Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Abstract

•We provide evidence supporting pre- and intra-operative management of patients undergoing gynecologic/oncology surgery.•This guideline will help integrate knowledge into practice, align perioperative care, and encourage future investigations. The systematic implementation of an evidence-based perioperative care protocol (or “enhanced recovery pathway,” ERP), such as that developed by the Enhanced Recovery After Surgery (ERAS®) Society, has resulted in an average reduction in length of stay of 2.5 days and a decrease in complications by as much as 50% for patients undergoing colorectal surgery [1Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2012; 37: 259-284Crossref Scopus (830) Google Scholar, 2Greco M. Capretti G. Beretta L. Gemma M. Pecorelli N. Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials.World J. Surg. 2014; 38: 1531-1541Crossref PubMed Scopus (540) Google Scholar]. These benefits are achieved by reducing surgical stress, maintaining normal physiological function postoperatively, and enhancing mobilization after surgery [[3]Ljungqvist O. Jonathan E. Rhoads lecture 2011: insulin resistance and enhanced recovery after surgery.J. Parenter. Enter. Nutr. 2012 Jul; 36: 389-398Crossref PubMed Scopus (126) Google Scholar]. Furthermore, use of ERP has resulted in a mean savings of $2245 (1651€) per patient [[4]Adamina M. Kehlet H. Tomlinson G.A. Senagore A.J. Delaney C.P. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery.Surgery. 2011; 6: 830Abstract Full Text Full Text PDF Scopus (414) Google Scholar]. ERAS® protocols have been published for rectal, urological, pancreatic and gastric surgeries [5Nygren J. Thacker J. Carli F. Fearon K.C. Norderval S. Lobo D.N. et al.Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2013 Feb; 37: 285-305Crossref PubMed Scopus (322) Google Scholar, 6Cerantola Y. Valerio M. Persson B. Jichlinski P. Ljungqvist O. Hubner M. et al.Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Clin. Nutr. 2013 Dec; 32: 879-887Abstract Full Text Full Text PDF PubMed Scopus (439) Google Scholar, 7Lassen K. Coolsen M.M. Slim K. Carli F. de Aguilar-Nascimento J.E. Schäfer M. et al.Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.World J. Surg. 2013 Feb; 37: 240-258Crossref PubMed Scopus (268) Google Scholar, 8Mortensen K. Nilsson M. Slim K. Schäfer M. Mariette C. Braga M. et al.Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Br. J. Surg. 2014 Sep; 101: 1209-1229Crossref PubMed Scopus (408) Google Scholar]. Given the proven benefit to both the patient and the healthcare system, several international groups are currently working with the ERAS® Society to develop protocols specific for breast and reconstructive surgery, head and neck cancer, thoracic, hepatobiliary, and orthopedic surgery. A recent review of ERP in gynecologic oncology [[9]Nelson G. Kalogera E. Dowdy S.C. Enhanced recovery pathways in gynecologic oncology.Gynecol. Oncol. 2014 Dec; 135: 586-594Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar] showed marked dissimilarities among the protocols and highlighted the need to develop a standardized, evidence-based guideline for our specialty. Standardizing perioperative care helps to ensure that all patients receive optimal treatment and is required to measure compliance. Auditing compliance has proven to be a key factor to successfully implement and sustain an ERAS® protocol. The goal of this article is to critically review existing evidence and make recommendations for elements of pre- and intra-operative care in our specialty. This effort forms the basis of the ERAS® Guideline for pre- and intra-operative care in gynecologic/oncology surgery. The authors convened in July 2014 to discuss topics for inclusion — the topic list was based on the ERAS® colonic surgery [[1]Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2012; 37: 259-284Crossref Scopus (830) Google Scholar] and rectal/pelvic [[5]Nygren J. Thacker J. Carli F. Fearon K.C. Norderval S. Lobo D.N. et al.Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2013 Feb; 37: 285-305Crossref PubMed Scopus (322) Google Scholar] guidelines which were used as templates. After the topics were agreed upon they were then allocated among the group according to expertise. The literature search (1966–2014) used Embase and PubMed to search medical subject headings including “gynecology”, “gynecologic oncology” and all pre- and intra-operative ERAS® items (see Table 1). Reference lists of all eligible articles were crosschecked for other relevant studies.Table 1Guidelines for pre- and intraoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.ItemRecommendationEvidence levelRecommendation gradePreoperative information education and counselingPatients should routinely receive dedicated preoperative counselingLowStrongPreoperative optimizationSmoking and alcohol consumption (alcohol abusers) should be stopped four weeks before surgerySmoking: HighStrongAlcohol: ModerateStrongAnemia should be actively identified, investigated, and corrected preoperativelyHighStrongPreoperative bowel preparationMechanical bowel preparation should not be used routinely even when bowel resection is plannedModerateStrongPreoperative fasting and carbohydrate treatmentClear fluids should be allowed up to 2 h and solids up to 6 h hours prior to induction of anesthesiaSolids/fluids: HighStrongCarbohydrate loading reduces postoperative insulin resistance and should be used routinelyCarb loading: Mod (outcome insulin resistance)Carb loading: Mod (other outcomes)StrongPreanesthetic medicationRoutine administration of sedatives to reduce anxiety preoperatively should be avoidedLowStrongThromboembolism prophylaxisPatients at risk of VTE should receive prophylaxis with either LMWH or heparin, commenced preoperatively, combined with mechanical methodsHigh (Preop admin: Mod)StrongPatients should be advised to consider stopping HRT or consider alternative preparations before surgeryLowWeakPatients should discontinue oral contraception prior to surgery and switch to another formHighStrongAntimicrobial prophylaxis and skin preparationIV antibiotics (1st generation cephalosporin or amoxi–clav) should be administered routinely within 60 min before skin incision; additional doses should be given during prolonged operations, severe blood loss and obese patientsHighStrongHair clipping is preferred if hair removal is mandatoryHighStrongChlorhexidine–alcohol is preferred to aqueous povidone-iodine solution for skin cleansingHighStrongStandard anesthetic protocolShort acting anesthetic agents should be used to allow rapid awakeningLowStrongA ventilation strategy using tidal volumes of 5–7 ml/kg with a PEEP of 4–6 cm H2O should be employed to reduce postoperative pulmonary complicationsModerateStrongPostoperative nausea and vomitingA multimodal approach to PONV with >2 antiemetic agents should be used for patients undergoing gynecologic proceduresModerateStrongMinimally invasive surgery (MIS)MIS is recommended for appropriate patients when expertise and resources are availableMorbidity: LowRecovery: HighStrongNasogastric intubationRoutine nasogastric intubation should be avoidedHighStrongNasogastric tubes inserted during surgery should be removed before reversal of anesthesiaPreventing intraoperative hypothermiaMaintenance of normothermia with suitable active warming devices should be used routinelyHighStrongPerioperative fluid managementVery restrictive or liberal fluid regimes should be avoided in favor of euvolemiaHighStrongIn major open surgery and for high risk patients where there is large blood loss (>7 ml/kg) or a SIRS response the use of advanced hemodynamic monitoring to facilitate individualized fluid therapy and optimize oxygen delivery during the perioperative period is recommendedModerateStrong Open table in a new tab Titles and abstracts were screened by individual reviewers to identify potentially relevant articles. Discrepancies in judgment were resolved by the lead (GN) and senior authors (OL, SD). Meta-analyses, systematic reviews, randomized controlled studies, non-randomized controlled studies, reviews, and case series were considered for each individual topic. The quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system (see Table 2a, Table 2b) [[10]Guyatt G.H. Oxman A.D. Vist G.E. Kunz R. Falck-Ytter Y. Alonso-Coello P. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar] whereby recommendations are given as follows: Strong recommendations indicate that the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. Weak recommendations indicate that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is less confident. Recommendations are based on quality of evidence: high, moderate, low and very low, but also on the balance between desirable and undesirable effects. As such, consistent with other ERAS® Guideline Working groups [1Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2012; 37: 259-284Crossref Scopus (830) Google Scholar, 6Cerantola Y. Valerio M. Persson B. Jichlinski P. Ljungqvist O. Hubner M. et al.Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Clin. Nutr. 2013 Dec; 32: 879-887Abstract Full Text Full Text PDF PubMed Scopus (439) Google Scholar], in some cases strong recommendations may be reached from low-quality data and vice versa. Of note, this would be considered a modified GRADE evaluation since we did not consider resource utilization when making our recommendations [[11]Brunetti M. Shemilt I. Pregno S. Vale L. Oxman A.D. Lord J. et al.GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence.J. Clin. Epidemiol. 2013 Feb; 66: 140-150Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar].Table 2aGRADE system for rating quality of evidence.Evidence levelDefinitionHigh qualityFurther research unlikely to change confidence in estimate of effectModerate qualityFurther research likely to have important impact on confidence in estimate of effect and may change the estimateLow qualityFurther research very likely to have important impact on confidence in estimate of effect and likely to change the estimateVery low qualityAny estimate of effect is very uncertainRef. [10]Guyatt G.H. Oxman A.D. Vist G.E. Kunz R. Falck-Ytter Y. Alonso-Coello P. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar. Open table in a new tab Table 2bGRADE system for rating strength of recommendations.Recommendation strengthDefinitionStrongWhen desirable effects of intervention clearly outweigh the undesirable effects, or clearly do notWeakWhen trade-offs are less certain — either because of low quality evidence or because evidence suggests desirable and undesirable effects are closely balancedRef. [10]Guyatt G.H. Oxman A.D. Vist G.E. Kunz R. Falck-Ytter Y. Alonso-Coello P. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar. Open table in a new tab Ref. [10]Guyatt G.H. Oxman A.D. Vist G.E. Kunz R. Falck-Ytter Y. Alonso-Coello P. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar. Ref. [10]Guyatt G.H. Oxman A.D. Vist G.E. Kunz R. Falck-Ytter Y. Alonso-Coello P. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar. The evidence base, recommendations, evidence level, and recommendation grade are provided for each individual ERAS® item below. Preoperative counseling helps to set expectations about surgical and anesthetic procedures and may diminish fear, fatigue, pain, and enhance recovery and early discharge [[12]Egbert L.D. Battit G.E. Welch C.E. Bartlett M.K. Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor–patient rapport.N. Engl. J. Med. 1964; 270: 825-827Crossref PubMed Scopus (748) Google Scholar]. Verbalized education, leaflets, and multimedia information containing explanations of the procedure and cognitive interventions may improve pain control, nausea and anxiety after surgery [[13]Ridgeway V. Mathews A. Psychological preparation for surgery: a comparison of methods.Br. J. Clin. Psychol. 1982 Nov; 21: 271-280Crossref PubMed Scopus (85) Google Scholar]. It is uncertain if formal education is superior to informal education [[14]Gurusamy K.S. Vaughan J. Davidson B.R. Formal education of patients about to undergo laparoscopic cholecystectomy.Cochrane Database Syst. Rev. 2014; (Art. No.: CD009933)https://doi.org/10.1002/14651858.CD009933.pub2Crossref Scopus (16) Google Scholar], but ideally patients should receive information in both written and oral form. The patient and a relative or care provider should meet with all members of the team including the surgeon, anesthetist and nurse. Studies show that patients with gynecologic cancer prefer to be well informed, and support from a nurse at the time of diagnosis reduced stress levels for up to 6 months [[15]Stewart D.E. Wong F. Cheung A.M. Dancey J. Meana M. Cameron J.I. et al.Information needs and decisional preferences among women with ovarian cancer.Gynecol. Oncol. 2000 Jun; 77: 357-361Abstract Full Text PDF PubMed Scopus (128) Google Scholar]. Summary and recommendation: Although quality evidence is lacking, most studies show that counseling provides beneficial effects with no evidence of harm. It is recommended that patients should routinely receive dedicated preoperative counseling. Evidence level: Low. Recommendation grade: Strong. Use of tobacco, alcohol, and the presence of anemia should be routinely assessed preoperatively. Also, previously undiagnosed diabetes/hyperglycemic states are becoming increasingly common. Evidence that interventions addressing these factors prior to elective surgery reduce perioperative morbidity and mortality is presented below. For patients with gynecologic cancer, the risk of delaying surgery in order to complete preoperative optimization must be carefully considered. Smoking is associated with a high risk of postoperative complications, but the pulmonary effects of smoking can be improved within four weeks of cessation [[16]Sorensen L.T. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review.Ann. Surg. 2012; 255: 1069-1079Crossref PubMed Scopus (374) Google Scholar]. While smoking cessation interventions such as behavioral support and nicotine replacement therapy are known to result in short term smoking cessation, there is weak evidence to show that these measures decrease postoperative morbidity. A trial of varenicline showed an increase in long term smoking cessation but no evidence of a reduction in postoperative morbidity [[17]Thomsen T. Villebro N. Møller A.M. Interventions for preoperative smoking cessation.Cochrane Database Syst. Rev. 2014; (Art no CD002294)PubMed Google Scholar]. The chronic effects of alcohol on the liver, pancreas and neurologic system are well known. In the perioperative period, effects of alcohol on cardiac function, blood clotting, immune function, and response to surgical stress contribute to excess morbidity. Intensive preoperative interventions aimed at complete alcohol cessation for at least four weeks reduces postoperative complications, but does not significantly reduce mortality or length of stay. However, only a small number of studies are available, the mechanism by which such interventions reduce complications is unknown, and the optimal timing of the interventions has yet to be determined [[18]Oppedal K. Møller A.M. Pedersen B. Tønnesen H. Preoperative alcohol cessation prior to elective surgery.Cochrane Database Syst. Rev. 2012; (Art no CD008343)PubMed Google Scholar]. A report by the American Society of Anesthesiologists in 2012 noted that up to 40% of preoperative patients may have an abnormal blood glucose level and of the 13% with diabetes, 40% were undiagnosed [[19]Apfelbaum J.L. Connis R.T. Nickinovich D.G. American Society of Anesthesiologists Task Force on preanesthesia evaluation. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on preanesthesia evaluation.Anesthesiology. Mar 2012; 116: 522-538Crossref PubMed Scopus (400) Google Scholar]. For the group with previously unrecognized hyperglycemia, the risk of adverse perioperative events was higher than the risks for patients with a known diagnosis of diabetes [[20]Kotagal M. Symons R.G. Hirsch I.B. Umpierrez G.E. Dellinger E.P. Farrokhi E.T. et al.Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes.Ann. Surg. Jan 2015; 261: 97-103Crossref PubMed Scopus (225) Google Scholar]. In a small study of 120 patients undergoing colorectal surgery, elevated hemoglobin A1c (HbA1c) was associated with an increased risk of postoperative complications [[21]Gustafsson U.O. Thorell A. Soop M. Ljungqvist O. Nygren J. Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery.Br. J. Surg. 2009; 96: 1358-1364Crossref PubMed Scopus (130) Google Scholar]. The benefit of tight glycemic control has not been shown conclusively but the authors of one review suggest that “it seems prudent to control blood glucose to a reasonable level preoperatively”, while acknowledging that “recommendations for exact targets cannot be made” [[22]Sheehy A. Gabbay R. An overview of pre-operative glucose evaluation, management, and perioperative impact.J. Diabetes Sci. Technol. Nov 2009; 3: 1261-1269Crossref PubMed Scopus (34) Google Scholar]. The results of a number of studies on tight glycemic control (TGC) are contradictory. Complicated and variable protocols are used to achieve glycemic control, the duration of TCG varies between studies, and there are persistent concerns with hypoglycemia. Delaying surgery to correct hyperglycemia has not been shown to improve surgical outcomes in existing larger observational datasets [[23]Holman R.R. Paul S.K. Bethel M.A. Matthews D.R. Neil H.A. 10-year follow-up of intensive glucose control in type 2 diabetes.N. Engl. J. Med. 2008; 359: 1577-1589Crossref PubMed Scopus (5245) Google Scholar]. Preoperative anemia is associated with postoperative morbidity and mortality. A comprehensive review of blood management in Europe and the NHS Blood Transfusion Committee Guidelines in the UK advocate for preoperative screening