receiving total hysterectomy. Int J Clin Exp Med 2014;7:331–6.
4. de Aguilar-Nascimento JE, Leal FS, Dantas DCS, et al. Preoperative education in cholecystectomy in the context of a multimodal protocol of perioperative care: a randomized, controlled trial. World J Surg 2014;38:357–62.
5. Cavallaro PM, Milch H, Savitt L, et al. Addition of a scripted preoperative patient education module to an existing ERAS pathway further reduces length of stay. Am J Surg 2018;216:652–7.
6. Angioli R, Plotti F, Capriglione S, et al. The effects of giving patients verbal or written pre-operative information in gynecologic oncology surgery: a randomized study and the medical-legal point of view. Eur J Obstet Gynecol Reprod Biol 2014;177:67–71.
7. Booth K, Beaver K, Kitchener H, et al. Women's experiences of information, psychological distress and worry after treatment for gynaecological cancer. Patient Educ Couns 2005;56:225–32.
8. Stewart DE, Wong F, Cheung AM, et al. Information needs and decisional preferences among women with ovarian cancer. Gynecol Oncol 2000;77:357–61.
8. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Summary and recommendation
Counseling provides beneficial effects with no evidence of harm
Patients should receive dedicated pre-operative counseling
Recommendation grade: Strong
1. Pre-admission Information, Education,
and Counseling
9. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Process on the continuum of care
Time of cancer diagnosis start of acute treatment
Physical and psychological assessments
Establishes baseline functional level,
Identification of impairment, and
Provide targeted interventions that reduce the incidence and severity of current
and future impairment. [1]
2. Cancer Prehabilitation
1. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 2013;92:715–27.
10. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Principles of Multimodal Approach [1]
Aerobic and resistance exercises – cardiorespiratory fitness
Targeted functional exercises – minimize/prevent impairments
Dietary interventions - support
Exercise-induced anabolism
Disease/treatment–related malnutrition
Psychological interventions – reduce stress/support behavior change/overall
well-being
2. Cancer Prehabilitation
1. Carli F, Silver JK, Feldman LS, et al. Surgical prehabilitation in patients with cancer: state-of-the-science and recommendations for future research from a panel of subject matter experts. Phys Med Rehabil Clin N Am 2017;28:49–64.
11. Click to edit Master title style
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Summary and recommendation
No high-quality direct evidence in gynecologic oncology patients [1,2]
Extrapolated work in colorectal surgery [3-5]
Certain patients benefit clinically from Prehabilitation but further work in
gynecologic oncology is needed.
Recommendation grade: Weak
2. Cancer Prehabilitation
1. Bolshinsky V, Li MH-G, Ismail H, et al. Multimodal Prehabilitation programs as a bundle of care in gastrointestinal cancer surgery: a systematic review. Dis Colon Rectum 2018;61:124–38.
2. Ebner F, Schulz SVW, de Gregorio A, et al. Prehabilitation in gynecological surgery? What do gynecologists know and need to know. Arch Gynecol Obstet 2018;297:27–31.
3. Gillis C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and metaanalysis. Gastroenterology 2018;155:391–410.
4. Moran J, Guinan E, McCormick P, et al. The ability of Prehabilitation to influence postoperative outcome after intra-abdominal operation: a systematic review and meta-analysis. Surgery 2016;160:1189–201.
5. Minnella EM, Bousquet-Dion G, Awasthi R, et al. Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience. Acta Oncol 2017;56:295–300
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Minimally invasive gynecologic surgery
Limited data from RCT
Conclusively showed no improved intraoperative visualization, ease of bowel
handling, or procedure performance. [1-5]
Open gynecologic surgery
Lack of data – extrapolated from colorectal surgery [6-9]
3. Pre-operative Bowel Preparation
1. Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review. J Minim Invasive Gynecol 2015;22:737–52.
2. Huang H, Wang H, He M. Is mechanical bowel preparation still necessary for gynecologic laparoscopic surgery? A meta-analysis. Asian J Endosc Surg 2015;8:171–9.
