Comprehensive Preoperative Evaluation for Gynecologic Oncology Surgery - Print Version
Slide 1
Comprehensive Preoperative Evaluation
for Gynecologic Oncology Surgery
Evidence-Based Guidelines and Clinical Implementation
Integrating ACC/AHA, ACOG, SGO, ASA, ATS, and NCCN Guidelines
Complete Clinical Reference and Tutorial
Slide 2
Clinical Competencies
- Master evidence-based preoperative evaluation principles avoiding routine testing
- Apply ACC/AHA cardiac risk stratification algorithms and management protocols
- Implement ASA guidelines for selective preoperative testing based on clinical indications
- Execute ACOG/SGO VTE prophylaxis protocols including extended prophylaxis
- Optimize perioperative medication management including anticoagulation and diabetes medications
Special Population Management
- Develop comprehensive plans for elderly patients using ACS/AGS geriatric assessment tools
- Address obesity-specific challenges including equipment, dosing, and positioning
- Manage post-chemotherapy patients including hematologic recovery and organ toxicity
- Coordinate multidisciplinary care for complex comorbidities
Slide 3
ASA Guidelines Core Principle: Preoperative tests should not be ordered indiscriminately but obtained selectively based on history, exam, and procedure risk.
Evidence-Based Approach Components
- Comprehensive History and Physical: Foundation of all preoperative assessment
- Risk Stratification Tools: ASA Physical Status (I-VI), RCRI, NSQIP calculator, Caprini score
- Selective Testing: Order only when results would change management
- Multidisciplinary Coordination: Early specialist involvement for complex cases
- Enhanced Recovery Principles: Patient engagement, health optimization, avoid prolonged stress
Key Evidence: Studies show blanket pre-op test panels rarely change management and add cost and potential harm. Each evaluation should be tailored to the individual patient.
Slide 4
| ASA Class |
Definition |
Examples |
Perioperative Risk |
| I |
Normal healthy patient |
No organic, physiologic, or psychiatric disturbance |
Minimal |
| II |
Mild systemic disease |
Well-controlled DM/HTN, mild lung disease |
Low |
| III |
Severe systemic disease |
Poorly controlled DM/HTN, COPD, BMI>40, active hepatitis |
Moderate-High |
| IV |
Severe disease, constant threat to life |
Recent MI/CVA, severe valve dysfunction, ESRD |
High |
| V |
Moribund, not expected to survive without surgery |
Ruptured AAA, massive trauma, intracranial bleed |
Very High |
Clinical Application: ASA III or IV patients require careful optimization and often benefit from specialist consultation and intensive monitoring.
Slide 5
Electrocardiogram (ECG)
- Indicated: Known CAD, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, multiple CV risk factors undergoing intermediate/high-risk surgery
- Not Routine: Asymptomatic patients undergoing low-risk surgery
Chest X-ray
- Indicated: Active pulmonary disease, COPD, poorly controlled asthma, unexplained respiratory symptoms where results would change management
- Not Routine: Patients without pulmonary symptoms or risk factors
Complete Blood Count (CBC)
- Indicated: History of anemia, malignancy patients (anemia of chronic disease common), expected significant blood loss, recent chemotherapy
- May Omit: Young healthy patients, minor procedures with minimal expected blood loss
Slide 6
Basic Metabolic Panel (BMP)
- Indicated: CKD, heart failure, on diuretics/ACE-I/ARBs, clinical suspicion of renal dysfunction, age >50-60, planned contrast imaging
- Not Routine: Healthy patients without risk factors (e.g., 30-year-old with no medical problems)
Glucose/HbA1c
- Check Glucose: Patients at risk for diabetes (obesity, steroids, family history)
- HbA1c: Known diabetics if not checked in past 3 months and suspect poor control
- Not Needed: Low-risk patients without diabetes risk factors
Coagulation Studies (PT/INR, PTT)
- Indicated: Bleeding disorder history, liver disease, anticoagulant therapy, neuraxial anesthesia planned
- Not Indicated: No bleeding history and not on anticoagulants
Slide 7
Type and Screen/Crossmatch
- Type & Screen: Any surgery with potential for major blood loss
