• Ovarian Cancer

The concept of ERAS (Enhanced Recovery After Surgery) aims at the reduction of peri-operative morbidity, accelerates the recovery process, and improves the quality of life of patients in gynecologic oncology.1 The strategy consists of a bundle of evidence-based interventions that emphasize the active role of the patient: patient education, avoidance of prolonged fasting, balanced fluid management, early feeding and mobilization, and opioid-sparing pain management are some of the key elements.2 3 Recent trials from other disciplines recommend the introduction of so-called prehabilitation (PREHAB) programs to improve the health status prior to complex surgery.4 5 For that reason, prehabilitation strategies have become an integral part of national and international surgical guidelines (Figure 1).6 Multimodal approaches include strategies for best supportive care, nutrition support, pain management, physiotherapy, and patient education.1 Nevertheless, PREHAB programs are yet not standardized and in general the evidence level specifically for gynecologic oncology is still low.1 Current studies seek to link pre-rehabilitation algorithms to the already established ERAS concepts in an effort to define a more global and inclusive concept with the ultimate aim to minimize surgical morbidity and mortality.7 The recently published European Society of Gynecologic Oncology (ESGO) consensus paper for the peri-operative management of advanced ovarian cancer patients undergoing debulking surgery emphasizes the following statements regarding prehabilitation, ERAS strategies, post-operative mobilization, and ileus prevention1:

Trimodal concepts consisting of physical exercise, nutritional assessment and intervention and psychological support, and patients' education are key elements of this program (III, B).

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Figure 1

Prehabilitation concepts are now an integral part of peri-operative enhanced recovery algorithms also for patients who undergo cytoreductive procedures for advanced and relapsed ovarian cancer.

The implementation of Enhanced Recovery After Surgery protocols in gynecological oncology is recommended, whereby monitoring of adherence is of fundamental importance (II, A).

A multimodal approach, comprising early feeding, goal-directed/balanced fluid therapy, physical activity, opioid-sparing pain therapy, and early mobilization, is recommended for the prevention of post-operative ileus (III, B).

Physiotherapy should be offered as part of routine peri-operative care for women with ovarian cancer (III, B).

Early mobilization after surgery is recommended (III, B).

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.