3. Mulayim B, Karadag B. Do we need mechanical bowel preparation before benign gynecologic laparoscopic surgeries a randomized, single-blind, controlled trial. Gynecol Obstet Invest 2018;83:203–8.
4. Ryan NA, Ng VS-M, Sangi-Haghpeykar H, et al. Evaluating mechanical bowel preparation prior to total laparoscopic hysterectomy. JSLS 2015;19.
5. Zhang J, Xu L, Shi G. Is mechanical bowel preparation necessary for gynecologic surgery? A systematic review and meta-analysis. Gynecol Obstet Invest 2016;81:155–61.
6. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012;27:803–10.
7. Dahabreh IJ, Steele DW, Shah N, et al. Oral mechanical bowel preparation for colorectal surgery: systematic review and metaanalysis. Dis Colon Rectum 2015;58:698–707.
8. Pineda CE, Shelton AA, Hernandez-Boussard T, et al. Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature. J Gastrointest Surg 2008;12:2037–44.
9. Slim K, Vicaut E, Launay-Savary M-V, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009;249:203–9.
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Summary and recommendation
Routine pre-operative bowel preparation should not be used before
minimally invasive gynecologic surgery.
Similarly discouraged before open laparotomy in gynecologic
surgery/gynecologic oncology
Surgeon Preference - limited to planned colonic resection
Oral antibiotics ± mechanical bowel preparation
High-quality data from colorectal surgery
Mechanical bowel preparation alone doesn’t reduce postoperative
morbidity and should be abandoned.
Recommendation grade: Strong
3. Pre-operative Bowel Preparation
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Surgical stress + Prolonged fasting – Post-operative catabolic response
RCTs [1,2] – elective surgery under G/A
Clear fluids – 2 hours / Light meal – 6 hours
Preoperative carbohydrate treatment - Oral 50 g 2-3 hours before induction of
anesthesia
Attenuate catabolic response [3]
Less post-operative nausea/vomiting, metoclopramide consumption, and
improved patient satisfaction [4]
4. Pre-operative Fasting and Carbohydrate
Treatment
1. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations: 2018. World J Surg 2019;43:659–95.
2. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;4.
3. Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate therapy. Curr Opin Anaesthesiol 2015;28:364–9.
4. Ajuzieogu OV, Amucheazi AO, Nwagha UI, et al. Effect of routine preoperative fasting on residual gastric volume and acid in patients undergoing myomectomy. Niger J Clin Pract 2016;19:816–20.
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Shaukat Khanum Memorial Cancer Hospital and Research Centre
Cochrane review [1] - Preoperative carbohydrate treatment
Reduced post-operative insulin resistance, improve well-being
Enhanced return of bowel function, and shorter hospital stay
With no effect on postoperative complication rates
Limitations
Delayed gastric emptying (overnight or 8 hours) or GI motility disorders
Emergency surgery
Obese [2] / Diabetic [3] (no issue with safety but insufficient data for general
recommendation)
4. Pre-operative Fasting and Carbohydrate
Treatment
1. Smith MD, McCall J, Plank L, et al. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014;8.
2. Azagury DE, Ris F, Pichard C, et al. Does perioperative nutrition and oral carbohydrate load sustainably preserve muscle mass after bariatric surgery? A randomized control trial. Surg Obes Relat Dis 2015;11:920–6.
3. Laffin MR, Li S, Brisebois R, et al. The use of a pre-operative carbohydrate drink in patients with diabetes mellitus: a prospective, non-inferiority, cohort study. World J Surg 2018;42:1965–70.
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Risk of VTE in Gynecologic Oncology Surgery [1-6]
Ovarian cancer: 17-38 %
Endometrial cancer: 4-9 %
Cervical cancer: 3-4 %
All Gynecologic Oncology patients – major surgery (> 30 mins) [7-9]
Dual VTE mechanical prophylaxis and chemoprophylaxis (LMWH or
unfractionated heparin) throughout the hospital stay
5. Venous Thromboembolism Prophylaxis
1. Matsuo K, Yessaian AA, Lin YG, et al. Predictive model of venous thromboembolism in endometrial cancer. Gynecol Oncol 2013;128:544–51.
