stockings decrease the incidence of venous thromboembolism and is recommended.13 Intravenous antibiotics and antimicrobial skin preparation is strongly recommended to prevent surgical site infections. Preoperative iron therapy in anemic patients reduces the need for perioperative transfusion, which along with erythropoiesis stimulating agents is associated with increased tumor recurrences. Recommended Intra-operative Management: Opioid sparing anesthetic techniques and lung protective ventilation are recommended. Due to the high incidence of postoperative nausea and vomiting in the gynecologic population multimodal antiemetic prophylaxis is recommended. Minimally invasive surgery improves patient outcomes and is strongly recommended. Nasogastric tubes increase postoperative pulmonary complications and patient discomfort and are strongly discouraged.14 Temperature monitoring and use of active warming devices is mandatory to prevent hypothermia and its consequences on coagulation, infection and cardiac complications. Maintaining normovolemia with goal directed fluid therapy has been demonstrated to reduce morbidity in the colorectal surgery and is strongly recommended. Balanced salt solutions are preferable to normal saline solutions. Advanced hemodynamic monitoring facilitates optimizing of patients volumes status in high risk patients or patients having extensive surgeries.15 Recommended Postoperatve Management: Thromboprophylaxis is recommended for 30 days postoperatively due to a high incidence of venous thrombosis in gynecologic oncology patients.16 Multimodal analgesia with scheduled administration of nonsteroidal anti-inflammatory agents, and acetaminophen is strongly recommended.17 9. A recent review of patients undergoing hysterectomy found that gabapentin has effective in reducing pain and opioid adverse effects. Dexamethasone is recommended for the analgesic and anti-emetic effects.18 The evidence supporting the use of epidural analgesia is weak, and, it may result in impaired mobilization and need for a urinary catheter. Systemic lidocaine analgesia is associated with opioid sparing effects and is gaining popularity, but the optimum dosage has to be determined.19 Conclusions These recommendations are based on current scientific literature and are subject to change(s) as additional institutions adopt the principles of ERAS and the number of high quality randomized controlled studies that incorporate ERAS principles increases. n References 1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-41. 2. Lu D, Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database Syst Rev. 2015; 19:3. 3. Miralpeix E, Nick AM, Meyer LA, Cata J, Lasala J, Mena GE, Gottumukkala V, Iniesta-Donate M, Salvo G, Ramirez PT. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141: 371-78. 4. Dickson E, Argenta PA, Reichert JA. Results of introducing a rapid recovery program for total abdominal hysterectomy. Gynecol Obstet Investig 2012; 73: 21-25. 5. Modesitt SC, Sarosiek BM, Trowbridge ER Redick DL, Shah PM, Thiele RH, Tiouririne M, Hedrick TL. Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol 2016; 123:457-66. It is strongly recommended that intravenous fluids be discontinued within 24 hours after surgery and oral diet and analgesics commenced. 6. Carter J. Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN surg 2012; 368014. 7. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013; 122, 1305. 8. Nelson G, Kalogera E, Dowdy S. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014 135(3): 586-94. 12 ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for pre- and intraoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations – Part I. Gynecol Oncol 2016; 140, 313-322. 10. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations – Part II. Gynecol Oncol 2016; 140, 323-332. 11. Egbert LD, Battit GE, Welch CE, Bartlett MK: Reduction in postoperative pain bt encouragement and instruction of patients. A study of patient-doctor rapport. NEJM 1964; 270: 825-827. 12. Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J: Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev (8) 2014. 13. Amato A, Pescatori M: Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev (1) 2006. 14. Cheatham MI, Chapman WC, Key SP, sawyers JL: A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221: 469-476. 15. Hamilton MA, Cecconi M, Rhodes A: A systematic review and meta-analysis on the use of pre-emptive hemodynamic intervention to improve postoperative outcomes in moderate and high risk surgical patients. Anesth Analg 2100; 112: 1392-1402 16. Rasmussen MS, Jorgensen LN, WilleJorgensen P: Prolonged thromboprophylaxis with low molecularweight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev (1) 2009. 17. Ong CK, Seymour RA, Lirk P, Merry AF: Combining paracetamol (acetaminophen) with nonsteroidal anti-inflammatory drugs; aqualitative systematic reviewof analgesic afficacy for acute postoperative pain. Anesth Analg 2010; 110: 1170-1179. 18. Alayed N, Alghanaim N, Tan X, Tulandi T: Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis. Obstet Gynecol 2014; 123: 1221-1229. 19. Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al; Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev (7), 2015.
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