The ERAS® Society Handbook for Obstetrics & Gynecology

By Michael J. Scott

The ERAS® Society Handbook for Obstetrics & Gynecology covers all aspects of enhanced recovery care for disciplines of general gynecology, gynecologic oncology, urogynecology and obstetrical surgery. Written by renowned experts in the field, chapters discuss foundational knowledge on ERAS and provide specific worked examples, ERAS order sets, and practical implementation tools. This book is an indispensable resource to researchers interested in ERAS, but it is also ideal for anesthesiologists, gynecologists and obstetricians interested in initiating an ERAS program.

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that originated in colorectal surgery and has now spread to numerous other disciplines, including gynecology (benign and malignant) and obstetrics (caesarean delivery). ERAS is associated with improvements in clinical outcomes (reduction in length of hospital stay, complications, readmissions), cost savings for the healthcare system, and patient satisfaction, hence the addition of this comprehensive resource on the topics is a welcomed addition to the available literature.

• Covers all aspects of enhanced recovery care for the disciplines of general gynecology, gynecologic oncology and obstetrical surgery
• Enables gynecologists and obstetricians to realize improvements in clinical outcomes for their patients by providing knowledge and practical tools for implementation of the ERAS program
• Discusses specific worked examples and provides practical implementation tools

• Language: English
• Publisher: Academic Press
• Release date: Jun 8, 2022
• ISBN: 9780323918251

Book preview

9780323918251_FC

The ERAS® Society Handbook for Obstetrics & Gynecology

First Edition

Gregg Nelson

Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Pedro T. Ramirez

Department of Gynecologic Oncology & Reproductive Medicine, MD Anderson Cancer Center, Houston, TX, United States

Sean C. Dowdy

Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, United States

R. Douglas Wilson

Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Michael J. Scott

Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States

Table of Contents

Cover

Title page

Copyright

Contributors

About the editors

Foreword

Preface

Section I: Preoperative

Chapter 1: Prehabilitation

Abstract

What is prehabilitation and why do we need it?

