Post-operative Protocol After Surgery for Carcinoma Ovary

1. Immediate Post-op (ICU/HDU) Monitoring

• Vitals every 15-30 min: BP, pulse, SpO2, temperature, RR
• Urine output monitoring hourly (target ≥ 0.5 mL/kg/hr) via Foley catheter
• Drain monitoring: note color and volume of abdominal/pelvic drains; if packing was used for intraoperative bleeding, do NOT remove before completing the 1st postoperative day (removal after 3 days risks infection)
• CBC, electrolytes, renal function, coagulation on POD 1
• Temperature: maintain normothermia (core temp > 34°C); active warming methods used

2. Pain Management (Multimodal - Opioid-Sparing)

• Multimodal analgesia: combine systemic NSAIDs/paracetamol + regional techniques
• Epidural analgesia is preferred where feasible - reduces surgical stress response and is associated with improved progression-free survival
• Prolonged opioid use is NOT recommended
• Shift to oral analgesia as early as tolerated

3. DVT / Thromboembolic Prophylaxis

• LMWH at prophylactic doses for 28 days postoperatively (extended prophylaxis)
• Mechanical prophylaxis (compression stockings, pneumatic compression devices) in addition to pharmacological prophylaxis - start intraoperatively and continue until mobile
• Patients with prior VTE or thrombophilia: same 28-day LMWH regimen, starting the evening before surgery

4. Fluid Management

• Balanced crystalloids (e.g., Ringer's lactate) for routine fluid replacement
• Goal-directed fluid therapy in the intraoperative and early postoperative period
• Avoid aggressive fluid resuscitation; monitor for fluid overload especially after extensive peritoneal surgery
• Albumin: hypoalbuminemia guides pre-op optimization, not a contraindication to surgery

5. Nutrition and Feeding (ERAS Principle)

• Early oral feeding on postoperative day 1 if no bowel resection was performed
• Bowel resection patients: manage as per colorectal pathway - NGT if needed, nil orally until return of bowel function
• Address malnutrition: high prevalence in advanced ovarian cancer patients at diagnosis
• Only 58% of gynecologic oncology patients historically received normal diet on POD 1 - ERAS aims to correct this

6. Mobilization and Physiotherapy

• Early mobilization (sitting up, standing, walking) from POD 1
• Physiotherapy offered as routine perioperative care
• Reduces DVT risk, improves respiratory function, accelerates bowel recovery

7. Wound and Drain Care

• Inspect wound on POD 1
• Abdominal drains removed when output < 50 mL/day (unless specific indication to keep)
• Foley catheter removed as early as possible (usually POD 1-2 if no urological surgery was performed)
• Skin staples/sutures: removed at POD 7-10 (if stable)

8. Antibiotics

• Perioperative prophylaxis only (no routine prolonged course unless complication occurs)
• In case of postoperative infection/fever: tailor antibiotics based on clinical picture, CRP/WBC, culture results, and prior treatments

9. Post-Splenectomy Protocol (if splenectomy was done)

• Vaccinations against S. pneumoniae (pneumococcus), H. influenzae type b, and N. meningitidis - given approximately 2 weeks after surgery
• Annual influenza vaccine
• Patient education on increased infection susceptibility
• Emergency antibiotic supply (penicillin V or amoxicillin) for acute infection

10. Respiratory Care

• Deep breathing exercises and incentive spirometry from POD 0
• Early ambulation to reduce atelectasis and pneumonia risk
• Chest physiotherapy if applicable

11. Bowel Management

• If bowel resection with anastomosis: cautious introduction of diet; monitor for anastomotic leak (fever, tachycardia, abdominal pain, elevated CRP on POD 3-5)
• Stoma care education if stoma was fashioned
• Prokinetics (metoclopramide) and early mobilization to prevent ileus

12. Psychological and Social Support

• Screen for emotional distress and depression (common post-cancer surgery)
• Offer psycho-oncological support routinely
• Discuss diagnosis, staging, and adjuvant therapy plan with patient

13. Adjuvant Chemotherapy Planning

• After staging + complete cytoreduction: plan adjuvant carboplatin + paclitaxel chemotherapy
• Typically started 4-6 weeks post-surgery
• Goal: no undue delay in starting chemotherapy; postoperative complications are the leading cause of delay (per PMC11430809)
• Intraperitoneal (IP) chemotherapy may be planned if no bowel resection performed and optimal debulking achieved