2. Levitan N, Dowlati A, Remick SC, et al. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. risk analysis using Medicare claims data. Medicine 1999;78:285–91.
3. Mokri B, Mariani A, Heit JA, et al. Incidence and predictors of venous thromboembolism after debulking surgery for epithelial ovarian cancer. Int J Gynecol Cancer 2013;23:1684–91.
4. Jacobson BF, Louw S, Büller H, et al. Venous thromboembolism: prophylactic and therapeutic practice guideline. S Afr Med J 2013;103:260–7.
5. Satoh T, Matsumoto K, Uno K, et al. Silent venous thromboembolism before treatment in endometrial cancer and the risk factors. Br J Cancer 2008;99:1034–9.
6. Greco PS, Bazzi AA, McLean K, et al. Incidence and timing of thromboembolic events in patients with ovarian cancer undergoing neoadjuvant chemotherapy. Obstet Gynecol 2017;129:979–85.
7. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013;31:2189–204.
8. Baykal C, Al A, Demirtaş E, et al. Comparison of enoxaparin and standard heparin in gynaecologic oncologic surgery: a randomized prospective double-blind clinical study. Eur J Gynaecol Oncol 2001;22:127–30.
9. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTe in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ED: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):e227S–77.
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Should be initiated preoperatively [1, 2] and continued postoperatively
Extended Chemoprophylaxis [3-6] (28 days post-op)
High-risk - Caprini Risk Assessment Model
ACCP [7], ASCO [8], NCCN [9]
5. Venous Thromboembolism Prophylaxis
1. Whitworth JM, Schneider KE, Frederick PJ, et al. Double prophylaxis for deep venous thrombosis in patients with gynecologic oncology who are undergoing laparotomy: does preoperative anticoagulation matter? Int J Gynecol Cancer
2011;21:1131–4.
2. Selby LV, Sovel M, Sjoberg DD, et al. Preoperative chemoprophylaxis is safe in major oncology operations and effective at preventing venous thromboembolism. J Am Coll Surg 2016;222:129–37.
3. Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 2002;346:975–80.
4. Felder S, Rasmussen MS, King R, et al. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2018;11.
5. Fagarasanu A, Alotaibi GS, Hrimiuc R, et al. Role of extended thromboprophylaxis after abdominal and pelvic surgery in cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 2016;23:1422–30.
6. Carrier M, Altman AD, Blais N, et al. Extended thromboprophylaxis with low-molecular weight heparin (LMWH) following abdominopelvic cancer surgery. Am J Surg 2018. doi:10.1016/j.amjsurg.2018.11.046. [Epub ahead of print: 16 Dec 2018].
7. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTe in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ED: American College of Chest Physicians evidence-based clinical practice guidelines. Chest
2012;141(2 Suppl):e227S–77.
8. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013;31:2189–204.
9. Streiff MB, National Comprehensive Cancer Center Network. The National Comprehensive Cancer Center Network (NCCN) guidelines on the management of venous thromboembolism in cancer patients. Thromb Res 2010;125 Suppl 2:S128–S133.
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Further studies needed
?Extended post-op prophylaxis – minimally invasive gynecologic surgery [1-4]
?Direct-acting oral anticoagulation [5]
?Ambulatory chemotherapy patients [6-8]
5. Venous Thromboembolism Prophylaxis
1. Ramirez PT, Nick AM, Frumovitz M, et al. Venous thromboembolic events in minimally invasive gynecologic surgery. J Minim Invasive Gynecol 2013;20:766–9.
2. Nick AM, Schmeler KM, Frumovitz MM, et al. Risk of thromboembolic disease in patients undergoing laparoscopic gynecologic surgery. Obstet Gynecol 2010;116:956–61.
3. Freeman AH, Barrie A, Lyon L, et al. Venous thromboembolism following minimally invasive surgery among women with endometrial cancer. Gynecol Oncol 2016;142:267–72.
4. Bouchard-Fortier G, Geerts WH, Covens A, et al. Is venous thromboprophylaxis necessary in patients undergoing minimally invasive surgery for a gynecologic malignancy? Gynecol Oncol 2014;134:228–32.
