Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

Altman, Alon D.; Robert, Magali; Armbrust, Robert; Fawcett, William; Nihira, Mikio A.; Jones, Chris; Tamussino, Karl; Sehouli, Jalid; Dowdy, Sean C.; Nelson, Gregg

doi:10.1016/j.ajog.2020.07.039

Cited by 37 publications

(40 citation statements)

References 102 publications

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“…Another systematic review has already described the need for further evidence in minimally invasive hysterectomies [39]. National and international guidelines recommend the vaginal approach [1,2,4,5], and according to fast track pathways [40] and ERAS protocols [3,7,7,37,41], multimodal analgesia protocols are recommended to reduce postoperative opioid consumption and improve patient recovery.…”

Section: Discussionmentioning

confidence: 99%

“…Hysterectomy for benign indications is one of the most common operations in gynecology. Multiple guidelines and reviews favor the vaginal approach for benign hysterectomy, if feasible [1][2][3][4][5]. In German-speaking countries, vaginal hysterectomy is the most common approach to hysterectomy, with about half of all benign hysterectomies done vaginally [1,6].…”

Section: Introductionmentioning

confidence: 99%

“…Many Enhanced Recovery After Surgery (ERAS) protocols in gynecology recommend multimodal analgesia using different agents addressing different pathways to reduce intra-and postoperative opioid requirements, speed recovery and reduce complications [2,3,7]. The reduction of opioid requirements is of particular significance considering the potential for misuse of these agents [8][9][10], their side effects and higher costs for the health care system [7].…”

Section: Introductionmentioning

confidence: 99%

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Preemptive local analgesia at vaginal hysterectomy: a systematic review

et al. 2021

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Introduction and hypothesis We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy. Methods MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review. Results Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery. Conclusion Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Preemptive local analgesia at vaginal hysterectomy: a systematic review

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“…Table 1 presents major guidelines addressing the use of thromboprophylaxis for abdominal and/or pelvic surgery [2,10,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. Thromboprophylaxis guidelines in general (abdominal) or gynecologic surgery have not generally made procedure-specific recommendations (Table 1).…”

Section: Introductionmentioning

confidence: 99%

“…The only completely procedure-(and approach-) specific guideline in abdominal and/or pelvic surgery is the European Association of Urology (EAU) guidelines, providing procedure-specific thromboprophylaxis recommendations for urologic surgery procedures . Overall, experts have failed to achieve a consensus regarding the use of VTE prophylaxis in general and gynecologic surgery [2,10,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. The significant practice variation within and between countries is therefore unsurprising [35][36][37].…”

Section: Introductionmentioning

confidence: 99%

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology

et al. 2021

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Background Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. Methods We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. Discussion This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. Systematic review registration PROSPERO CRD42021234119

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Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery

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ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.OBSERVATIONS Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low-and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS. CONCLUSIONS AND RELEVANCETo date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

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Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

Cited by 37 publications

References 102 publications

Preemptive local analgesia at vaginal hysterectomy: a systematic review

Preemptive local analgesia at vaginal hysterectomy: a systematic review

Systematic reviews of observational studies of Risk of Thrombosis and Bleeding in General and Gynecologic Surgery (ROTBIGGS): introduction and methodology

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery

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