Page 28 - Ovarian Cancer Surgery - Quality Indicators

5.7 QI 7 - Pre-, intra-, and post-operative management

5.7.1 Description of the QI

TYPE Structural indicator.

DESCRIPTION The minimal requirements are: 1 intermediate care facility, and access to an intensive

care unit in the center are available, 2 an active perioperative management program is
established1 .

SPECIFICATIONS Numerator: not applicable.
Denominator: not applicable.

TARGETS Not applicable.

SCORING RULE 3 if the minimal requirements are met.

1) Details of perioperative management includes non -exhaustive list: preoperative hemoglobin optimization and iron deficit correction; correction of denutrition
and immunonutrition according the current guidelines; fluid management, involving a Goal Directed Therapy GDT policy rather than liberal fluid therapy
without hemodynamic goals. However, the superiority of GDT compared to restrictive fluid strategy remains unclear. There is no recognized standard method of
monitoring; pain management, including in the absence of contra-indication the use of epidural analgesia in order to avoid opioids; while routine premedication
is no longer recommended, prevention of postoperative nausea and vomiting should be systematic.

5.7.2 Rationale

Malnutrition has been demonstrated to affect two third of ovarian cancer patients at the time of diagnosis and
portends poor surgical outcomes259. Malnutrition at the time of surgery is an important contributor to
perioperative morbidity. It makes patients more vulnerable to surgical site infections. Malignancy related
malnutrition causes alterations in immune function that impairs a patient’s response to surgical stress and places
malnourished surgical patients at increased risk for the development of surgical site infections260,261.
Immunomodulating diets in ovarian cancer patients could provide an effective way to minimize the post-
operative morbidity associated with surgical site infections.

The overall reduction of mortality and morbidity rates after surgery has consistently decreased over the last
decade with the introduction of innovative perioperative care, which has made difficult to assess the independent
role of each single perioperative intervention. However, the high morbidity of ovarian cancer surgery, which
increases with complexity71,131,262, justifies the implementation of the concept of “fast-track surgery” or
“enhanced recovery programs” involving procedure-specific evidence-based care principles which has been
demonstrated to result in enhanced recovery with reduced of stay and morbidity263.

While no specific research on this topis has been carried out in ovarian cancer surgery, the abundant available
literature concerning open colorectal surgery provides compelling data which can reasonably be transposed264.
Perioperative management includes: 1 preoperative hemoglobin optimization 265 and iron deficit correction266,
2 correction of denutrition according the current guidelines 267, 3 fluid management, involving a GDT policy
rather than liberal fluid therapy without hemodynamic goals; however, the superiority of GDT compared to
restrictive fluid strategy remains unclear268; there is no recognized strandard method of monitoring269. While
routine premedication is no longer recommended270, prevention of postoperative nausea and vomiting should be
systematic271.

One previous initiative53 published a QI for this topic.

5.7.3 Summary of available scientific evidence

No directly applicable clinical studies have been identified.

 OVARIAN CANCER SURGERY - QUALITY INDICATORS 
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