- Crossmatch: Ovarian cancer cytoreduction, radical hysterectomy, pelvic exenteration
- Not Required: Low-bleed-risk cases (diagnostic laparoscopy, minor biopsies)
Note: In cancer surgery, type & screen commonly done due to unpredictable bleeding potential
Additional Testing
- Urinalysis: Only if urinary symptoms or urologic procedure planned
- Pregnancy Test: All women of childbearing potential (day of surgery)
- Pulmonary Function Tests: Severe COPD, unexplained dyspnea, considering regional anesthesia in severe lung disease
- Echocardiography: Unexplained dyspnea, known HF without recent echo, significant murmur, prior anthracycline chemotherapy
Slide 8
Step 1: Identify Active Cardiac Conditions
If present, postpone elective surgery for treatment:
- Unstable angina or recent MI (within 1-3 months)
- Decompensated heart failure
- Significant arrhythmias
- Severe valvular disease (critical aortic stenosis)
Step 2: Assess Functional Capacity
- Good (≥4 METs): Can climb flight of stairs, walk briskly → Usually proceed without further testing
- Poor (<4 METs): Cannot perform above activities → Consider further evaluation
Step 3: Calculate Risk
- RCRI Points: Ischemic heart disease, HF, CVD, diabetes, renal insufficiency, high-risk surgery
- Low Risk (<1% MACE): Proceed without further workup
- Elevated Risk: Consider additional testing or interventions
Slide 9
Class III Recommendation (No Benefit): Routine stress testing for all patients
Consider Stress Testing ONLY If ALL Criteria Met:
- Poor or unknown functional capacity
- Undergoing elevated-risk surgery
- Test results would change management (e.g., revascularization or medical changes)
Do NOT Perform Stress Testing:
- Patients with good functional capacity (>4 METs)
- Low predicted risk patients
- When results wouldn't change management
- As routine screening
Remember: Unnecessary stress tests lead to false positives, delays, and potentially harmful invasive procedures
Slide 10
| Medication Class |
Perioperative Management |
Rationale |
| Beta-blockers |
Continue if already on for CAD/arrhythmia |
Abrupt cessation causes rebound |
| Statins |
Continue throughout perioperative period |
Plaque stabilization, Class IIa recommendation |
| ACE-I/ARBs |
Often held morning of surgery |
Avoid intraoperative hypotension |
| Aspirin |
Continue for secondary prevention; Stop 7d prior if primary prevention only |
Balance thrombosis vs bleeding risk |
| SGLT2 inhibitors |
Stop 3-4 days before surgery |
Risk of euglycemic ketoacidosis |
Beta-blocker Initiation: If starting new, must be done days-weeks in advance with careful titration. High-dose initiation at last minute associated with stroke and hypotension (Class IIb - optional, use caution).
Slide 11
Warfarin Management
- Hold 5 days before surgery
- Verify INR <1.5 on day of surgery
- Resume as soon as safe post-op
Direct Oral Anticoagulants (DOACs)
- Standard: Hold 2 days prior to surgery
- Renal impairment or high bleeding risk: Hold 3-4 days
- Resume: 24-48 hours post-op depending on bleeding status
Bridging Therapy Guidelines (ACC/AHA 2024)
Routine bridging NOT recommended (Class III) - increases bleeding risk
Consider Bridging ONLY for:
- Mechanical mitral valve
- Recent stroke or VTE (within 3 months)
- Very high-risk atrial fibrillation (CHA₂DS₂-VASc ≥5)
Slide 12
Timing of Surgery After Stent Placement
| Stent Type |
Minimum Delay |
Optimal Delay |
DAPT Duration |
| Bare Metal Stent (BMS) |
30 days |
30 days |
1 month minimum |
| Drug-Eluting Stent (DES) |
3 months (urgent) |
6 months |
6-12 months |
Cancer Surgery Considerations
- Often cannot delay 6 months for optimal timing
- Multidisciplinary discussion required (cardiology, surgery, oncology)
- Consider continuing aspirin throughout perioperative period
- Resume second antiplatelet ASAP after surgery
Key Point: Premature DAPT interruption before 6 months for DES can precipitate stent thrombosis
Slide 13
Patient Risk Factors
Major Risk Factors
- Age >60 years
- COPD or asthma
- Smoking history
- Obesity (BMI >40)
- Obstructive sleep apnea
Additional Factors
- Poor functional status
- Heart failure
- Malnutrition
- Immunosuppression
- Prior chest/mediastinal radiation