Current status of prehabilitation programs

Elements of prehabilitation

Conclusions

Summary points

References

Chapter 2: Preoperative optimization

Abstract

Introduction

Preoperative optimization as part of enhanced recovery pathway

Patient risk assessment

Age and frailty

Anemia

COVID-19 status

Psychological factors: Chronic pain and opioid tolerance

Pulmonary and OSA

Hypertension

Cardiovascular: Atrial fibrillation, coronary artery disease

Diabetes

Renal disease

Anticoagulation: DOACs, warfarin, and antiplatelet therapy

Antibiotics and allergy testing

Decolonization

Day of surgery routine medications

Hydration and carbohydrate loading

Conditions specific to GYN oncology

Timeline for preoperative optimization

Implementing a preoperative clinic into a health system

Summary points

References

Chapter 3: Bowel preparation

Abstract

Introduction

Definitions

Discussion

Summary points

References

Chapter 4: Preoperative fasting and carbohydrate loading

Abstract

Preoperative fasting

Preoperative carbohydrate loading

Immunonutrition

Summary points

References

Section II: Intraoperative

Chapter 5: Anesthetic protocol

Abstract

Introduction

Obstetrics

Central neuraxial block in obstetrics

General anesthesia in obstetrics

Gynecology

Anesthetic protocol for major gynecology procedures

Conclusions

Summary points

References

Chapter 6: Surgical site infection prevention

Abstract

Introduction

Terminology

Antimicrobial prophylaxis

Smoking cessation

Skin and vaginal preparation

Avoidance of hyperglycemia

Wound interventions

Nutritional status

Conclusion

Summary points

References

Chapter 7: Avoidance of drains and tubes

Abstract

Background

Nasogastric tube

Peritoneal drains

Urinary catheter

Cesarean section

Subcutaneous drain/groin drain

Pleural cavity drains

Conclusion

Summary points

References

Chapter 8: Maintenance of normothermia

Abstract

Introduction

Physiology of thermoregulation

Thermoregulation under different types of anesthesia

The impact of hyperthermia

The impact of hypothermia

How to maintain normothermia

Monitoring of body temperature

Conclusions

Summary points

References

Chapter 9: Fluid and hemodynamic therapy

Abstract

Introduction

Fluids and enhanced recovery after surgery programs

Surgical stress response

Types of intravenous fluids

Cardiac output monitoring

Goal-directed fluid therapy

Obstetrics

Gynecology

Conclusion

Summary points

References

Chapter 10: Postoperative nausea and vomiting: A pragmatic program

Abstract

Introduction

Prevention and risk stratification

Standardized multimodal approach

Pathways, pharmacology, and side effects

Treatment

Special considerations

Summary

Summary points

References

Section III: Postoperative

Chapter 11: Postoperative opioid sparing analgesia

Abstract

Introduction

Opioid use considerations

Preoperative opioid use

Postoperative local/regional analgesia

Opioid-sparing multimodal approach

Reducing discharge opioid prescriptions

Pharmacogenomics

Pain control after cesarean section

Considerations in minimally invasive surgery

Summary

Summary points

References

Chapter 12: Impact of early oral intake

Abstract

Introduction

Early oral intake paradigm as part of the ERAS multimodal process of care

The impact of early oral intake

Evidence in specific subspecialties

Nutritional supplementation

Future developments

Conclusion

Summary points

References

Chapter 13: Venous thromboembolic prophylaxis

Abstract

Preoperative anticoagulation

Intraoperative prophylaxis

Immediate postoperative prophylaxis

Extended postoperative prophylaxis

Special populations

Summary points

References

Chapter 14: Early mobilization and impact on recovery

Abstract

Introduction

Early mobilization

Early mobilization in different ERAS pathways

Early mobilization in gynecological surgery

Barriers and facilitators to mobilization

Role of physiotherapists

Conclusion

Summary points

References

Chapter 15: Patient reported outcomes (PROs): Considerations for implementation in your ERAS program

Abstract

Introduction

Using PROs in clinical practice: Background and applicability to ERAS

Planning PRO implementation: Basics for consideration

Planning PRO implementation: Considering resource limitations and respondent burden

Planning PRO implementation: Data interpretation and analysis

PROs in the surgical literature

Summary points

References

Section IV: ERAS implementation

Chapter 16: Creating an ERAS team and order set

Abstract

Introduction

Creating the ERAS team

Creation of the order set

Summary points

References

Chapter 17: Audit of compliance and clinical outcomes

Abstract

Introduction

Designing a robust audit for compliance

Assessing clinical outcomes

Applications of compliance data to clinical research

Reporting compliance for ERAS

Conclusion

Summary points

References

Section V: Discipline specific considerations and outcomes

Chapter 18: Cesarean delivery

Abstract

Introduction

Overview of ERAS and ERAC guidelines

Care pathway elements

Overview of published studies

Summary

Summary points

Conflict of interest to declare

References

Chapter 19: Minimally invasive surgery

Abstract

Introduction

Preoperative considerations

Intraoperative considerations

Postoperative considerations

Minimally invasive bowel surgery for benign disease and ERAS

ERAS outcomes in MIGS

Summary points

References

Chapter 20: Gynecologic oncology

Abstract

Introduction

A brief history of ERAS research in gynecologic oncology

Patient considerations in gynecologic oncology

Surgical considerations of gynecologic oncology

Controversies and areas of uncertainty

Summary points

References

Chapter 21: Urogynecology and pelvic reconstructive surgery

Abstract

Introduction

ERAS protocols in urogynecology

Same-day discharge

Geriatric factors: Frailty, functional, and cognitive status

Perioperative pain management

Persistent chronic pain

Voiding dysfunction

Vaginal packing

Conclusion

Summary points

References

Index

Copyright

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Contributors

Chahin Achtari

Gynaecology Unit, Department Women-Mother-Child, Lausanne University Hospital (CHUV)

University of Lausanne, Lausanne, Switzerland

Alon D. Altman

Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba

Research Institute, CancerCare Manitoba, Winnipeg, MB, Canada

Jamie N. Bakkum-Gamez     Gynecologic Oncology, Mayo Clinic, Rochester, MN, United States

Victoria Bennett     Department of Anaesthesia, Royal Surrey NHS Foundation Trust, Guildford, United Kingdom

Geetu Bhandoria (Prakash)     Department of Obstetrics and Gynecology, Command Hospital, Kolkata, India

Steven Bisch     Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada

Hans D. de Boer     Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands

Laurent Bollag     Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States

Adela Cope     Division of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States

Kevin M. Elias

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women’s Hospital

Dana-Farber Cancer Institute

Harvard Medical School, Boston, MA, United States

William John Fawcett     Department of Anaesthesia, Royal Surrey NHS Foundation Trust, Guildford, United Kingdom

Emily Fay     Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States

Gretchen E. Glaser     Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States

Sarah P. Huepenbecker     Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States

Maria D. Iniesta     Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, TX, United States

Chris Jones     Department of Anaesthesia, Royal Surrey NHS Foundation Trust, Guildford, United Kingdom

Eleftheria Kalogera     Gynecologic Oncology, Miami Cancer Institute, Miami, FL, United States

Leigh Kelliher     Department of Anaesthesia, Royal Surrey NHS Foundation Trust, Guildford, United Kingdom