5. Forster R, Stewart M. Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair. Cochrane Database Syst Rev 2016;3.
6. Greco PS, Bazzi AA, McLean K, et al. Incidence and timing of thromboembolic events in patients with ovarian cancer undergoing neoadjuvant chemotherapy. Obstet Gynecol 2017;129:979–85.
7. Wagner BE, Langstraat CL, McGree ME, et al. Beyond prophylaxis: extended risk of venous thromboembolism following primary debulking surgery for ovarian cancer. Gynecol Oncol 2019;152.
8. Schmeler KM, Wilson GL, Cain K, et al. Venous thromboembolism (VTe) rates following the implementation of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies. Gynecol Oncol 2013;128:204–8.
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20–30% of open Gynecologic Oncology surgery [1-5]
Bundle Elements
i. Antimicrobial Prophylaxis
ii. Skin Preparation
iii. Prevention of Hypothermia
iv. Avoidance of Drains/Tubes
v. Control of Perioperative Hyperglycemia
6. Surgical Site Infection Reduction
Bundles
1. de Lissovoy G, Fraeman K, Hutchins V, et al. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 2009;37:387–97.
2. Nugent EK, Hoff JT, Gao F, et al. Wound complications after gynecologic cancer surgery. Gynecol Oncol 2011;121:347–52.
3. Taylor JS, Marten CA, Munsell MF, et al. The DISINFECT Initiative: decreasing the incidence of surgical infections in gynecologic oncology. Ann Surg Oncol 2017;24:362–8.
4. Tran CW, McGree ME, Weaver AL, et al. Surgical site infection after primary surgery for epithelial ovarian cancer: predictors and impact on survival. Gynecol Oncol 2015;136:278–84.
5. Bakkum-Gamez JN, Dowdy SC, Borah BJ, et al. Predictors and costs of surgical site infections in patients with endometrial cancer. Gynecol Oncol 2013;130:100–6.
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1st Generation cephalosporin – 1st line antibiotic for hysterectomy [1,2]
Addition of anaerobe coverage in pelvic cancer or bowel surgery [2,3]
Dosage according to body weight [1,2]
Within 1 hour of skin incision [1,2]
Redosing:
> 2 half-lives of drug i.e. 3-4 hours or
blood loss > 1500 ml
CDC (1B recommendation)
Recommendation grade: Strong
6.1 Antimicrobial Prophylaxis
1. ACOG practice Bulletin No. 195: prevention of infection after gynecologic procedures. Obstet Gynecol 2018;131:e172–89.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect 2013;14:73–156.
3. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg 2011;253:1082–93.
4. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–91.
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Shower before surgery with a chlorhexidine-based antimicrobial soap
Chlorhexidine-alcohol skin preparation in OR
CDC 1A recommendation [6]
40 % lower SSI compared to povidone-iodine [7] (Level I evidence)
Recommendation grade: Strong
6.2 Skin Preparation [1-5]
1. Johnson MP, Kim SJ, Langstraat CL, et al. Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery. Obstet Gynecol 2016;127:1135–44.
2. Lippitt MH, Fairbairn MG, Matsuno R, et al. Outcomes associated with a five-point surgical site infection prevention bundle in women undergoing surgery for ovarian cancer. Obstet Gynecol 2017;130:756–64.
3. Taylor JS, Marten CA, Munsell MF, et al. The DISINFECT Initiative: decreasing the incidence of surgical infections in gynecologic oncology. Ann Surg Oncol 2017;24:362–8.
4. Schiavone MB, Moukarzel L, Leong K, et al. Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery. Gynecol Oncol 2017;147:115–9.
5. ACOG practice Bulletin No. 195: prevention of infection after gynecologic procedures. Obstet Gynecol 2018;131:e172–89.
6. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–91.
7. Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidine–alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18–26.
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Hypothermia – Cardiac events, SSI
Maintenance of perioperative normothermia should be incorporated in all
ERAS programs
CDC: Category 1 recommendation [2]
Recommendation grade: Strong
6.3 Prevention of Hypothermia [1]
1. Wong PF, Kumar S, Bohra A, et al. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007;94:421–6.
2. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–91.