for anemia. Anemia should be identified and corrected for iron deficiency and any underlying disorder before elective surgery [[24]NHS Blood Transfusion Committee Patient blood management — an evidence-based approach to patient care.http://www.transfusionguidleines.org.uk/uk-tranfusion-committees/national-blood-transfusion-committee/patient-blood-managementDate: June 2014Google Scholar]. Treating anemia preoperatively helps to avoid adverse effects from anemia, transfusion or both. The risks are increased with the severity of the anemia [[25]Kotzé A. Harris A. Baker C. Iqbal T. Lavies N. Richards T. et al.British committee for standards in haematology guidelines on the identification and management of pre-operative anaemia.Br. J. Haematol. Sep 6 2015; https://doi.org/10.1111/bjh.13623Crossref Scopus (97) Google Scholar]. The speed of response to iron therapy (oral or intravenous) is greater in more severe iron deficiency anemia and therefore prompt identification and treatment is important to reduce the need for erythropoiesis-stimulating agents or transfusion. Although not gynecological-cancer specific, both erythropoiesis-stimulating agents and perioperative transfusion have been associated with poorer outcomes for cancer patients, with a Cochrane review showing an increase in cancer recurrence following perioperative transfusion [26Amato A. Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer.Cochrane Database Syst. Rev. Jan 25 2006; 1CD005033PubMed Google Scholar, 27Tonia T. Mettler A. Robert N. Schwarzer G. Seidenfeld J. Weingart O. et al.Erythropoietin or darbepoetin for patients with cancer.Cochrane Database Syst. Rev. Dec 12 2012; 12: CD003407PubMed Google Scholar]. The recent guideline from the British Committee for Hematology showed no strong evidence of benefit from preoperative transfusion to improve surgical outcomes (in cardiac surgery patients) and, in the absence of other blood management measures, did not reduce total transfusion requirements. Where transfusion is considered to be unavoidable there is no evidence to suggest advantages of pre- over intraoperative transfusion [[25]Kotzé A. Harris A. Baker C. Iqbal T. Lavies N. Richards T. et al.British committee for standards in haematology guidelines on the identification and management of pre-operative anaemia.Br. J. Haematol. Sep 6 2015; https://doi.org/10.1111/bjh.13623Crossref Scopus (97) Google Scholar]. If possible, the focus should be on preventing further blood loss intraoperatively. Summary and recommendations: Smoking is associated with increased postoperative morbidity and should be stopped at least four weeks before surgery. Alcohol is associated with increased perioperative morbidity and mortality and should be avoided for at least four weeks before surgery in patients who abuse alcohol. Anemia is associated with an increase in postoperative morbidity and mortality and should be identified, investigated, and corrected preoperatively. Iron therapy is the preferred first line treatment for the correction of iron deficiency anemia. Evidence level: Smoking: High. Alcohol: Moderate (small number of studies). Anemia: High. Recommendation grade: Smoking: Strong. Alcohol: Strong. Anemia: Strong. Mechanical bowel preparation (MBP) often results in patient distress, may cause dehydration, and evidence of benefit to the patient is lacking. A systematic review of 18 randomized clinical trials (5805 patients) found no statistically significant evidence that patients benefit from either bowel preparation or rectal enemas [[28]Guenaga K.F. Matos D. Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery.Cochrane Database Syst. Rev. 2011; CD001544PubMed Google Scholar] — the infection and anastomotic leak rates in patients with a bowel preparation was 9.6% and 4.4%, respectively, compared to 8.5% and 4.5% for those without. The authors concluded that in colonic surgery, bowel cleansing may be safely omitted. Recently, a number of large retrospective studies have suggested that oral antibiotic bowel preparation may be associated with decreased infection rates [[29]Toneva G.D. Deierhoi R.J. Morris M. Richman J. Cannon J.A. Altom L.K. et al.Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery.J. Am. Coll. Surg. 2013; 216 (discussion 762-3): 756-762Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. This, however, has not been verified in randomized trials investigating oral antibiotics alone (without MBP) in sufficient numbers of patients. There is some debate currently as to the benefit of bowel preparation in patients undergoing low anterior resection. In a single-blind, RCT of rectal cancer patients undergoing low anterior resection, patients were randomized to preoperative MBP versus no preparation [[30]Bretagnol F. Panis Y. Rullier E. Rouanet P. Berdah S. Dousset B. et al.Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial.Ann. Surg. 2010 Nov; 252: 863e8Crossref Scopus (162) Google Scholar]. Overall and infectious morbidity were higher in the no MBP group. However, there was no significant difference in the rate of anastomotic leakage between groups. Further studies are required in this area. Finally, the routine use of mechanical bowel preparation before minimally invasive gynecologic surgery has not been shown to improve intraoperative visualization, bowel handling, or ease of performing the procedure [31Arnold A. Aitchison L.P. Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review.J. Minim. Invasive Gynecol. 2015; 22: 737-752Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 32Kantartzis K.L. Shepherd J.P. The use of mechanical bowel preparation in laparoscopic gynecologic surgery: a decision analysis.Am. J. Obstet. Gynecol. 2015; (pii: S0002-9378(15)00480-9)https://doi.org/10.1016/j.ajog.2015.05.017Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 33Ryan N.A. Ng V.S. Sangi-Haghpeykar H. Guan X. Evaluating mechanical bowel preparation prior to total laparoscopic hysterectomy.JSLS. 2015; 19 (pii: e2015.00035)https://doi.org/10.4293/JSLS.2015.00035Crossref Scopus (15) Google Scholar]. Summary and recommendation: Routine oral mechanical bowel preparation should not be used in gynecologic/oncology surgery, including patients with a planned enteric resection. Evidence level: Moderate (extrapolated from results in colorectal patients). Recommendation grade: Strong. Scientific evidence has shown that intake of clear fluids until 2 h before surgery does not increase gastric content, reduce gastric fluid pH, or increase complication rates. Hence, in patients without conditions associated with delayed gastric emptying, the intake of clear fluids until 2 h before the induction of anesthesia as well as a 6 h fast for solid food is now recommended [[34]Smith I. Kranke P. Murat I. Smith A. O'Sullivan G. Soreide E. et al.Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.Eur. J. Anaesthesiol. 2011; 28: 556-569Crossref PubMed Scopus (542) Google Scholar]. In order to reduce postoperative insulin resistance and associated increased risks for complications, carbohydrate loading before surgery has been advocated to achieve a metabolically fed state. In the last decade an increasing number of original studies, systematic reviews, and meta-analyses have shown that carbohydrate loading attenuates the increase in insulin resistance related to surgery, and hence should be used routinely in major abdominal surgery [1Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J. Surg. 2012; 37: 259-284Crossref Scopus (830) Google Scholar, 35Smith M.D. McCall J. Plank L. Herbison G.P. Soop M. Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery.Cochrane Database Syst. Rev. 2014; Google Scholar]. Carbohydrate drinks for preoperative use should be properly tested as not all carbohydrate drinks have the same effects on gastric emptying. Although no studies have been performed in patients undergoing major gynecological surgery, these findings are considered valid for gynecologic patients given similarities in patient characteristics. Randomized trials have demonstrated that preoperative carbohydrates improve wellbeing and reduce nausea and vomiting [[36]Hausel J. Nygren J. Thorell A. Lagerkranser M. Ljungqvist O. Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy.Br. J. Surg. Apr 2005; 92: 415-421Crossref PubMed Scopus (212) Google Scholar]. No studies have specifically addressed diabetic patients, although limited data indicate it is likely to be safe in well controlled diabetics. Summary and recommendation: Patients should be permitted to drink clear fluids until 2 h before anesthesia and surgery. Patients should abstain from solids 6 h prior to induction of anesthesia. Oral carbohydrate loading reduces postoperative insulin resistance, improves preoperative wellbeing, and should be used routinely. Insufficient data is available for diabetic patients. Evidence level: Solids and fluids: High. Carbohydrate loading, primary outcome insulin resistance: Moderate. Carbohydrate loa