Perioperative care in gynecologic oncology

Direct oral anticoagulants (DOACs) for postoperative venous thromboembolism prophylaxis in patients with gynecologic malignancies: A quality mini-review

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in gynecologic oncology patients with an increased risk in the postoperative period. Historically, international guidelines have recommended 28 days of low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for extended VTE prophylaxis after major abdominal and pelvic surgery for gynecologic malignancies. Direct oral anticoagulants (DOACs) have emerged as an attractive alternative to injectable anticoagulants. This quality mini-review evaluated the literature around the use of DOACs for postoperative VTE prophylaxis after surgery for gynecologic cancer. Overall, the reviewed literature supports the use of DOACs in select patients within this population which may lead to an improved patient experience, higher rates of treatment compliance, and increased cost savings.

Direct oral anticoagulant (DOACs) prescribing practices of members of the Society of Gynecologic Oncology and American Society of Clinical Oncology

BACKGROUND

Cancer associated venous thromboembolism (VTE) is associated with significant morbidity and mortality. Direct oral anticoagulants (DOACs) have emerged as alternatives to injectable medications for both thromboprophylaxis and treatment of VTE. Several recent clinical trials have demonstrated safety and efficacy of DOACs in high risk patients receiving systemic chemotherapy as well as postoperative prophylaxis after surgery for gynecologic cancer. Major consensus guidelines from multiple organizations support the use of DOACs for these indications but prescription practices are not well characterized.

METHODS

A survey study was sent concurrently to members of the Society of Gynecologic Oncology (SGO) and American Society of Clinical Oncology (ASCO) Research Survey Pool between May and June of 2021. The study was designed to assess DOAC prescription practices amongst members of these societies who routinely prescribe chemotherapy. Bivariate analyses comparing responses from ASCO participants and SGO participants were compared using chi-squared and Fisher exact tests.

RESULTS

A total of 103 physicians were included in the ASCO group and 139 in the SGO group. A majority of participants in both groups reported familiarity with prescribing DOACs (99% of ASCO and 96% of SGO respondents). ASCO respondents were more likely to consider DOACs as first line therapy for treatment of cancer-associated VTE than SGO members (82% vs 63%, p < 0.01) and SGO members were more likely to consider low molecular weight heparin (LMWH) the standard of care treatment (66% vs 25% p < 0.01). Most respondents in both groups (75%) felt DOACs were equally safe and effective compared to LMWH but more ASCO members felt DOACs were cost effective (70% vs 49%, p < 0.01). More SGO respondents reported having prescribed prophylactic anticoagulation during chemotherapy than ASCO members (53% vs 35%, p < 0.01).

CONCLUSION

ASCO respondents were more likely to prescribe DOACs for both treatment and prophylaxis of cancer-associated VTE than SGO members. However, SGO members were more likely to prescribe prophylactic anticoagulation to high risk patients initiating chemotherapy compared to ASCO members.

Which patients on a gynecologic oncology service will require perioperative transfusion? A single-center retrospective cohort study

The purpose of this study was to determine which patient- or surgery-related factors are predictive of need for perioperative transfusion to avoid obtaining unnecessary pre-operative type and screens (T&S). We conducted an observational retrospective cohort study of 1200 women ≥ 18 years old undergoing gynecologic surgery for benign, possibly benign, or malignant indications on a gynecologic oncology service at a university medical center from 2009-2016. A logistic regression model was used to examine patient-related and surgery-related variables predictive of outcome of transfusion. Independent variables included patient demographics, comorbidities, and surgical indication surgical route, and surgical type. Dependent variable was transfusion outcome (T&S only, conversion to type and cross (T&C), or transfusion). Eight hundred ninety-nine (74.9%) women underwent pre-operative T&S, of which 118 (9.8%) were converted to T&C, and 80 (6.7%) received a transfusion of blood or blood products. Cancer indication, major surgery, and preoperative hematocrit less than 36% were significantly associated with need for transfusion (P = 0.002, P < 0.0001, P < 0.0001, respectively). Patients with a benign indication undergoing minor procedures and with normal preoperative hematocrit are least likely to require transfusion.

