The perioperative management of patients with gynaecological cancer undergoing major surgery: A debated clinical challenge

Major extensive surgery still represents a cornstone of therapy of gynaecological cancer, and the adoption of implemented clinical guidelines for perioperative management can significantly decrease patient morbidity and mortality and reduce hospital stay. The overall risk of deep venous thrombosis in patients undergoing gynaecological surgery ranges from 7% to 45%, and fatal pulmonary embolism occurs in approximately 1% of these women. A meta-analyses of randomised trials showed a significant decrease in deep venous thrombosis in women receiving unfractioned heparin [UFH] compared with controls, and revealed no significant difference in deep venous thrombosis and pulmonary embolism between patients who received UFH and those who received low-molecular weight heparin [LMWH]. Potential advantages favouring LMWH over UFH include once-daily versus repeated daily injections and a lower risk of heparin-induced thrombocytopenia. All patients undergoing major surgical operations should receive LMWH that should be started preoperatively and then given for 7-10 days at least and prolonged for up to 4 weeks in high-risk cases. Antithrombotic mechanical methods can be added to pharmacological agents, but should not been used alone. Cephalosporins and amoxicillin-clavulanic acid have been widely used in gynaecological surgery prophylaxis. Both amoxicillin-clavulanic acid and cefazolin have good in vitro activity against the microbes more frequently involved in postoperative infections, such as Gram-negative bacilli, but amoxicillin-clavulanic acid is more effective against anaerobes. A single dose of antibiotics has been shown to be as effective as multiple doses in many trials that have compared a single-dose regimen with a multiple-dose regimen. Amoxicillin-clavulanic acid prophylaxis at the induction of anaesthesia can be suggested for gynaecological cancer patients undergoing major gynaecological surgery with or without colorectal resection. An additional antibiotic dose is recommended for prolonged operations or when intraoperative blood loss is important. Cephalosporins can be administered to women with a history of penicillin allergy not manifested by an immediate hypersensitivity reaction, whereas tigecyclin should be reserved to patients with a prior anaphylactic reaction to beta-lactams. Recent meta-analyses of randomised trials on patients undergoing elective colorectal surgery found more anastomotic leakages in patients who had preoperative mechanical bowel preparation with oral administration of different solutions than in those who had not, whereas there were no significant differences between the two arms as for wound infections, other septic complications, and non-septic complications. Therefore, preoperative mechanical bowel cleansing is not warranted for gynaecological cancer patients scheduled for surgery that may involve colon-rectum. After major abdominal gynaecological surgery, early oral feeding (within the first 24h regardless of the resolution of postoperative ileus) appears to be associated with increased nausea, shorter time to the presence of bowel sound, shorter time to first solid diet, and a trend toward shorter hospital stay when compared with delayed feeding. Since early oral feeding is safe but associated with increased nausea, the decision whether to adopt this postoperative regimen should be individualised. Decision making processes about thromboprophylaxis, antibiotic prophylaxis, bowel preparation for surgery that may involve colon-rectum, and timing of postoperative oral feeding will become more and more relevant for improved safety and quality of life of women with gynaecological cancer.