Zaraq Khan

Division of Minimally Invasive Gynecologic Surgery

Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, MN, United States

Fleurisca J. Korteweg     Department of Obstetrics and Gynecology, Martini General Hospital Groningen, Groningen, The Netherlands

Amanika Kumar     Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States

Jenna K. Lovely     Pharmacy, Mayo Clinic, Rochester, MN, United States

Larissa A. Meyer     Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States

Ester Miralpeix     Obstetrics and Gynecology, Hospital del Mar, Barcelona, Spain

Basile Pache

Gynaecology Unit, Department Women-Mother-Child, Lausanne University Hospital (CHUV)

University of Lausanne, Lausanne, Switzerland

Magali Robert     Section of Urogynecology and Pelvic Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Michael J. Scott     Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States

Pranav Shah     Anesthesiology and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States

T.S. Shylasree     Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Henriette Smid-Nanninga     Scientific Institute, Martini General Hospital Groningen, Groningen, The Netherlands

Diana Encalada Soto     Division of Minimally Invasive Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States

Pervez Sultan     Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States

Carolyn Swenson     Division of Urogynecology and Pelvic Reconstructive Surgery, University of Utah, Salt Lake City, UT, United States

Jolyn S. Taylor     Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States

Pat Trudeau     Surgery Strategic Clinical Network™, Alberta Health Services, Edmonton, AB, Canada

Leense S. Wagenaar     Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands

Sumer K. Wallace     Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States

Simrit K. Warring     Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, United States

Lena Wijk     Department of Obstetrics and Gynaecology, Örebro University Hospital, School of Medical Sciences, Faculty of Health and Medicine, Örebro University, Örebro, Sweden

About the editors

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Gregg Nelson

Dr. Gregg Nelson is Professor and Chief of Gynecologic Oncology at the Cumming School of Medicine, University of Calgary, in Calgary, Alberta, Canada. His principal research interest is the development and study of Enhanced Recovery After Surgery (ERAS) protocols in OB-Gyn and cancer surgery. He holds the position of Surgical Lead, ERAS Alberta and leads the ERAS Society Women’s Health Chapter that published the ERAS Guidelines for Gynecologic/Oncology Surgery, ERAS Guidelines for Cesarean Delivery, ERAS Guidelines for vulvar/vaginal surgery, and ERAS Guidelines for Cytoreductive Surgery/HIPEC. Dr. Nelson has authored over 180 peer-reviewed publications, has been invited to present on ERAS numerous times internationally, and is the Secretary of the ERAS Society.

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Pedro T. Ramirez

Dr. Pedro T. Ramirez is Professor in the Department of Gynecologic Oncology & Reproductive Medicine at MD Anderson Cancer Center in Houston, Texas, United States. He is the David M. Gershenson Distinguished Professor in Ovarian Cancer Research, Director of Minimally Invasive Surgical Research & Education, and the Director of the Gynecologic Oncology Enhanced Recovery After Surgery (ERAS) Program. In addition, he is the Editor-in-Chief of the International Journal of Gynecological Cancer. He is the Chair of the Global Gynecologic Oncology Consortium (G-GOC) for the Gynecologic Oncology Intergroup (GCIG). Dr. Ramirez has written Principles of Gynecologic Oncology Surgery, a textbook that addresses the strategies of preoperative evaluation of patients undergoing gynecologic oncology surgery, techniques and details of such procedures, and prevention and management of postoperative complications. Dr. Ramirez has published a total of 275 peer-reviewed articles and 19 book chapters.

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Sean C. Dowdy

Dr. Sean C. Dowdy is a consultant in the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology with a joint appointment in the Department of Surgery at Mayo Clinic in Rochester, Minnesota, United States. He serves as Vice Chair of the Department of Obstetrics and Gynecology. Dr. Dowdy also serves as Chief Value Officer of Mayo Clinic and is the Robert D. and Patricia E. Kern Associate Dean for Practice Transformation. Dr. Dowdy’s current research focuses on the study of quality and value in surgery, and he has worked to disseminate his surgical quality improvements beyond Mayo Clinic to national and international audiences. Dr. Dowdy is credited with more than 230 peer-reviewed publications. He serves as Associate Editor of Gynecologic Oncology and has held multiple leadership positions in international societies, including the Society of Gynecologic Oncologists, the International Gynecologic Cancer Society, the Society of Gynecologic Surgeons, and the Society of Pelvic Surgeons.

