Evidence-Based GYN Surgery

Check out: https://www.ajog.org/article/S0002-9378(18)30583-0/fulltext

Remember the evidence-based C-section? Turns out, there is also good evidence for gyn surgery practices!

Preoperative - Includes things that are part of the ERAS protocol

1. Patient Education 

   • Two randomized control trials 

   • There was some potential association between preoperative patient education and improved outcomes (low level evidence) —> perhaps some decrease in length of stay and pain.

2. Bowel Prep

   • Minimally invasive gyn surgery:

     • Strong evidence that oral mechanical bowel prep should not be used.

   • In those with high risk of colorectal resection:

     • Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective 

     • Use of one of the following regimens can be considered: (moderate level evidence) 

       • Oral bowel prep AND oral antibiotic 

       • Oral antibiotic alone

3. Surgical site infection bundles - high level of evidence

   • High level of evidence - use of surgical site infection bundles should be considered! 

     • Listen back to our episode on “Infection Prevention and Gynecologic Surgery”: https://creogsovercoffee.com/notes/2019/10/13/infection-prevention-and-gynecologic-surgery

     • Sometimes, it’s not always just a single thing, but the whole bundle!

4. Glucose management 

   • Goal of <180 mg/dL (high level of evidence) 

5. Diet

   • Reduce fasting - may ingest solids until 6 hours prior to anesthesia induction and clear liquids until 2 hours prior to induction 

     • High level of evidence 

   • Carbohydrate loading - routine carbohydrate loading is recommended (moderate level of evidence) 

     • May ingest 2-3 hours up to induction of anesthesia - can include things like apple juice, ensure clear, etc. 

6. Pre-anesthesia medication 

   • Pain:

     • Combination of acetaminophen, COX-2 inhibitor (celecoxib, for example), and/or gabapentin - level of evidence is high!

   • Nausea:

     • Scopolamine, midazolam, or gabapentin (high level of evidence) 

7. VTE prophylaxis - moderate evidence 

   • Overall low rates of VTE in general, but preoperative intermittent pneumatic compression alone for patients undergoing MIS or laparotomy for benign disease

   • Weak evidence from observational studies supports adding preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies  

Intra-operative 

1. Drains 

   • Routine NG tube - associated with patient discomfort and no known benefit (high level of evidence) - from the ERAS Society 

   • Routine peritoneal drains - not recommended routinely in gyn or onc surgery including cases with lymphadenectomy or bowel surgery

     • 2017 Cochrane Database showed drainage was not associated with reduced rates of lymphocyst formation. However, use of surgical drains increased rates of symptomatic lymphocyst formation when the pelvic peritoneum was left open 

     • Overall, moderate evidence  

2. Antibiotic prophylaxis

   • Given within 1 hour prior to incision per CDC and ACOG; redose prophylactic antibiotics for long procedures (ie. Ancef 3-4 hours after incision)

     • Level of evidence is high

3. Skin prep

   1. Ideally use 2% chlorhexidine and 70% isopropyl alcohol solution (high level of evidence) 

4. Blood transfusion (for hemoglobin 6-10) and fluids to maintain intraoperative euvolemia

5. Maintain normothermia 

6. Pain management - liposomal bupivicaine for laparotomy cases (moderate)  

Postoperative

1. Early mobilization - moderate level of evidence 

   • Has been shown to be beneficial and to avoid prolonged bedrest; basically meaning out off bed and mobilizing within 24 hours of surgery 

     • Reduces PEs and VTEs, also may protect against muscle atrophy and deconditioning 

2. Early alimentation 

   • Postoperative feeding - within 24 hours of surgery (can be as early as 4 hours after surgery with or without bowel resection) 

   • Two systematic reviews and 1 meta-analysis - early feeding is safe, well-tolerated and results in earlier return of bowel function and shorter LOS 

3. Early urinary bladder catheter removal (mod level evidence) 

   • Catheter use for < 24 hours, but appropriate to consider fall risk and necessity of urine output monitoring 

   • Uncomplicated surgeries: consider removal at 6 hours to balance rate of infection vs retention 

   • Complicated: morning after may be more appropriate (ie. urogyn or gyn onc cases) 

4. Prevention of ileus and accelerate return of bowel function

   • Use of postop laxatives (recommended for gyn surg, low level of evidence) 

     • Docusate sodium (Colace): more about its lack of utility here.

   • Chewing gum (high level of evidence) 

   • Alvimopan (novel peripheral u-opioid antagonist) - may not be beneficial in benign gyn 

     • However, may decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection  

5. Early IV fluid discontinuation 

   • Discontinue maintenance IV fluids within 12-24 hours following surgery, especially with early PO intake (low level of evidence) 

     • Urine output as low as 20 mL/hour

       • Can be normal post op stress response 

       • Intervention not required 

6. Postoperative VTE: 

   • Mechanical prophylaxis for duration of hospitalization in all gyn surg patients 

   • Mechanical and/or pharmacologic prophy for gyn onc surgical patients (high level of evidence) 

     • Additionally, for oncology cases with laparotomy, should extend VTE prophylaxis for 4 weeks following surgery 

#MedEd: Applying into Gynecologic Oncology

Today we welcome one of our colleagues, Dr. Deanna Glassman, current PGY-4 at Women and Infants / Brown University, but heading off to Houston, TX this summer to become a new fellow in gynecologic oncology at MD Anderson Cancer Center!

