First Enhanced Recovery After Surgery guideline for minimally invasive gynecologic surgery

The guideline, which was formulated by an American Association of Gynecologic Laparoscopists (AAGL) Task Force of U.S. and Canadian gynecologic surgeons, incorporates the five canonical components of every ERAS protocol: preoperative patient education and optimization; multimodal, narcotic-sparing analgesia; nausea, surgical site infection (SSI) and venous thromboembolism (VTE) prophylaxis; maintenance of euvolemia; and liberalization of activity.

When it comes to improving quality and outcomes, it is not enough to ‘simply do a good job in the operating room,’ said senior author Rebecca Stone, MD, an associate professor of gynecologic oncology at Johns Hopkins School of Medicine.

Rebecca Stone, MD

At the 2018 annual AAGL meeting, only a third of attendees surveyed at the inaugural Enhanced Recovery After MIS Surgery (ERAmiS) Panel Session reported using a formal ERAS pathway for perioperative management of patients undergoing minimally invasive endoscopic and vaginal surgery, according to Stone. “This was attributed in part to the lack of formalized ERAS guidelines dedicated to MIGS,” she told Contemporary OB/GYN.

Several guideline recommendations may be new to clinicians, including a “pathway to surgery” that minimizes missed opportunities to treat the most relevant and common medical comorbidities, such as obstructive sleep apnea, anemia, and diabetes. “The goal is to ensure that the patient is as well prepared as possible, in order to maximize their resilience to the physiological stress of surgery,” Stone said. “The surgeon and patient should partner in tackling risks related to functional status, chronic health and acute physiological deterioration.”

Gabapentinoids (pregabalin and gabapentin) have long been part of enhanced recovery multimodal, narcotic-sparing medication bundles. “However, recent FDA warnings about respiratory depression from gabapentinoids, with particular increased risk in narcotic-naïve older patients and/or those with obstructive sleep apnea, led us to recommend against their routine use in the prevention/treatment of surgical pain,” Stone said.

Intravenous first-generation cephalosporins, most commonly cefazolin, are the preferred prophylactic antibiotics for hysterectomy. “But emerging data indicate that SSI rates are higher when beta-lactam alternatives like clindamycin plus gentamycin are used, so their use should be restricted to those patients with a history of bonafide immunoglobulin E (IgE)-mediated penicillin hypersensitivity reactions, including urticaria, not just rash; angioedema; and anaphylaxis,” Stone said.

Conversion to chlorhexidine gluconate (CHG) for perioperative vaginal preparation also is recommended.

“There is a lot of controversy over the need for extended VTE prophylaxis following MIGS for cancer,” Stone said. “This has resulted in huge practice variation in the prescribing of extended thromboprophylaxis for MIGS, which is inconsistent with the overall ERAS mission of evidence-based care standardization.”

The new guideline modifies the historic Caprini scoring system for VTE risk assessment and prescribing of extended thromboprophylaxis, based on clinical risk factors like cancer stage, grade and extent of lymphadenectomy that now align with the VTE incidence observed during the past 10 years of MIGS in over 10,000 women with gynecologic cancer.

“In general, the guideline provides a real opportunity for us to intensify the known benefits of MIGS, including decreased pain, complications and recovery time,” Stone said. “Another advantage of protocolized perioperative care is reducing clinically inappropriate variability in care. This is important for cost containment and eradicating health inequalities.”

Moreover, the guideline facilitates shared care, encourages multidisciplinary communication and action in general, which is especially critical during the COVID-19 pandemic.

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Disclosures

Stone reports no relevant financial disclosures.

Stone R, Carey E, Fader A, et al. Enhanced recovery and surgical optimization protocol for minimally invasive gynecologic surgery: an AAGL white paper. JMIG. Published online August 19, 2020. doi:org/10.1016/j.jmig.2020.08.006.