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R. Douglas Wilson, MD, MSC

Dr. R. Douglas Wilson is Professor Emeritus in the Department of Obstetrics & Gynecology and the Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Canada. He is a member of the Society of Obstetricians & Gynaecologists of Canada (SOGC), a member of the SOGC Board and Executive, SOGC President-Elect 2022–23, and Co-Chair of the SOGC Guideline Management Oversight Committee. He is a Core Member of the Alberta Strategic Clinical Network MNCY (Maternal Newborn Child and Youth). Dr. Wilson is the lead author of the ERAS Society Guidelines for Cesarean Delivery. His research interests include rural obstetrics and surgery, quality improvement, maternal morbidity and mortality, and ERAS (Cesarean Delivery). He has authored over 325 peer-reviewed publications and 10 book chapters.

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Michael J. Scott

Dr. Michael Scott is Professor and Division Chief in Critical Care Medicine in the Department of Anesthesiology at the University of Pennsylvania, United States. He has an extensive background in perioperative surgical outcome quality improvement and implementation science. He is a longstanding member of the Executive Committee of the ERAS Society and is currently President of ERAS USA. He has championed the reduction in opioid use in surgery and has been involved in webinars for the Office of the White House Office of National Drug Policy (ONDCP). He has an interest in telemedicine/ICU and the use of artificial intelligence and machine learning with physiological waveforms. Dr. Scott was a member of the World Health Organization Lifebox Project Committee which is saving countless lives around the world by providing pulse oximeters and training teams in low- and middle-income countries. Dr. Scott has authored numerous ERAS guidelines, textbooks, and peer-reviewed scientific papers.

Foreword

Olle Ljungqvist, MD, PhD, Cofounder and Chairman of the ERAS® Society, Professor of Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden

As you are reading this text, you are holding in your hand a brand-new treasure containing all you need to know about modern care for the patient undergoing surgery for obstetrics and gynecology. This ERAS® Society Handbook for Obstetrics & Gynecology serves both as a textbook and a handbook. It is based on the latest ERAS Society guidelines in perioperative care for obstetrics and gynecology and presents the optimal care pathway available today.

The enhanced recovery after surgery (ERAS) way of delivering care to surgical patients, employing a multimodal, multiprofessional and evidence-based approach has revolutionized care for surgical patients in all disciplines worldwide in recent years. For obstetrics and gynecology, this development has been moving fast in the past few years as the ERAS principles and guidelines have shown to result in substantial improvements for everyone involved, not least the patient. ERAS reports major improvements in recovery with several days fewer required for hospital care, marked reductions in complications, and overall substantial savings for the care providers and health system.

In this book the knowledge of each evidence-based guideline care element is expanded and presented in an easy-to-read handbook format complemented by the facts and nice illustrations. It also gives the reader practical tips on how to employ the guideline care elements in daily practice.

This handbook is the first of its kind in the field of obstetrics and gynecology from the ERAS® Society written under the leadership of Professor Gregg Nelson. Professor Nelson has involved world-leading authors to help bring the reader the best available knowledge in each part of the patient’s journey. Starting from the preadmission phase covering prehabilitation and general optimization of the patient, to the immediate preoperative issues, including preoperative fasting and metabolic preparation with carbohydrate treatments, as well as bowel preparation. Further, all relevant details on intraoperative management including anesthetic protocols, infection control, fluid management and hemodynamics, and prophylaxis for postoperative nausea and vomiting and venous thromboembolism. The postoperative chapters cover analgesia management minimizing opioid use, early feeding, mobilization and patient involvement, and reporting. Importantly, the book also covers the importance of auditing in implementing the ERAS methodology, and the final chapters are more specifically directed at issues in obstetric surgery, gynecologic oncology, urogynecology and minimally invasive gynecologic surgery.

The ERAS® Society Handbook for Obstetrics & Gynecology is a book that can help support every gynecologist and obstetrician, anesthesiologist, nurse, physiotherapist, nutritionist, and student involved in the care of these patient groups and deliver the most updated modern care available. This handbook is wholeheartedly recommended for all the above as well as for teachers and students at every level, from undergraduate to postgraduate, in these areas of medicine.

Preface

Gregg Nelson, Editor, Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada

It was in June 2013 when I first met Professor Olle Ljungqvist. He and his group from the ERAS® Society had been invited to Alberta to help teach a couple of our colorectal surgery teams how to undertake the enhanced recovery after surgery (ERAS) protocols. We were having a problem in our province of spending lots of money on surgery but not obtaining improved outcomes in return. ERAS was thought to be a potential solution. I had been named Surgical Lead, ERAS Alberta a couple of months earlier and was tasked with overseeing the proof-of-concept colorectal ERAS implementation along with gastroenterologist, Professor Leah Gramlich (the fact that a gynecologist and internist ended up leading ERAS for the province is another story). After the weekend-long session, Olle asked me, over a couple of beers, if I would be interested in leading the expansion of ERAS into obstetrics and gynecology, as up until this point, most of the ERAS activity globally had been in the areas of colorectal, pancreas, gastric, and urological surgery. I immediately recognized the incredible opportunity that was presented before me and said yes! And as they say, the rest is history.