She shares with us her own story of applying into GynOnc and the essential facts of this field.

Adnexal Masses Part IV: Sex Cord Stromal Tumors

Thanks for sticking with us until the end of this adnexal mass journey! Today we’re going to cover some rare tumors that always find themselves on CREOGs — the sex cord stromal tumors. These only comprise about 1.2% of primary ovarian cancers. Most people are fortunately diagnosed at an early stage due to the fact that symptoms tend to be much more overt with these types of tumors.

Granulosa Cell Tumors

There are two subtypes of granulosa cell tumors: adult and juvenile. Adult type comprises 95% of these neoplasms, and generally occur in women aged 50-54 years. Juvenile type typically develops before puberty. It has a higher proliferative rate, but lower risk for late recurrences. Regardless of type, these typically present as a large, unilateral mass clinically, with a mean diameter of 12cm. They can produce estrogen and/or progesterone, so symptoms can be related to hyperestrogenism particularly in juveniles (i.e., precocious puberty). The production of estrogen in adult types is also associated with concomitant endometrial hyperplasia or cancer; with EIN present in 25-50%, and endometrial carcinoma present in 5-10% of patients. Thus, it is important to perform endometrial sampling when one of these tumors is suspected or diagnosed.

The histopathology is classic: “Call-Exner bodies", where the pale, round, coffee-bean shaped nuclei characteristic of granulosa cells arrange themselves into rosettes around a central cavity.

Thecomas

Thecomas are solid, fibromatous, generally benign neoplasms. They are generally unilateral, and are comprised of theca cells. The theca cells appear in normal ovulation as follicles develop into secondary follicles, and under the influence of LH produce androgens. After ovulation, theca cells also help to form the corpus luteum with granulosa cells.

Because of this high production of androgen that will be converted, endometrial hyperplasia or cancer can also be found in these patients, and it is wise to perform endometrial sampling for that reason. Up to 20% of patients may have synchronous endometrial cancer.

Fibromas

These are the most common type of sex cord stromal tumor. They are benign, solid, unilateral neoplasms, generally occurring in postmenopausal women, and are not hormonally active. However these can be implicated in Meigs’ syndrome, where the tumor is associated with extensive ascites or a pleural effusion.

Sertoli / Leydig Cell Tumors

These two are the rarest of the sex cord stromal tumors, accounting for less than 0.5% of these. The histopathology of the hollow tubules (Sertoli) surrounded by fibrous stroma (Leydig) is classic. These will often produce androgens and be associated with virilizing symptoms. They also are unilateral and are often associated with large masses, with a mean size of 16cm at presentation. AFP is often another marker.

Adnexal Masses Part III: Germ Cell Tumors

Germ cell tumors are our next foray into these adnexal masses. They comprise 20-25% of ovarian neoplasms, can be benign or malignant, and occur generally in younger women: between ages 10-30 years.

Many of these for CREOGs are distinguished by specific tumor markers and specific histopathology. We’ve put a brief table together here to help with the episode and get some of those visual references!

View fullsize

(C) CREOGs Over Coffee (2019)

Adnexal Masses Part 1: Imaging

Today we’re embarking on a multi-part series through adnexal masses.

To frame our initial conversation on imaging features of adnexal masses, we’ve relied heavily on a golden piece of literature from the Radiological Society of North America, detailing the features and management of these findings on imaging. This paper contains a super nice table that should be considered a table-side reference for your own viewing of images.

Generally speaking, signs more suggestive of malignancy include:

• Patient age/menopausal status: One of the biggest contributing risk factors, even before you know what the cyst looks like. In postmenopausal women with asymptomatic adnexal masses, the incidence of malignancy approaches 30%, while it is only 6-11% in premenopausal women.

• Large size: cysts greater than 5cm should receive consideration for surgical intervention or closer follow up in premenopausal women. In postmenopausal women though, even small 1cm cysts should be considered for close interval follow up at a minimum.

• Thickness: thicker walls (>3mm) portend more significant pathology.

• Septations: multiple septations are also concerning for malignancy, though again this corresponds with the thickness; thinner septations may suggest more likely benign disease.

• Nodularity: cysts with nodules or calcifications, particularly with vascularity, are more concerning.

• Contents: one of the more nuanced findings; however, can help determine etiology: i.e., cysts with a reticular or lacy appearance are more suggestive of hemorrhagic cysts, while hyper echoic lines and dots with areas of acoustic shadowing are more suggestive of dermoid cysts.

Be sure to also check out ACOG PB 174 (membership required) and/or the OBG Project’s helpful bulleted summary! We definitely think looking through images alongside descriptive text is the primary way to learn this information, and we hope the podcast can help supplement that for some of you.