Surgical Risk Factors
- General anesthesia and intubation
- Surgery duration >3 hours
- Upper abdominal/pelvic incisions
- Pneumoperitoneum in laparoscopy
- Steep Trendelenburg positioning
Slide 14
Smoking Cessation
- 4 weeks: Significant reduction in pulmonary complications
- 8+ weeks: Improvements in bronchial reactivity and ciliary function
- Key message: No bad time to quit - earlier is better
Obstructive Sleep Apnea (OSA) Screening - STOP-Bang
- Snoring loudly
- Tiredness/daytime sleepiness
- Observed apneas
- Pressure (hypertension)
- BMI >35
- Age >50
- Neck circumference >40cm
- Gender (male)
OSA Management
- Bring CPAP machine to hospital
- Use postoperatively when sleeping
- Consider higher acuity monitoring
- Multimodal analgesia to minimize opioids
Slide 15
Asthma Management
- Ensure optimal control - patient at personal best peak flow/FEV₁
- Step up controller therapy if using rescue inhaler frequently
- Consider inhaled bronchodilator prior to induction
- Stress-dose steroids if recent oral steroid use or frequent exacerbations
COPD Management
- Optimize therapy (long-acting bronchodilators)
- Consider short course systemic steroids if baseline exacerbation
- Pulmonology consultation for severe COPD
- Consider spirometry to quantify obstruction
Preventive Strategies for All High-Risk Patients
- Teach incentive spirometry preoperatively
- Chest physiotherapy for chronic bronchitis with sputum
- Nutritional support (COPD patients often malnourished)
- Plan lung-protective ventilation strategies
Slide 16
CKD Staging and Implications
| CKD Stage |
eGFR (mL/min/1.73m²) |
Perioperative Considerations |
| Stage I-II |
>60 |
Standard management |
| Stage III |
30-59 |
Avoid nephrotoxins, dose adjust medications |
| Stage IV |
15-29 |
Nephrology consult, intensive monitoring |
| Stage V |
<15 or dialysis |
Coordinate dialysis timing, protect access |
CKD Optimization
- Electrolytes: Correct K+ >5.5, check bicarbonate, Ca/Phos
- Hydration: Maintain euvolemia, avoid NSAIDs
- Medications: Dose-adjust antibiotics, enoxaparin
- Dialysis patients: Schedule surgery day after dialysis, check K+ morning of surgery
Slide 17
Child-Pugh Score Components
| Parameter |
1 Point |
2 Points |
3 Points |
| Bilirubin (mg/dL) |
<2 |
2-3 |
>3 |
| Albumin (g/dL) |
>3.5 |
2.8-3.5 |
<2.8 |
| INR |
<1.7 |
1.7-2.3 |
>2.3 |
| Ascites |
None |
Mild |
Moderate-Severe |
| Encephalopathy |
None |
Grade I-II |
Grade III-IV |
Child C cirrhosis: Very high surgical risk with high mortality - consider alternative therapy
Cirrhosis Optimization
- Treat encephalopathy with lactulose
- Paracentesis for tense ascites (few days pre-op)
- Address coagulopathy selectively
- Plan alcohol withdrawal prophylaxis if needed
Slide 18
Preoperative Glycemic Goals
- Ideal HbA1c: <8% for elective surgery
- Morning glucose: 100-180 mg/dL
- Very poor control (A1c >10%): Consider brief delay if oncologically safe
Day of Surgery Medication Management
| Medication |
Management |
| Metformin |
Hold day of surgery (48h if contrast used) |
| SGLT2 inhibitors |
Stop 3-4 days prior (euglycemic ketoacidosis risk) |
| Sulfonylureas |
Hold morning of surgery |
| Long-acting insulin |
Give 50-80% of usual dose night before |
| Short-acting insulin |
Hold morning of surgery |
Intraoperative: Goal glucose 140-180 mg/dL; use insulin infusion for long surgeries
Slide 19
Stress-Dose Steroids for Chronic Steroid Users
Indication: Prednisone >5mg daily for >3 weeks in past year
Protocol:
- Hydrocortisone 100mg IV before induction
- Then 50mg IV q8h × 24-48 hours
- Taper to maintenance dose
Immunotherapy-Related Endocrinopathies
- Check for hypophysitis → secondary adrenal insufficiency
- Screen for thyroid dysfunction
- Manage as primary endocrine disorder
Thyroid Disorders
- Hypothyroidism: Mild-moderate okay; severe myxedema requires treatment first
- Hyperthyroidism: Risk of thyroid storm - achieve euthyroid state before elective surgery
Slide 20
Malnutrition Screening Criteria
- Weight loss >5-10% in past 6 months
- BMI <18.5
- Albumin <3.0 g/dL
- Poor oral intake
Nutritional Interventions
- 7-14 days preop repletion: High-protein, high-calorie diet
- Oral supplements: Ensure, Boost, etc.