I cannot give enough thanks to those who have joined me on this fantastic journey since the beginning, specifically my coeditors Professor Sean C. Dowdy (Mayo Clinic), Professor Pedro T. Ramirez (MD Anderson), and Professor Michael J. Scott (University of Pennsylvania), all of whom were original coleads on the first ERAS Society Guideline for Gynecologic/Oncology published in 2016. In fact, there was such a clinical need for this first guideline that it was highlighted as one of the most downloaded items in Elsevier’s Health and Medical Science portfolio, which ultimately led to the idea for, and development of, The ERAS® Society Handbook for Obstetrics & Gynecology. I must also thank coeditor Professor R. Douglas Wilson (University of Calgary) for taking on the monumental task of leading the international OB group that developed the ERAS® Society Guidelines for cesarean delivery; he was the obvious choice to oversee the obstetrical content of this book.

Finally, The ERAS® Society Handbook for Obstetrics and Gynecology would not be possible without the contributions from the chapter authors. All authors are recognized enhanced recovery experts and I am humbled by the time and effort each of them has invested in this handbook of perioperative care devoted exclusively to the field of obstetrics and gynecology. I know that you will enjoy reading this book, and most importantly, your patients will benefit from the recommendations contained within.

Section I

Preoperative

Chapter 1: Prehabilitation

Amanika Kumara; Ester Miralpeixb    a Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States

b Obstetrics and Gynecology, Hospital del Mar, Barcelona, Spain

Abstract

Prehabilitation is a concept in which interventions aim to improve a patient’s resilience so that she may be able to better endure the stressors of surgery. It has been shown that prehabilitation strategies are more effective when multimodal, targeting physical function, nutrition, and psychological reserves. Currently there is little data about who will most benefit from prehabilitation in gynecologic oncology; efforts to identify the targetable population and to develop feasible and effective interventions are needed. Implementation of such strategies will take institutional efforts to identify appropriate patients, create acceptable interventions, and determine appropriate surrogate endpoints to measure success.

Keywords

Prehabilitation; Exercise; Nutrition; Depression; Anxiety; Frailty

What is prehabilitation and why do we need it?

There is a growing body of literature focusing on the functional status of gynecologic cancer patients at the time of diagnosis, and the interaction of patient performance status with treatment tolerance and long-term survival. This focus on age-related functional decline is more important when considering the aging population and the rapid increase in cancer diagnoses in older adults [1]. The term frailty is a clinical syndrome characterized by a lack of reserve and a poor response to stressors [2]. Patients can be generally characterized as fit, prefrail, or frail depending on their functional status. Cancer prehabilitation is a conceptual model that aims to improve individual resilience in order to withstand not only the disease itself, but treatment-related stressors and accelerate the posttreatment recovery back to baseline. Fig. 1 demonstrates this concept.

Fig. 1

Fig. 1 Trajectory of functional status: The blue line represents a prefrail/frail patient who does not do any prehabilitation, has surgery and declines significantly postoperatively and then fails to recover to baseline long term. The red line represents that same prefrail/frail patient who undergoes a prehabilitation program, improving function preoperatively. This patient will still have a decline postoperatively but will recover long term to a better functional status than baseline due to pre /rehabilitation efforts. The yellow line represents a nonfrail patient that does not undergo prehabilitation, demonstrating a nonfrail patient’s ability to recover from the stressors of cancer surgery and recover to baseline status.

In patients with gynecologic cancer, these stressors can be the disease itself, the treatments of the disease, other nutritional or functional derangements, and/or psychological and emotional stress. Frailty in these patients has been associated with a number of poor outcomes including shorter overall survival, more treatment-related toxicity, and increased costs [3–7]. Therefore, assessing for frailty, intervening, and measuring the outcomes of these frailty-targeted interventions is important for the future of gynecologic cancer care.

Prehabilitation is one method of frailty-targeted intervention. For patients with gynecological malignancy, surgery is a stressful event. Recent enhanced recovery after surgery (ERAS) efforts have improved the intraoperative and postoperative experience and outcomes for patients [8,9], however minimal attention has been paid to the preoperative period. The preoperative period is an opportunity to identify a patient’s comorbidities and functional capacity and to refer the person to a prehabilitation program. Moreover, the perioperative period can be the time to motivate patients and prepare them for their upcoming surgery and their recovery. A prehabilitation program starts at the time of diagnosis and continues during preoperative, perioperative, and postoperative time periods. Assessments of patient function at relevant time points through the disease trajectory will provide the necessary information to develop evidence-based therapeutic prehabilitation strategies and determine the effectiveness of these interventions.