14. Follow-up Planning

• Post-discharge review at 2 weeks (wound, recovery, plan chemotherapy)
• CA-125 level to be checked as baseline before first cycle of chemo
• CT scan if residual disease assessment needed

Recent ASCO / ESGO-ESMO Guidelines: Adjuvant Chemotherapy After Ovarian Cancer Surgery

Key Guideline Documents

1. Who Needs Adjuvant Chemotherapy? (Stage-by-Stage)

Stage IA / IB (Grade 1)

• Observation after surgery - chemotherapy NOT indicated
• ESMO-ESGO: no adjuvant therapy in fully staged, grade 1 disease
• NCCN: observation acceptable for staged IA-IB low-grade

Stage IC / Grade 2-3 (Early Stage, High Risk)

• Carboplatin + paclitaxel x 3-6 cycles recommended
• All societies agree high-grade (grade 3) and clear cell carcinoma at stage IC warrant chemotherapy

Stage II

• Adjuvant chemotherapy recommended - carboplatin + paclitaxel x 6 cycles
• ESMO-ESGO: adjuvant chemo "may be considered" for stage II, with optional maintenance endocrine therapy after

Stage III - IV (Advanced Disease)

• Chemotherapy is standard for all patients - see regimens below

Histotype exceptions: Clear cell and mucinous carcinomas are less chemosensitive. NCCN recommends treatment regardless of stage for clear cell; ESMO-ESGO permits omitting chemo in fully staged IA/IB clear cell. Mucinous carcinoma: consider oxaliplatin-based or FOLFOX regimens.

2. Standard First-Line Chemotherapy Regimen

• Bevacizumab 15 mg/kg q3w - added to chemotherapy and continued as maintenance for 15-22 cycles (GOG-0218, ICON7 trials). Preferred in: stage IV, incomplete cytoreduction, high-risk features, need for rapid symptom control
• Intraperitoneal (IP) chemotherapy: ASCO 2025 notes this may be offered during interval cytoreductive surgery (ICS) for stage III patients with good performance status and adequate renal function who received NACT (HIPEC during ICS)

3. Maintenance Therapy After First-Line Chemotherapy (Major 2024-2025 Update)

Step 1 - Mandatory Genetic/Molecular Testing

"All patients with EOC should be offered germline genetic AND somatic tumor testing at diagnosis."

• BRCA1/2 germline + somatic testing
• HRD (homologous recombination deficiency) status via validated genomic instability assay (e.g., Myriad myChoice)

Maintenance Therapy by Biomarker Status (ESMO / ESGO-ESMO 2024)

A. BRCA1/2 Mutated (germline or somatic)

ASCO 2025: "Patients with EOC should be offered FDA-approved maintenance treatments." (olaparib and niraparib are FDA-approved first-line maintenance for BRCA-mutated patients)

B. BRCA Wild-type / HRD-Positive

C. BRCA Wild-type / HRD-Negative

Note: In the US (FDA), niraparib maintenance is restricted to HRD-positive tumors. In Europe (EMA), it is approved for all-comers. This is a significant US/European divergence.

4. Neoadjuvant Chemotherapy (NACT) Pathway - ASCO 2025 Update

1. NACT = platinum-taxane doublet (carboplatin + paclitaxel)
2. Interval cytoreductive surgery (ICS) after ≤4 cycles (if response or stable disease)
3. After ICS: continue chemotherapy to complete a 6-cycle total plan
4. Optional bevacizumab may be added
5. HIPEC during ICS may be offered (stage III, good PS, adequate renal function)
6. After completing 6 cycles → offer maintenance therapy as above

5. Special Populations

• Older/frail patients: Single-agent carboplatin (AUC 5-6) is acceptable if paclitaxel not tolerated - ESGO-ESMO consensus
• Stage IV with pleural effusion only: May be treated same as stage III regarding maintenance eligibility
• Low-grade serous carcinoma (LGSOC): Adjuvant chemo NOT recommended for stage IA; optional for stage IB/IC. Letrozole or endocrine maintenance is preferred after chemo

6. Post-Chemotherapy Follow-up

• CA-125 + clinical examination every 3 months for 2 years, then 6-monthly
• Imaging (CT abdomen/pelvis) guided by symptoms or rising CA-125 - not routine
• Routine follow-up monitoring during PARP inhibitor maintenance per drug-specific protocols (CBC for niraparib; creatinine for olaparib)

Summary Table