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Lack of high-quality data- role in the reduction of SSI
Drain biofilm colonization – as early as 2 hours after placement [1]
NGT – increased post-op pneumonia, no effect on wound dehiscence or intestinal
leaks. [2,3]
Tailored according to surgical procedure and rationale for individual drain
placement
Summary and recommendation
Peritoneal drains, subcutaneous drains, and NGT should be avoided after
abdominal surgery.
Recommendation grade: Strong
6.4 Avoidance of Drains/Tubes
1. Dower R, Turner ML. Pilot study of timing of biofilm formation on closed suction wound drains. Plast Reconstr Surg 2012;130:1141–6.
2. Cheatham ML, Chapman WC, Key SP, et al. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469–78.
3. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007;8:CD004929.
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Associated with SSI in both diabetic and non-diabetic patients [1-8]
CDC (Category 1A) [9]
Perioperative glucose levels - maintained at < 200 mg/dL in diabetics and
non-diabetics.
All surgical patients should be screened for diabetes
Reduced Insulin resistance: Oral carbohydrate loading, MIS, early feeding [10]
Recommendation grade: Strong
6.5 Control of Perioperative Hyperglycemia
1. Bakkum-Gamez JN, Dowdy SC, Borah BJ, et al. Predictors and costs of surgical site infections in patients with endometrial cancer. Gynecol Oncol 2013;130:100–6.
2. Hopkins L, Brown-Broderick J, Hearn J, et al. Implementation of a referral to discharge glycemic control initiative for reduction of surgical site infections in gynecologic oncology patients. Gynecol Oncol 2017;146:228–33.
3. Steiner HL, Strand EA. Surgical-site infection in gynecologic surgery: pathophysiology and prevention. Am J Obstet Gynecol 2017;217:121–8.
4. Mahdi H, Goodrich S, Lockhart D, et al. Predictors of surgical site infection in women undergoing hysterectomy for benign gynecologic disease: a multicenter analysis using the National surgical quality improvement program data. J Minim Invasive Gynecol
2014;21:901–9.
5. Martin ET, Kaye KS, Knott C, et al. Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2016;37:88–99.
6. Al-Niaimi AN, Ahmed M, Burish N, et al. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol 2015;136:71–6.
7. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med Overseas Ed 2001;345:1359–67.
8. van den Boom W, Schroeder RA, Manning MW, et al. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries. Diabetes Care 2018;41:782–8.
9. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–91.
10. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations: 2018. World J Surg 2019;43:659–95.
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Laparoscopic surgery (vs open /moderate-highly invasive surgery)
Decreased inflammatory and immunomodulatory response [1-3]
MIS (including vaginal surgery) recommended/preferred
Appropriate patients (long-term oncologic outcomes-similar), and
Expertise and resources are available (feasible)
7. Minimally Invasive Surgery
1. Kehlet H, Nielsen HJ. Impact of laparoscopic surgery on stress responses, immunofunction, and risk of infectious complications. New Horiz 1998;6(2 Suppl):CD009642):S80–8.
2. Holub Z. Impact of laparoscopic surgery on immune function. Clin Exp Obstet Gynecol 2002;29:77–81.
3. Prete A, Yan Q, Al-Tarrah K, et al. The cortisol stress response induced by surgery: a systematic review and meta-analysis. Clin Endocrinol 2018;89:554–67.
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Goal
To provide hypnosis and analgesia
To optimize surgical condition and cardiovascular system
With minimal residual anesthesia effect for rapid neurocognitive recovery and
minimize nausea/vomiting.
Summary and recommendation
Use of short-acting anesthetics
Complete reversal of NM blockage
Protected ventilation strategy (Tidal Volume 6-8 ml/Kg, PEEP 6-8 cm H2O)
Recommendation grade: Strong
8. Standard Anesthetic Protocol
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Hypervolemia – paralytic ileus, nausea/vomiting, increased length of stay [1-3]
Hypovolemia – AKI, SSI, Sepsis, Delirium, increased hospital stay [4-6]
Goal-directed fluid therapy - physiological measurements of blood flow, fluid
responsiveness, and organ perfusion [7-10]
High-risk (high blood loss and high comorbid)
Fluids /inotropes; Improve end –organ tissue perfusion and oxygenation [11-12]
Improved short and long term outcomes [13-14]
Reduces length of stay and complications undergoing abdominal surgery.
