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Surgery for advanced ovarian cancer has drastically evolved over the last decades with an increased radicality on multiple levels. Patients with high tumor burden, relapsed disease, and multiple previous lines of treatment are now being offered debulking surgery, in an effort to prolong their remission and survival.1 National and international guidance emphasizes the importance of performing these surgeries within dedicated specialist teams, to achieve best possible outcomes with acceptable morbidity. The European Society of Gynaecological Oncology (ESGO) has already defined quality indicators for surgery in advanced disease.2 Now, as a continuation of ESGO's mission to optimize and homogenize surgical standards, we present to our membership—and beyond—the peri-operative guidelines for ovarian cancer surgery. This is a guide to support ovarian cancer surgeons in the pre-operative, intra-operative, and post-operative care of their patients covering all relevant aspects (Figure 1).
A dedicated body of experts comprising of gynecologists/medical oncologists, anesthetists, psycho-oncologists, microbiologists, hematologists, nutritionists, and interventional radiologists followed the well-defined standard operating procedures by ESGO to provide evidence-based guidance, in a process overseen by an independent methodologist to ensure elimination of bias.3
The guidance addresses surgical aspects and also how to manage long-term morbidity, psychosocial support, interaction with novel targeted agents, pharmacologic treatment of infections and thromboembolic events as well as interventional radiology options.
We emphasize the importance of a comprehensive assessment of pre-operative nutritional status via validated nutritional screening tools for malnutrition to guide personalized nutritional supplementation where necessary. The enhanced recovery and prehabilitation principles4 are embraced with recommendation of carbohydrate pre-loading prior to surgery. Dietary support should be provided in those patients with extensive bowel surgery and stoma formation.
At the start of the operation, surgical site antisepsis should be performed using 4% chlorhexidine gluconate with alcohol.5 Pre-operative hair shaving and patients bathing or showering with antiseptic solutions is not recommended.
The WHO surgical checklist is an essential part of surgical safety, as is appropriate and correct patients positioning and placement of retractors to avoid nerve and vessels injuries and possible long-term dysfunctions.6
Data availability statement
Data are available in a public, open access repository.
Patient consent for publication
Christina Fotopoulou is the Professor of Gynaecological Cancer Surgery in the Department of Surgery and Cancer, Faculty of Medicine of Imperial College London, UK. She is the Deputy director of the Ovarian Cancer Action Research Centre at Imperial College. She holds an honorary chair in the Gynaecology Department at the Charite’ University of Berlin, where she was trained and then later took the role of the Vice Director of the Gynecological Department. Her surgical and scientific expertise focuses on the management of patients with advanced and relapsed ovarian cancer, profiling of tumor heterogeneity and integration of tumor biology factors with surgical effort under the umbrella of individualization of surgical care. She has served as the Chair of the guidelines committees of the British Gynaecological Cancer Society (BGCS) and of ESGO (European Society of Gynaecologic Oncology). She has been an elected member of the ESGO Council and is also a member of the German AGO- Ovarian Cancer Group. She is on the editorial board and reviewer of numerous international gynaecological and oncological journals and is a member of various international oncological committees, including BGCS, ASCO, ESGO, IGCS, ESMO, ENGOT, AGO, SGO and NOGGO.
Presented at Published in partnership with the European Society for Gynecologic Oncology and BMJ
Contributors All authors collected data, wrote the statements and made the videos.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.