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In select patients with advanced ovarian cancer, primary cytoreductive surgery remains a standard approach with the aim of complete resection of all gross visible tumor.1 Prior data have demonstrated that survival outcomes are driven by geographical access and the use of specialized referral centers.2 Standardization of care is critical when managing patients with advanced ovarian cancer and assuring that consistent patterns of practice are established will likely increase potential for faster recovery and return to intended oncologic therapy.
In this September 2021 Lead Article of the International Journal of Gynecological Cancer,3 Fotopoulou et al provide a detailed outline focusing on essential elements of peri-operative care developed through a consensus process from an international multidisciplinary team of leaders in the field of gynecologic oncology. These guidelines were based on a thorough evaluation of the published literature and serve not as a tool to dictate a single strategy for management, but rather as a reference point to aid clinicians and surgeons in optimizing care and providing patients with the best outcomes.
Among the many highlights of these guidelines is an emphasis on patient education and discussion of the decision for surgery versus neoadjuvant chemotherapy. Information should be routinely provided to patients as to the ideal timing of surgery, the rationale for intervention, the potential peri-operative complications, and the anticipated expectations on post-operative management, and subsequent maintenance therapy and surveillance. In preparation for surgery, the authors highlight evidence-based data addressing routine points of discussion such as the use of bowel preparation, strategies for antibiotic prophylaxis, and prevention of peri-operative infections. A key component of all surgical interventions today is also stressed in this publication, this being the importance of a detailed and targeted surgical safety checklist, as this has been shown to decrease the intra-operative errors in the planning and execution of surgical procedures. Similarly, these guidelines provide key recommendations on the use of blood transfusions, peri-operative fluid replacement, and prevention of hypothermia. In addition, tools that may help surgeons in the reduction of blood loss are discussed including options of hemostatic agents, indications and use of abdominal packing in the setting of more traumatic blood loss, and considerations of interventional radiology options.
These guidelines will provide surgeons with an in-depth analysis of management of complications related to extensive cytoreductive techniques. These include, but are not limited to, strategies for liver resection and related adverse outcomes, biliary leaks, issues dealing with splenectomy, distal pancreatectomy, diaphragmatic resection, and pericardial lymph node resections. Often gynecologic oncology surgeons encounter the need for bowel resection, along with reconstructive procedures of the urinary tract. To that end, the authors of these guidelines have provided key tips on how to prevent and manage anastomotic leaks and stomal complications, as well as issues related to urological complications such as hydronephrosis, ureteric fistulae, and iatrogenic ureteral injuries.
Lastly, the authors provide a thorough discussion on post-operative management of patients undergoing cytoreductive surgery. This segment emphasizes the importance of thromboprophylaxis, treatment of deep venous thromboembolic events, and pulmonary emboli. There is also valuable information on different options for pain management and as well nutritional support for patients who may not be able to recover within the anticipated time frame expected after cytoreductive surgery. In addition, there is a very important segment presented in these guidelines referring to the management of frail patients and on the relevance of psycho-oncological and social support.
The authors ought to be congratulated for putting in the time, effort, resources, and expertize required to deliver this valuable tool for all surgeons and clinicians who provide peri-operative care to women undergoing cytoreductive surgery in the setting of advanced ovarian cancer.
Contributors PTR is the sole author.
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.