Preoperative frailty assessment

In order to best determine candidates for prehabilitation, measure the effect of prehabilitation, and determine relevant surrogate endpoints, one must begin with a baseline assessment of patients and understand the cancer treatment course that is specific to each patient. Appropriate patient selection for multimodal prehabilitation is imperative for success. Frailty may be assessed with a number of tools, all of which have advantages and potential disadvantages. These include ease of interpretation, ability to operationalize in the outpatient setting, accuracy to predict outcomes, and responsiveness to patient changes. Below we outline a few common options for frailty assessments.

One tool is a deficit index. In this method, a number of functional parameters and comorbidities are assessed, and frailty is scored according to percentage deficits [3,6]. However, it does not directly measure any function of the patient and there is no adjustment for severity or length of diagnosis for any of the parameters measured. There are several combined tools that measure a number of domains of frailty. These include, but are not limited to, the Edmonton frailty index, the Fried frailty index, and the Comprehensive Geriatrics Assessment. Again, no single tool has been shown to correlate exactly to patient outcomes in gynecologic cancers. The convenience and objectivity of serum laboratory values has made this an attractive area of research, and the measurement of frailty through serum biomarkers is an area of research for multiple tumor types, including gynecologic malignancies [10].

Functional assessments

Functional assessments include the measurement of objective physical skills and are an important part of baseline patient evaluation. Assessments may include a number of physical function tests such as the timed up and go, hand grip strength, 5 chair rise, 6 min walk test (6-MWT) or the short performance physical battery (SPPB). These tests directly measure the functional ability of an individual. When administered appropriately, they are reproducible and accurate. However, no single functional test fully evaluates the psychological, social, and nutritional parameters. These functional tests are often inaccurate in the clinical, nonresearch setting, and are difficult to implement in the patient care setting. Exercise capacity can be evaluated by cardiopulmonary exercise testing (CPET); however, this requires significant resources including equipment, personnel, and expertise [11].

The 6-MWT is a reproducible test that has been validated in surgical populations and is considered a good screening tool. 6-MWT is associated with the capacity to perform daily activities and registers the maximum distance a patient is able to walk during 6 min at moderate intensity [12,13]. This test is linearly correlated to maximum oxygen consumption (VO2max) that is associated with postoperative morbidity and complications [14]. Patients who walk a total distance less than 350 m are considered to have low physical fitness and experience more short- and long-term morbidity and higher mortality [15].

Timed up and go (TUG) is a similar test in which the time is assessed for a patient to start sitting, stand, walk a distance of 10 ft, turn around, walk back and sit down. The TUG has correlated with outcomes in healthy older adult populations, and is part of a current multicenter trial of ovarian cancer in the Netherlands (NL6745). The SPPB is a multicomponent test measuring gait speed, balance, and chair rise. It has shown predictive validity in both community-dwelling older adults and hospitalized older adults.

Given the challenges of these different functional tests, one strategy for functional evaluation is a two-step screening then confirmatory testing approach. Patients identified as high-risk by one of these single screening tools could undergo further assessment of physical status, performed by a trained specialist who can evaluate a more accurate functional capacity by CPET [16]. The decision as to which functional test is used is dependent upon the institutional expertise and capacity, as no single test is clearly superior to others, and all have limitations. We recommend that institutions choose a test that can be performed easily and reliably in their institution, and use it as a screening tool to identify those patients who may be at risk.

Nutritional assessments

Nutritional screening is also an important component of preoperative assessments. Although nutritional supplementation could be beneficial for all surgical patients, malnourished patients should be identified early during preoperative evaluation to enable appropriate nutritional intervention. There are many nutrition screening tools designed to detect malnutrition. The malnutrition universal screening tool (MUST) is described as a simple and quick method that is easy to use by healthcare professionals, with high validity for early detection of malnutrition and guide for intervention [17]. MUST compiles data on a patient’s body mass index, weight loss, and nutritional intake over 5 days. Patients score a 0, 1, or 2 in each of these categories, and the summation of the scores will help decide whether routine care, close observation, or treatment is recommended.

Laboratory data such as levels of albumin, prealbumin, and transferrin may reflect inflammation rather than nutritional status and should be interpreted carefully. Hypoalbuminemia is associated with increased risk of complications and increased risk of death after complications in a number of studies evaluating surgery for advanced ovarian cancer [18,19]. Computed tomography (CT) images have been used as an additional nutrition screening [20]. The presence of preoperative low muscle mass (sarcopenia) and lipid infiltration to muscle cells (myosteatosis) (defined through CT analysis) has been associated with prolonged hospital stay and readmission in colorectal cancer patients [21]. In gynecologic cancer, myosteatosis has been shown to be increased in frail patients and predict poor outcomes, however, the exact mechanisms behind these changes are not well understood and likely reflects long term inflammation, poor nutrition, and tumor effects [22,23].