9. Perioperative Fluid Management/Goal-
Directed Fluid Therapy
1. Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61.
2. 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 assessor-blinded multicenter trial. Ann Surg 2003;238:641–8.
3. Adesanya A, Rosero E, Timaran C, et al. Intraoperative fluid restriction predicts improved outcomes in major vascular surgery. Vasc Endovascular Surg 2009;42:531–6.
4. Thom O, Taylor DM, Wolfe RE, et al. Pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients. Emerg Med J 2010;27:470–2.
5. Davies SJ, Wilson RJT. Preoperative optimization of the high-risk surgical patient. Br J Anaesth 2004;93:121–8.
6. Bennett-Guerrero E, Welsby I, Dunn TJ, et al. The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg 1999;89:514–9.
7. Doherty M, Buggy DJ. Intraoperative fluids: how much is too much? Br J Anaesth 2012;109:69–79.
8. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, doubleblind study. Br J Anaesth 2007;99:500–8.
9. Chong PC, Greco EF, Stothart D, et al. Substantial variation of both opinions and practice regarding perioperative fluid resuscitation. Can J Surg 2009;52:207–14.
10. Lilot M, Ehrenfeld JM, Lee C, et al. Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis. Br J Anaesth 2015;114:767–76.
11. Miralpeix E, Nick AM, Meyer LA, et al. A call for new standard of care in perioperative gynecologic oncology practice: impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016;141:371–8.
12. Thiele RH, Raghunathan K, Brudney CS, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med
2016;5.
13. Michard F. The burden of high-risk surgery and the potential benefit of goal-directed strategies. Crit Care 2011;15.
14. Pearse R, Dawson D, Fawcett J, et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomized, controlled trial. Crit Care 2005;9:R687–R693.
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Post-operative pain
Quality of life, high complications, increased hospital stay, readmission/cost [1,2]
Opioids alone for post-op pain [3-5]
Nausea, sedation, fatigue, addiction –financial / Social cost
Non-opioids [6-7]
NSAIDs, paracetamol, gabapentin; Combined analgesia Synergetic effects [8]
Summary and recommendation
Multimodal post-operative analgesic protocol successfully reduces opioid
administration both in the hospital and at discharge.
10. Opioid Sparing Multimodal Post-
operative Analgesia
1. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Patient safety and quality: an evidence-based Handbook for nurses. Rockville (MD), 2008.
2. Massicotte L, Chalaoui KD, Beaulieu D, et al. Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy. Acta Anaesthesiol Scand 2009;53:641–7.
3. Florence CS, Zhou C, Luo F, et al. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care 2016;54:901–6.
4. Woodhouse A, Mather LE. The effect of duration of dose delivery with patient-controlled analgesia on the incidence of nausea and vomiting after hysterectomy. Br J Clin Pharmacol 1998;45:57–62.
5. Dolin SJ, Cashman JN. Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritus, and urinary retention. Evidence from published data. Br J Anaesth 2005;95:584–91.
6. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013;122:319–28.
7. Meyer LA, Lasala J, Iniesta MD, et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol 2018;132:281–90.
8. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 2009;22:588–93.
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Preoperative: ORAL paracetamol/celecoxib/gabapentin [1]
Intraoperative: Incisional bupivacaine [2,3]
Postoperative: non-opioid ORAL analgesia (tolerate oral diet)
IV analgesia: Limited to breakthrough pain
PCA: < 5 % laparotomy
10. Opioid Sparing Multimodal Post-
operative Analgesia
1. Ong CKS, Seymour RA, Lirk P, et al. Combining Paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170–9
2. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013;122:319–28.
3. Kalogera E, Bakkum-Gamez JN, Weaver AL, et al. Abdominal incision injection of liposomal bupivacaine and opioid use after laparotomy for gynecologic malignancies. Obstet Gynecol 2016;128:1009–17.
