- •We provide evidence supporting postoperative management of patients undergoing gynecologic/oncology surgery.
- •This guideline will help integrate knowledge into practice, align perioperative care, and encourage future investigations.
2.1 Literature search
|Item||Recommendation||Evidence level||Recommendation grade|
|Prophylaxis against thromboembolism||Patients should wear well-fitting compression stockings and have intermittent pneumatic compression||High||Strong|
|Extended prophylaxis (28 days) should be given to patients after laparotomy for abdominal or pelvic malignancies||High||Strong|
|Postoperative fluid therapy||Intravenous fluids should be terminated within 24 h after surgery; balanced crystalloid solutions are preferred to 0.9% normal saline||Moderate||Strong|
|Perioperative nutritional care||A regular diet within the first 24 h after gynecologic/oncology surgery is recommended||High||Strong|
|Prevention of postoperative ileus||The use of postoperative laxatives should be considered||Low||Weak|
|The use of chewing gum should be considered||Moderate||Weak|
|Postoperative glucose control||ERAS elements that reduce metabolic stress should be employed to reduce insulin resistance and the development of hyperglycemia||High||Strong|
|Perioperative maintenance of blood glucose levels (<180–200 mg/dL) results in improved perioperative outcomes; glucose levels above this range should be treated with insulin infusions and regular blood glucose monitoring to avoid the risk of hypoglycemia||High||Strong|
|Postoperative analgesia||A multimodal approach to analgesia should be adopted including use of NSAIDS/acetaminophen, gabapentin and dexamethasone (unless contraindications exist)||Multimodal: high|
|Paracervical nerve block or intrathecal morphine can be used to reduce pain and opioid consumption||Low||Weak|
|Open general gynecologic surgery|
|Spinal anesthesia with intrathecal morphine is recommended||Moderate||Strong|
|Alternatively, thoracic epidural analgesia (TEA) with low concentration local anesthetic solutions with the addition of opiates for 24-48 h can be considered||High||Strong|
|Truncal nerve blocks (TAP or ilioinguinal) can be recommended where patients have undergone general anesthesia without neuraxial blockade||Moderate||Strong|
|Continuous wound infiltration (CWI) of local anesthetic can be considered||Moderate||Strong|
|Major oncologic surgery|
|TEA may be considered but patients frequently require additional IV opioids in addition to TEA to achieve adequate analgesia||Low||Weak|
|Laparoscopic gynecologic/oncology surgery|
|Lack of evidence makes it difficult to recommend one analgesic intervention over another, however a multimodal approach should be employed||Low||Weak|
|Peritoneal drainage||Peritoneal drainage is not recommended routinely in gynecologic/oncology surgery including for patients undergoing lymphadenectomy or bowel surgery||Moderate||Strong|
|Urinary drainage||Urinary catheters should be used for postoperative bladder drainage for a short period preferably <24 h postop||Low||Strong|
|Early mobilization||Patients should be encouraged to mobilize within 24 h of surgery||Low||Strong|
2.2 Study selection
2.3 Quality assessment and data analyses
|High quality||Further research unlikely to change confidence in estimate of effect|
|Moderate quality||Further research likely to have important impact on confidence in estimate of effect and may change the estimate|
|Low quality||Further research very likely to have important impact on confidence in estimate of effect and likely to change the estimate|
|Very low quality||Any estimate of effect is very uncertain|
|Strong||When desirable effects of intervention clearly outweigh the undesirable effects, or clearly do not|
|Weak||When trade-offs are less certain — either because of low quality evidence or because evidence suggests desirable and undesirable effects are closely balanced|
4. Postoperative thromboembolism prophylaxis
4.1 Immediate postoperative prophylaxis
- Clarke-Pearson D.L.
- Synan I.S.
- Dodge R.
- Soper J.T.
- Berchuck A.
- Coleman R.E.
4.2 Extended postoperative prophylaxis
- Gould M.K.
- Garcia D.A.
- Wren S.M.
- Karanicolas P.J.
- Arcelus J.I.
- Heit J.A.
- et al.
4.2.1 Summary and recommendations
4.2.2 Evidence level
4.2.3 Recommendation grade
5. Postoperative fluid therapy
5.1 Summary and recommendations
5.2 Evidence level
5.3 Recommendation grade
6. Perioperative nutritional care
6.1 Summary and recommendation
6.2 Evidence level
6.3 Recommendation grade
7. Prevention of postoperative ileus
7.1 Summary and recommendations
7.2 Evidence level
7.3 Recommendation grade
8. Postoperative control of glucose
- Qaseem A.
- Humphrey L.L.
- Chou R.
- Snow V.
- P S.
8.1 Summary and recommendation
8.2 Evidence level
8.3 Recommendation grade
9. Postoperative analgesia
9.1 Multimodal analgesia
9.1.1 Summary and recommendations
9.1.2 Level of evidence
9.1.3 Recommendation grade
9.2 Analgesia for vaginal hysterectomy
9.2.1 Summary and recommendations
9.2.2 Evidence level
9.2.3 Recommendation grade
9.3 Analgesia for open general gynecologic surgery
- Ferguson S.E1.
- Malhotra T.
- Seshan V.E.
- Levine D.A.
- Sonoda Y.
- DS C.
- et al.
- Bertoglio S.
- Fabiani F.
- Negri P.D.
- Corcione A.
- Merlo D.F.
- Cafiero F.
- et al.
9.3.1 Summary and recommendations
9.3.2 Evidence level
9.3.3 Recommendation grade
9.4 Analgesia for major oncologic surgery
- Ferguson S.E.
- Malhotra T.
- Seshan V.E.
- Levine D.A.
- Sonoda Y.
- Chi D.S.
- et al.
9.4.1 Summary and recommendations
9.4.2 Evidence level
9.4.3 Recommendation grade
9.5 Analgesia for laparoscopic gynecologic/oncology surgery
9.5.1 Summary and recommendations
9.5.2 Level of evidence
9.5.3 Recommendation grade
10. Peritoneal drainage
10.1.1 Summary and recommendation
10.1.2 Evidence level
10.1.3 Recommendation grade
11. Urinary drainage
11.1.1 Summary and recommendation
11.1.2 Evidence level
11.1.3 Recommendation grade
12. Early mobilization
12.1.1 Summary and recommendation
12.1.2 Evidence level
12.1.3 Recommendation grade
- ERAS Interactive Audit System (EIAS)
Conflict of interest statement
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