Psychological assessments

The preoperative period is an uncertain time for patients, who usually experience anxiety for a variety of reasons, including cancer diagnosis, surgery, and possible complications. Patients who present with preoperative psychological distress may have a worse surgical recovery and a higher risk of mortality [24,25]. The preoperative period is an opportunity to reduce stress by reinforcing and developing psychological strategies for emotional well-being.

Psychological status should be assessed in all cancer patients using basic screening tools to detect anxiety and depression. A simple and validated tool for screening is the Hospital Anxiety and Depression Scale (HADS) [26] which includes anxiety and depression subscales. Each scale has seven items scored 0 to 3, and the total score ranges from 0 to 21, with higher scores indicating worse affective or mood disorders. Another easily accessible option is the short form or computerized adaptive testing PROMIS (patient-reported outcomes measurement information system) for anxiety or depression or fatigue.

Once a preliminary screening and assessment of the patient’s functional capacity has been completed, including physical, nutritional, and psychological status, a structured and personalized multidisciplinary prehabilitation program can be started before surgery and continued after surgery. These programs must be designed to fit the needs of the patient and the needs of the cancer-directed treatment. For example, the prehabilitation for a fit advanced ovarian cancer patient undergoing primary debulking surgery will be different from that of the frail early endometrial cancer patient undergoing minimally invasive hysterectomy, or a frail patient undergoing neoadjuvant chemotherapy for advanced ovarian cancer. A large proportion of patients will not need prehabilitation, depending on the baseline assessment, cancer treatment plan, and patient goals. Prehabilitation must be distinguished from medical optimization, such as glycemic control, tobacco cessation, weight loss, or anticoagulation management as these are suggested for every preoperative patient. The window of time between diagnosis and surgery is an optimal therapeutic opportunity where alongside tumor-directed treatment, prehabilitation interventions may improve the tolerance of therapy and overall quality of life for prefrail and frail patients.

Current status of prehabilitation programs

There are very few studies published on prehabilitation programs in gynecologic surgery, and even fewer in gynecological oncology. Carli et al. reported a frail 88-year-old patient with endometrial cancer who underwent robotic-assisted total hysterectomy, and was enrolled in a prehabilitation program for three weeks prior to surgery. The patient was monitored for 8 weeks post-surgery and showed a general health improvement in exercise tolerance and cognitive function [27]. In reference to benign gynecologic surgery, a prospective, multicenter, single-blind, randomized trial by Vonk Noordegraaf et al. included 215 patients who underwent hysterectomy or laparoscopic surgery for benign adnexal masses. The intervention group received personal pre- and postsurgical recommendations for daily activity, work, and self-empowerment. They reported a significant benefit related to timeframes to return to work, pain intensity, and quality of life [28].

There is a review in gynecological surgery that cited five studies regarding optimal surgery self-preparation including weight loss, pelvic floor exercises, or a prehabilitation program; however, the patients in that study did not undergo cancer surgery [29]. In reference to gynecologic oncology surgery, our group published a qualitative study evaluating 15 patients with advanced ovarian cancer undergoing neoadjuvant chemotherapy and studied how patients experienced exercise and physical activity during treatment. A semistructured one-on-one interview identified that patients demonstrated a high motivation to exercise when it was recommended by their healthcare team and when the patients believed there would be a direct benefit on treatment options or cancer cure [30]. Our study did identify some exercise barriers: cancer and treatment related symptoms, access to programs, and social and mental barriers.

Additionally, there are two published trial protocols for ovarian cancer patients: One is a prospective multicenter randomized trial to assess whether prehabilitation improves physical capacity in patients undergoing neoadjuvant treatment prior to ovarian cancer surgery. The trial aims to include 136 patients during 5 years of follow-up to evaluate treatment morbidity and oncological outcomes [31]. The second is a planned dual-center clinical trial that evaluates a novel treatment algorithm combining ERAS and prehabilitation interventions for patients undergoing open abdominal surgery for ovarian cancer to evaluate perioperative morbidity [32]. Until now, studies on ERAS and prehabilitation protocols in gynecology have been rare and there are no data available concerning the adherence to or effectiveness of prehabilitation for gynecologic oncology patients [33].

