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PREOPERATIVE RISK EVALUATION

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A thorough preoperative history and physical should be taken from all patients undergoing surgery. Pre-operative testing may include a complete blood count and chemistries with additional testing being based on the findings of the preoperative history, physical examination, indication for surgery, and planned procedures. Special attention needs to be paid to the preoperative and intraoperative issues that arise in the care of obese patients, cardiac patients, respiratory-compromised patients, and any other patients with significant medical comorbidities including patients with venous thromboembolism or malnutrition. Counseling and postoperative management of patients and their families will be influenced by the unique surgeries and conditions encountered in gynecologic oncology.

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In general, preoperative evaluation and testing are stratified based on a patient's comorbidities. All patients undergoing surgery for gynecologic cancer should undergo a thorough evaluation of other medical issues. Such evaluations will provide an individualized preoperative assessment. In addition, the identification of preoperative medical issues will allow these conditions to be medically optimized.

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Preoperative Testing

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Many patients with gynecologic malignancies will be of older age. As a result, they often have other medical comorbidities. In 2007, the leading causes of death in the United States were heart disease, cancer, stroke, chronic lower respiratory disease, and accidents. Given the prevalence of coronary artery disease, diabetes, peripheral vascular occlusive disease, and obesity in our population, many patients will require some preoperative testing to assess their cardiopulmonary function in anticipation of anesthesia and surgery.

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In healthy patients, the likelihood of an unrecognized medical condition that will cause undue surgical risk is low. A review of studies investigating routine preoperative laboratory evaluations with subsequent likelihood of postoperative complications demonstrated that only hematocrit, creatinine, and electrolytes provided a modest benefit to predict for postoperative complications. Preoperative tests should be selected judiciously, because the addition of unnecessary tests has been found to add a significant cost burden.1 Additionally, in patients who have had a recent laboratory evaluation, retesting will not likely lead to identification of new abnormalities. Our anesthesiologists recommend that preoperative laboratory tests be performed no more than 30 days before surgery to have an up-to-date baseline.

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There is also little utility in screening electrocardiograms (ECGs) and chest radiographs (CXRs) in otherwise healthy patients. An abnormal preoperative ECG is not a useful predictor of postoperative cardiac complications, even in elderly patients. However, a preoperative ECG can be helpful as a baseline for comparison with postoperative ECG abnormalities. The 2007 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on perioperative cardiac evaluation include a recommendation for a preoperative 12-lead resting ECG prior to intermediate-risk noncardiac or vascular surgery for patients with known cardiovascular disease, cerebrovascular disease, or peripheral artery disease.2 Intermediate-risk procedures include intraperitoneal and intrathoracic procedures, which are commonly performed in the surgical staging and treatment of patients with gynecologic malignancies. The ACC/AHA guidelines also recommend preoperative ECG in patients with other ...

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