- Immunonutrition: Arginine, omega-3 fatty acids (evidence mixed)
Frailty Assessment Tools
Clinical Frailty Scale
- 1-9 point scale
- Based on function
- Predicts outcomes
FRAIL Questionnaire
- Fatigue
- Resistance (stairs)
- Ambulation
- Illnesses
- Loss of weight
Slide 21
Preoperative Components
- Patient education and counseling
- No prolonged fasting: Solids until midnight, clear liquids until 2h pre-op
- Carbohydrate loading: Evening before and morning of surgery
- No routine bowel prep
- Antibiotic and DVT prophylaxis
Intraoperative Components
- Regional anesthesia when possible
- Goal-directed fluid therapy
- Avoid drains when possible
- Minimize opioids
Postoperative Components
- Early mobilization (day of surgery)
- Early feeding
- Remove catheters POD#1
- Multimodal analgesia
Slide 22
Equipment and Logistics
- Bariatric OR table (weight limits: standard 350-400 lbs)
- Long surgical instruments
- Extra personnel for transfers
- Appropriate positioning devices
Medication Dosing Adjustments
- Antibiotics: Cefazolin 3g IV if >120kg
- VTE prophylaxis: Enoxaparin 40mg BID if BMI >40
- Consider: 60mg daily or 0.5mg/kg dosing
Surgical Approach Considerations
- Prefer minimally invasive when oncologically feasible
- Panniculectomy if needed for exposure
- Prophylactic retention sutures for open cases
- Consider closed-incision negative pressure therapy
Slide 23
Risk Factor Point Values
1 Point Each
- Age 41-60
- Minor surgery
- BMI >25
- Varicose veins
- Pregnancy/postpartum
2 Points Each
- Age 61-74
- Major surgery >45 min
- Malignancy
- Central venous access
3 Points Each
- Age ≥75
- History VTE
- Family history VTE
- Factor V Leiden
5 Points Each
- Stroke (<1 month)
- Elective arthroplasty
- Hip/pelvis/leg fracture
- Acute spinal cord injury
Most gynecologic oncology patients score ≥5 (high risk) simply from cancer + age + surgery duration
Slide 24
ACOG/SGO Guidelines for Gynecologic Oncology
| Risk Level |
Prophylaxis Strategy |
Duration |
| Low (Caprini 0-2) |
Mechanical only (SCDs) |
Until ambulatory |
| Moderate (Caprini 3-4) |
Mechanical + consider pharmacologic |
During hospitalization |
| High (Caprini ≥5) |
Dual prophylaxis (mechanical + pharmacologic) |
Hospital + consider extended |
| Cancer surgery |
Dual prophylaxis |
28 days total (extended) |
Key Evidence: Extended prophylaxis (28 days) reduces post-discharge VTE by 50% in cancer surgery patients
Slide 25
Timing Considerations
- Interval surgery typically 3-4 weeks after last chemo cycle
- Allows blood count recovery
- Assess tumor response with imaging
Hematologic Requirements
| Parameter |
Preferred Value |
Management if Low |
| ANC |
>1,500/µL |
Delay or consider G-CSF |
| Platelets |
>100,000/µL |
Delay or transfuse perioperatively |
| Hemoglobin |
>8-9 g/dL |
Transfuse if symptomatic |
Chemotherapy-Specific Toxicities
- Platinum: Check creatinine (nephrotoxicity)
- Anthracyclines: Echo for EF (cardiomyopathy)
- Bleomycin: Minimize O₂ during anesthesia (pulmonary toxicity)
- Bevacizumab: Must stop 6-8 weeks pre-op (wound healing)
Slide 26
Patient: 75F with Stage IIIC ovarian cancer, MI 5 years ago with DES × 2, atrial fibrillation on warfarin, mild COPD
Surgery: Exploratory laparotomy, cytoreductive surgery, staging
Step-by-Step Management
- Cardiac:
- Cardiology consult (high risk patient)
- ECG and possibly echo if not recent
- Continue beta-blocker and statin
- RCRI score likely ≥2 (10% cardiac risk)
- Anticoagulation:
- Stop warfarin 5 days pre-op
- No bridging per guidelines (increases bleeding)
- Continue aspirin for stents
- Resume therapeutic anticoagulation 48-72h post-op
- VTE Prophylaxis:
- Very high risk (age + cancer + prior MI)