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Transverse Abdominis Plane (TAP) block [1-5] (Low*)
Thoracic epidural [6] (Moderate*)
Incisional Bupivacaine injection (High*)
No direct comparison
Current literature [7-12] : failed to show improvement over local injection
Recommendation grade: Strong (* Level of Evidence)
10. Opioid Sparing Multimodal Post-
operative Analgesia
1. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005;103:1079–88.
2. Carli F, Mayo N, Klubien K, et al. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002;97:540–9.
3. Ready LB. Acute pain: lessons learned from 25,000 patients. Reg Anesth Pain Med 1999;24:499–505.
4. Hübner M, Blanc C, Roulin D, et al. Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 2015;261:648–53.
5. Chen L-M, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient-controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol 2009;115:357–61.
6. Champaneria R, Shah L, Geoghegan J, et al. Analgesic effectiveness of transversus abdominis plane blocks after hysterectomy: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2013;166:1–9.
7. Gasanova I, Alexander J, Ogunnaike B, et al. Transversus abdominis plane block versus surgical site infiltration for pain management after open total abdominal hysterectomy. Anesth Analg 2015;121:1383–8.
8. Levy BF, Scott MJ, Fawcett W, et al. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 2011;98:1068–78.
9. Calle GA, López CC, Sánchez E, et al. Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta Obstet Gynecol Scand 2014;93:345–50.
10. Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, et al. Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery. Am J Obstet Gynecol 2012;207:419.e1–419.e5.
11. El Hachem L, Small E, Chung P, et al. Randomized controlled double-blind trial of transversus abdominis plane block versus trocar site infiltration in gynecologic laparoscopy. Am J Obstet Gynecol 2015;212:182.e1–182.e9.
12. Torgeson M, Kileny J, Pfeifer C, et al. Conventional epidural vs transversus abdominis plane block with liposomal bupivacaine: a randomized trial in colorectal surgery. J Am Coll Surg 2018;227:78–83
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Shaukat Khanum Memorial Cancer Hospital and Research Centre
Maintenance of Appropriate post-op nutrition
Early return of bowel activity, short hospital stay
Equivalent complication rate [7]: Pulmonary, wound healing, anastomosis leaks
Immune Nutrition and High Protein diet
Low risk of infection and hospital stay
Summary and recommendation
A Regular diet within the first 24 hours after Gynecologic/oncology surgery
is recommended.
High protein diet may be considered in post-operative surgical patients
11. Perioperative Nutrition [1-6]
1. Cutillo G, Maneschi F, Franchi M, et al. Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: a randomized study. Obstet Gynecol 1999;93:41–5.
2. Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2014;12.
3. Minig L, Biffi R, Zanagnolo V, et al. Early oral versus "traditional“ postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial. Ann Surg Oncol 2009;16:1660–8.
4. Minig L, Biffi R, Zanagnolo V, et al. Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial. Ann Surg Oncol 2009;16:3101–10.
5. Pearl ML, Valea FA, Fischer M, et al. A randomized controlled trial of early postoperative feeding in gynecologic oncology patients undergoing intra-abdominal surgery. Obstet Gynecol 1998;92:94–7.
6. Schilder JM, Hurteau JA, Look KY, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol 1997;67:235–40.
7. Wischmeyer PE, Carli F, Evans DC, et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesth Analg 2018;126:1883–95.
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Shaukat Khanum Memorial Cancer Hospital and Research Centre
30 % - 40 % in gynecologic oncology surgery [1,2]
Preventive Measures [3-7] (2-5 x low)
MIS, Euvolemia,
Opioids sparing analgesia,
Early mobilization, Early feeding,
Coffee Consumption,
Gum Chewing ?[8], and
Alvimopan [9-11]
12. Prevention of Post-operative Ileus
1. Güngördük K, Özdemir İsa Aykut, Güngördük Özgü, et al. Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial. Am J Obstet Gynecol 2017;216:145.e1–145.e7.
2. Bakkum-Gamez JN, Langstraat CL, Martin JR, et al. Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma. Gynecol Oncol 2012;125:614–20.
