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Peri-operative ovarian cancer guidelines: major intra-operative and post-operative bleeding and thromboembolic events
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  1. Christina Fotopoulou1

    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.


    ,
  2. Dimitrios Haidopoulos2 and
  3. Ralf Ulrich Trappe3
  1. 1Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, UK
  2. 2Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
  3. 3Department of Hematology and Oncology, Christian-Albrechts-Universität zu Kiel, Kiel, Schleswig-Holstein, Germany
  1. Correspondence to Professor Christina Fotopoulou, Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, London, UK; chfotopoulou{at}gmail.com

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Intra-operative and post-operative bleeding is not common in advanced ovarian cancer surgery. Nevertheless, a multidisciplinary major hemorrhage protocol should be adopted by any center performing cytoreductive procedures. Surgical, pharmacological, and interventional radiology options should be part of the armamentarium, depending on each individual situation, timing, and available resources (Figure 1).

Figure 1

The risk profile of patients with ovarian cancer who undergo radical cytoreductive procedures has evolved over time, bringing more challenges to the peri-operative care of such patients. A thorough understanding of aspects around thrombophilia and thrombogenesis is crucial to minimize surgical morbidity. LMWH, low molecular weight heparin; VKA, vitamin-K antagonists; VTE, venous thromboembolism.

Surgical options include standardized maneuvers for prophylaxis and bleeding control, local hemostatic agents, and ligation of relevant feeding vessels.1 Packing of the abdomen is seen as ‘ultima ratio’ in cases of uncontrollable bleeding and hemodynamic instability.2 ,3 Close interdisciplinary collaboration between anesthetists, interventional radiologists, surgeons, and hematologists4 is key for the successful management without excessive increase of morbidity and mortality.5

The same applies also for the prophylaxis and management of peri-operative thromboembolic events: restrictive use of inferior vena cava filters, prolonged post-operative prophylactic anticoagulation, increased use of NOAKs, postponing elective/non-emergency procedures after a fresh thromboembolic event, are some of the key principles of thromboembolic management.

Video 1 The risk profile of patients with ovarian cancer who undergo radical cytoreductive procedures has evolved over time bringing more challenges to the peri-operative care of such patients. A thorough understanding of aspects around thrombophilia and thrombogenesis is crucial to minimize surgical morbidity.

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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.


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Footnotes

  • 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.