Other specialties, such as colorectal cancer surgery, have made headway with prehabilitation. Noncancer surgery specialties, such as cardiac surgery and transplant surgery, have published information about experiences with prehabilitation. Early reports focused on single mode intervention with exercise alone, but more recent reports have evolved, and a more comprehensive approach has been shown to be more effective [34,35]. In colorectal surgery, there have been reported outcomes from prehabilitation programs that included shorter hospital stays and fewer complications [36,37].

Elements of prehabilitation

Exercise intervention

In surgery, low exercise capacity has been associated with poor perioperative outcome [38]. Exercise is a key strategy to improve functional reserve and preoperative status in a prehabilitation program. In the literature, there is large heterogeneity according to type, intensity, duration, timing, and supervision of exercise interventions in prehabilitation programs; however, most have proved to improve recovery after surgery and reduce postoperative complications [36,39–42].

Physical intervention in prehabilitation programs may be limited to inspiratory muscle training (IMT) which has been associated with shorter length of hospital stay after major abdominal cancer surgery [43] and reduces postoperative pulmonary complications in elective cardiac surgery, thoracic, abdominal, and orthopedic surgery [44,45]. IMT involves 15–30 min daily sessions using an inspiratory threshold-loading device with a patient-tailored program or daily home breathing exercises through a flow volume incentive spirometer [46]. However, this has not been studied in gynecologic oncology patients.

Physical intervention may include aerobic training, muscle strengthening, increasing flexibility, and IMT. The frequency and the duration depend upon the nature of the disabilities, aging, treatment behavior and motivation, but ideally the recommendations include daily physical activity [47]. Examples of exercise options include daily brisk walking, strength training with body weight alone, or with light weights or resistance bands. At the Mayo Clinic, we have developed a progressive resistance band upper and lower body strength training program that can be done whilst the patient is sitting or standing [48,49]. This program, in addition to walking, includes the current exercise intervention for our open clinical trial for prehabilitation in advanced ovarian cancer patients. To date, there is no proven best exercise program for prehabilitation for gynecologic oncology patients. Prospective evaluation of any program’s feasibility, adherence, and effectiveness is important. After surgery, impaired muscle function occurs that may lead to limited mobilization and aerobic capacity. Therefore, recommendations of physical activity should continue and be tailored during the immediate postoperative period and after discharge.

Physical training is the main target of most prehabilitation programs, but one should consider that some frail patients who lack physiologic reserves or poor muscle mass may be unable to withstand intense exercise training alone, and this might be detrimental without adequate energy and protein supplementation [50]. Training should be individually prescribed prior to a physical assessment, specifically in high-risk groups [51]. Physical intervention may be home-based or performed under the supervision of a healthcare provider. Although both types of training have been reported to be beneficial, supervised structured exercises encourage patient compliance and enhance functional capacity after surgery, although this is often impractical for both patients and healthcare systems [52].

Nutritional intervention

Nutritional status is frequently impaired in the surgical population, particularly in advanced ovarian cancer. Regardless of baseline nutritional status, surgery induces a stress response that increases oxygen consumption, mobilizes energy reserves, and promotes protein catabolism, ultimately resulting in skeletal muscle wasting [53]. Additionally, malnutrition and cachexia are common in patients undergoing cancer surgery due to neoplastic disease, tumor directed treatments, chronic inflammatory state, alimentary tract dysfunction, or psychological disorders such as low mood and stress-related anorexia [54]. As a result, patients may undergo surgery in a suboptimal nutritional state, lacking the ability to respond to surgical stress demands [53]. Malnourished surgical patients have a greater risk of morbidity and mortality, prolonged hospital stay, and higher complications [55,56]. Therefore, nutritional intervention before surgery is particularly relevant. It is important to take into account that nutritional supplements act synergistically with exercise by allowing successful muscle gain during physical exercise and optimizing its effect [57].

Recent literature shows significant benefits of nutritional supplementation in surgical patients. Preoperative carbohydrate treatment compared with placebo or fasting reduces the length of hospital stay in patients undergoing elective surgery (abdominal, orthopedic, cardiac, and thyroidectomy) [58]. In malnourished patients who received adequate preoperative nutrition, postoperative complication rates before abdominal surgery decrease [59]. In nonmalnourished patients, nutritional supplementation for 14 days before abdominal cancer surgery significantly reduced the number and severity of postoperative complications [60]. Adequate food intake, use of protein supplements, and regular exercise promotes a positive protein balance in muscle and attenuates postoperative lean body mass loss [61].

One recommended option, in addition to protein supplementation and nutritional awareness, is the involvement of a dietitian. Nutrition management must begin preoperatively to optimize nutritional status for surgery but should continue during recovery and the postoperative period, especially in the setting of postoperative pain, abdominal distention, bowel surgery, and postoperative nausea and vomiting.

Psychological