- SCDs + pharmacologic prophylaxis
- Extended prophylaxis × 28 days
Slide 27
Patient: 50F, BMI 45, endometrial cancer, DVT 2 years ago, diabetes, probable OSA
Surgery: Total hysterectomy, BSO, lymph node assessment
Comprehensive Management Plan
- Equipment/Logistics:
- Reserve bariatric OR table
- Long laparoscopic/robotic instruments
- Plan robotic approach if feasible
- Airway/OSA:
- Anesthesia evaluation for difficult airway
- Bring CPAP to hospital
- Plan step-down unit monitoring post-op
- VTE Prevention:
- Extremely high risk (obesity + cancer + prior DVT)
- Weight-adjusted dosing: enoxaparin 40mg BID
- Early mobilization critical
- Extended prophylaxis × 28 days mandatory
- Medication Dosing:
- Cefazolin 3g for prophylaxis
- Hold metformin, manage glucose
Slide 28
Patient: 60F with advanced ovarian cancer, completed 3 cycles carboplatin/paclitaxel
Surgery: Interval cytoreductive surgery planned 3 weeks after last chemo
Systematic Evaluation
- Timing: Confirm 3-4 weeks since last chemo for count recovery
- Hematologic Assessment:
- CBC: Need ANC >1,500, platelets >100k
- If anemic (Hgb <9), consider transfusion
- Type & cross 2-4 units for cytoreduction
- Organ Function:
- Creatinine (platinum nephrotoxicity)
- LFTs (paclitaxel can elevate)
- Document neuropathy from paclitaxel
- Nutritional Status:
- Address chemo-related anorexia
- High-protein supplements if needed
- VTE Prophylaxis:
- High risk (cancer + major surgery)
- Standard dual prophylaxis
- Extended × 28 days
Slide 29
When to Involve Specialists
| Specialty |
Indications for Consultation |
| Cardiology |
Active cardiac conditions, recent MI/stents, severe valve disease, high RCRI |
| Pulmonology |
Severe COPD/asthma, unexplained dyspnea, severe OSA |
| Nephrology |
CKD stage IV-V, dialysis planning, severe electrolyte abnormalities |
| Hepatology |
Cirrhosis (especially Child B-C), acute hepatitis |
| Hematology |
Complex anticoagulation, bleeding disorders, severe thrombocytopenia |
| Geriatrics |
Age >75, frailty, cognitive impairment, complex polypharmacy |
| Anesthesia |
ASA III-IV, difficult airway, complex medical conditions |
Early consultation allows time for optimization and prevents day-of-surgery cancellations
Slides 30-39
The complete presentation includes detailed coverage of:
- Comprehensive Geriatric Assessment (Slide 30)
- Delirium Prevention Protocols (Slide 31)
- Chemotherapy Agent-Specific Concerns (Slide 32)
- Surgical Site Infection Prevention (Slide 33)
- Emergency Surgery Modifications (Slide 34)
- Documentation Requirements (Slide 35)
- Quality Metrics and SCIP Measures (Slide 36)
- Common Pitfalls to Avoid (Slide 37)
- Quick Reference Medication Hold Times (Slide 38)
- Evidence Base and Guidelines (Slide 39)
Slide 40
Core Principle: Evidence-based, patient-specific evaluation avoiding routine testing
Essential Actions for Every Patient
- Risk stratify: Use validated tools (RCRI, Caprini, ASA class)
- Test selectively: Order only tests that change management
- Optimize conditions: Focus on modifiable risk factors
- VTE prophylaxis: All cancer patients need dual + extended prophylaxis
- Coordinate care: Early specialist involvement for complex patients
- Document thoroughly: Risk assessment, optimization, and plans
Special Population Reminders
- Elderly: Screen cognition, assess frailty, consider prehabilitation
- Obese: Weight-adjust doses, assume OSA, prefer MIS approach
- Post-chemo: Ensure count recovery, check organ function
Final Message: Thorough preoperative evaluation and optimization, following evidence-based guidelines, leads to optimal surgical outcomes while avoiding unnecessary interventions and delays.