Direct oral anticoagulant use in gynecologic oncology: A Society of Gynecologic Oncology Clinical Practice Statement

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in women with gynecologic malignancies. This practice statement provides clinical data and overall quality of evidence regarding the use of direct oral anticoagulants (DOACs) in this patient population. Specifically, it reviews patient selection, safety measures, and nuances of perioperative use of these medications. The scope of this document is limited to DOAC use in gynecologic oncology rather than a broad discussion of VTE prophylaxis and management in general. The following recommendations and examination of extant data are based on DOAC trials conducted primarily in mixed populations with different cancer subtypes. Many of these trials include few, or no, women with gynecologic cancer. However, because there is very limited data in gynecologic cancer-specific populations, the results of these studies represent the best available evidence to support treatment recommendations in our patients. The members of the Society of Gynecologic Oncology (SGO) Clinical Practice Committee believe that the results of these studies may be extrapolated, with caution, to VTE treatment and prophylaxis for patients with gynecologic cancer.

Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature

PURPOSE

The purpose of this review is to assess the impact of mechanical and oral antibiotics bowel preparation on surgical performance and to investigate their role before gynecologic surgical procedures regarding the infection rates. We also aim to study the updated evidence regarding the use of these different types of bowel preparation, as well as the current preoperative practice applied.

METHODS

An extensive search of the literature was conducted with Medline/PubMed, and the Cochrane Library Database of Systematic Reviews being used for our primary search.

RESULTS

To date, due to the conflicting guidelines by the scientific societies, surgeons do not use a specific pattern of bowel preparation regimen. There are no strong evidence supporting mechanical bowel preparation, but instead, in many cases, patients' adverse effects, both physiological and psychological have been noted. On the other hand, the combined use of oral antibiotic and mechanical bowel preparation has been proven beneficial in colorectal surgery in reducing postoperative morbidities.

CONCLUSION

Based on current literature, in gynecologic surgeries with minimal probability of intraluminal entry, a regimen without any bowel preparation should be applied. The combined administration of both mechanical and oral antibiotic bowel preparation, or even the use of the oral antibiotics alone, should be preserved for cases of increased complexity, where bowel involvement is highly anticipated, such as in gynecologic oncology, as stated in the ERAS protocols. Nonetheless, further research specific to gynecologic surgery is required.

Is Mechanical Bowel Preparation Necessary for Gynecologic Surgery? A Systematic Review and Meta-Analysis

OBJECTIVE

To clarify the efficacy and side effects of mechanical bowel preparation (MBP) before gynecologic surgery.

METHODS

A systematic review was conducted. Embase, PubMed, the Cochrane Central Register of Controlled Trials in the Cochrane Library and China National Knowledge Infrastructure were searched. Randomized controlled trials on MBP prior to gynecologic surgery were included. The software package Revman 5.3 was used for statistical analysis. Odds ratio (OR) and standard mean deviation were calculated for dichotomous and continuous variable, respectively.

RESULTS

The quality of the included studies was moderate to good. MBP prior to laparoscopic gynecologic benign surgery or vaginal prolapse surgery has not been proven to be valuable for surgical performance, mainly involving visualization of the surgical field (OR 1.52, 95% confidence interval [CI] 1 to 2.32; Z = 1.95, p = 0.05), bowel handling (OR 2.21, 95% CI 0.83 to 5.84; Z = 1.59, p = 0.11), surgical complications (OR 1.3, 95% CI 0.46 to 3.67; Z = 0.5, p = 0.62) and bowel preparation. The discomfort due to oral catharsis is severer than no bowel preparation and enema, however without any difference between enema and no bowel preparation.

CONCLUSION

The routine practice of MBP before gynecologic surgery needs to be reconsidered. This traditional clinical behavior has to be abandoned before benign laparoscopic surgery. Studies on the role of MBP for gynecologic laparotomy and gynecologic cancer are urgent. © 2015 S. Karger AG, Basel.

Unintended consequences: surgical complications in gynecologic cancer

More than 91,000 women in the USA will be diagnosed with a gynecologic malignancy in 2013. Most will undergo surgery for staging, treatment or both. No therapeutic intervention is without consequence, therefore, it is imperative to understand the possible complications associated with the perioperative period before undertaking surgery. Complication rates are affected by a patient population that is increasingly older, more obese and more medically complicated. Surgical modalities consist of abdominal, vaginal, laparoscopic and robotic-assisted approaches, and also affect rates of complications. An understanding of the various approaches, patient characteristics and surgeon experience allow for individualized decision-making to minimize the complications after surgery for gynecologic cancer.