3. Müller SA, Rahbari NN, Schneider F, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. Br J Surg 2012;99:1530–8.
4. Bisch SP, Wells T, Gramlich L, et al. Enhanced recovery after surgery (ERAS) in gynecologic oncology: system-wide implementation and audit leads to improved value and patient outcomes. Gynecol Oncol 2018;151:117–23.
5. Boitano TKL, Smith HJ, Rushton T, et al. Impact of enhanced recovery after surgery (ERAS) protocol on gastrointestinal function in gynecologic oncology patients undergoing laparotomy. Gynecol Oncol 2018;151:282–6.
6. Jernigan AM, Chen CCG, Sewell C. A randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery. Int J Gynaecol Obstet 2014;127:279–82.
7. Vergara-Fernandez O, Gonzalez-Vargas AP, Castellanos-Juarez JC, et al. Usefulness of gum chewing to decrease postoperative ileus in colorectal surgery with primary anastomosis: a randomized controlled trial. Rev Invest Clin 2016;68:314–8.
8. de Leede EM, van Leersum NJ, Kroon HM, et al. Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery. Br J Surg 2018;105:820–8.
9. Wolff BG, Weese JL, Ludwig KA, et al. Postoperative ileus-related morbidity profile in patients treated with Alvimopan after bowel resection. J Am Coll Surg 2007;204:609–16.
10. Lee CT, Chang SS, Kamat AM, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol 2014;66:265–72.
11. Bakkum-Gamez JN, Langstraat CL, Lemens MA, et al. Accelerating gastrointestinal recovery in women undergoing ovarian cancer debulking: a randomized, double-blind, placebo-controlled trial. Gynecol Oncol 2016;141.
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Summary and recommendation
Consistent collection and documentation of patient reported outcomes within
ERAS programs allow institutions to monitor, understand, and compare
functional recovery in a patient-centered fashion.
Patient reported outcomes, including symptom burden assessment, can also be
utilized to guide individual post-operative care.
Recommendation grade: Strong
13. Patient Reported Outcomes, Including
Functional Recovery
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14. Role of ERAS in Pelvic Exenteration
and HIPEC
Summary and recommendation
Currently, a paucity of data on the impact of an ERAS program specifically
targeting patients undergoing high complexity procedures, such as pelvic
exenteration and HIPEC surgery.
Further research is needed from high-volume referral centers in order to
document outcomes of ERAS programs in this patient population.
Recommendation grade: Weak
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15. ERAS Audit and Reporting
Summary and recommendation
Auditing is an essential component of an ERAS program.
Reports on ERAS pathways should include detailed information on the
relationship between outcomes and compliance with individual ERAS
elements.
Recommendation grade: Strong
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ERAS Items
(Unchanged from 1st Version)
Pre-operative optimization
4 weeks – smoking/alcohol cessation, anemia correction
Pre-anesthetic medication
Avoid sedative for anxiety
Nausea and Vomiting Prophylaxis
Multimodal approach, > 2 anti-emetic in postoperative time
Urinary Drainage / Catheter (< 24 hours)
Early mobilization (< 24 hours)
Recommendation grade: Strong
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Summary
Continued Quality Improvement Team Activities
Analyze and share quality measures, patient survey, an staff input to celebrate successes and identify opportunities for improvement
Post-discharge Phase
Monitor for symptoms or changes in health
to seek assistance
Follow-up with surgeon, primary care and/or
specialty care
Continue therapy and other interprofessional
activities as planned
Postoperative Phase
Early nutrition Early mobilization
Multimodal
analgesia
Nausea/Vomiting
management
No or judicious IV
fluid management
Patient & family
education
Intraoperative Phase
Opioid Sparing
multimodal
analgesia
Normothermia
Nausea/Vomiting
prophylaxis
Normovolemia Normoglycemia
Avoid tubes and
drains
Preoperative Phase
Limit fasting (light meal up to 6
hrs. preop)
Carbohydrate beverage up to 2
hrs. preop
Initial multimodal medications
and/or regional block placement
Discharge planning, education,
and home medication plan
Pre-hospital Phase
Patient/family education Pain management plan Patient optimization Prehabilitation of select patients
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