Hysterectomy: GKS: Recommendations for pre-and postoperative treatment

GKS 27.9.2007

Anna-Mari Heikkinen

KYS naistenklinikka

Hysterectomy: Preoperative recommendationsThrombosis prophylaxis

Antibiotic prophylaxis

Other

Hysterectomy: Postoperative recommendationsThrombosis prophylaxisSick leaveOther

Käypä Hoito

”Laskimotukos ja keuhkoembolia” 2004, new version coming Preoperative prevention of venous

thromboembolism ”Leikkausta edeltävä arviointi ja hoito” will be

published 2007-2008 Special preoperative guidelines (cardiac stents,

varfarin treatment etc.)

Hysterectomy and prevention of venous thromboembolism: References Käypä Hoito: Laskimotukos ja keuhkoembolia

2004 Prevention and Treatment of Venous

Thromboembolism: International Consensus Statement 2006

ACOG Practice Bulletin: Clinical Management Guidelines for Ob/Gyn Number 84, August 2007

Hysterectomy and the risk of venous thromboembolism Gynecologic surgery without prophylaxis: 15-

40%

FINHYST 1996: Thromboembolism AH 0,2% VH 0,2% LH 0,3%

FINHYST 2006: Only 2 cases of pulmonary embolism reported! Not a single venous thromboses of the lower limb were reported.

Hysterectomy and prevention of venous thromboembolism : Methods of choice Early mobilization! Graduated compression stockings (GCS) Intermittent pneumatic compression (IPC) LMWH

Enoxaparin (Klexane®) 40 mgx1 Dalteparin (Fragmin®) 5000 IUx1

Thrombin inhibitors Ximelagatran (Exanta®) Melagatraani (Melagatran®) Bivalirudin (Angiox®)

FX infibitor: Fondaparinux (Arixtra®)

Hysterectomy and prevention of venous thromboembolism: LMWH treatment 12 h preop, continuing >12 h after postop. OR: 6-12 h postoperatively Duration: Immobilization (hospitalization or 7-10 days?) Prolonged: 1 month Tiny / obese patients

Hysterectomy and prevention of venous thromboembolism: Estimation of risk LOW RISK: Risk of TE 2-3%

No prophylaxis (early mobilization) Duration of operation less than 45 min < 40 years No risk factors

MODERATE RISK: Risk of TE 10-20%

HIGH RISK: Risk of TE 40-80%GCS (IPC) + LMWH 1 month Cancer Previous TE (idiopatic/recurent) Coagulopathy Severe medical illness/complication 6 w postpartum

Hysterectomy and prevention of venous thromboembolism: Moderate risk A. LMWH during hospitalization

B. LMWH during hospitalization, 7-10 days if risk factors

C. LMWH 7-10 if risk factors,

GCS if no risk factors

IMMOBILIZATION ----- HOSPITALIZATION

Risk factors 7-10 d prophylaxis: 1-2 p4 w prophylaxis: > 3 p

5p History of TE, coagulopathy, cancer, severe trauma3p Immobilization, paresis, pregnancy, puerperium1p Infection/complication

Age > 60yBMI > 30SmokingOC, HT, SERMInflammatory bowel diseaseHeart failure, MCIVenous disorder (varicosis, thromboflebitis)Central venous catheterizationAc/chr medical illness increasing risk of TE

When no LMWH prophylaxis? Uncomplicated operation and cure < 40-60y patient, no risk factors Early mobilization, short hospitalization

Intermittent pneumatic compression (IPC) Level 2 evidence Possible indications during hysterectomy

High risk patient: LMWH + IPC Moderate risk patient, prolonged immobilization:

LMWH + IPC Moderate risk patient, contraindication for LMWH

Other medications affecting coagulation

ASA (50-100mg): Stop 1 week preop Plavix®: Stop 1 week preop Marevan®: Stop 4-5 d preop. Bridge therapy! KÄYPÄ HOITO: Leikkausta edeltävä arvio ja

hoito (2007 -2008)

FINHYST: Thrombosis prophylaxisFINHYST 2006

+ LMWH Duration

specified

Duration

(mean)

Hospitalization

If LMWH given

AH (908)

72%

97% 41% 4,3 4,0

LH (1002)60%

97% 40% 3,1 2,2

VH (1517)65%

97% 44% 3,2 2,5

FINHYST 1996: AH 37,5% VH 47,1% LH 21,9%

≥60years: Prophylaxis 79%Postoperative bleeding complication: 2,7%

-Prophylaxis given -> bleeding 3,0%-No prophylaxis -> bleeding 2,1%

Hysterectomy and prevention of venous thromboembolism :GKS recommendation LOW RISK: No prophylaxis (early mobilization)

Duration of operation less than 45 min , <40 years patient, no risk factors

MODERATE RISK : ”Normal hysterectomy” GCS alone if no risk factors LMWH always > 60 yr, or < 60yr and at least 1 risk factor 7-10 days prophylaxis according pre- and postop. risk factors

HIGH RISKI: GCS (IPC) +LMWH 1 month Cancer Previous TE (idiopatic/recurent) Coagulopathy Severe medical illness/complication 6 w postpartum

Hysterectomy and risk of infectionsUTI: 5-10%

AH: wound infection 3-5%, pelvic cellulitis 10-20% without AB-proph. Postop. fever 16-36% FINFYST 1996: AB-proph. 78.9%; UTI 4,2%, operation-side

infection/fever 6,0% VH: pelvic cellulitis 35% without AB-proph. Postop. fever 7-55% FINFYST 1996: AB-proph. 79,5%; UTI 7,3%, operation-side

infection/fever 5,4%LH: Postop. fever 10% FINFYST 1996: AB-proph. 92,3%; UTI 2,6%, operation-side

infection/fever 5,9%

Antibiotic prophylaxis

ACOG Practice Bulletin (Ob Gyn July/2006):

Always antibiotic prophylaxis before hysterectomy

> 30 prospective clinical trials 2 meta-analysis

Hysterectomy and antibiotic prophylaxis GKS recommendation Single-dose AB during induction of anesthesia (< 60min but always

before incision)

Cephalosporins! BMI < 30:cefuroxim 1.5g BMI > 30: cefuroxim 3g Allergic reactions to B-lactam AB:

clindamycin 600mg or vankomycin 1g + tobramycin 120mg / netilmycin 150mg

Second dose: Lengthy operation (3 h after incision) Blood loss > 1500ml

Metronidatzol useless

FINHYST 2006: Postoperative infections

Abdominal Laparoscopic Vaginal

Pelvic infection: hematoma/abcess 0,5% 2,9% 2,0%Wound infection 2,2% 1,5% 0,9%Urinary infection 2,1% 0,7% 1,5%Fever for unknown cause 2,6% 1,4% 0,9%

FINHYST 1996 vs. 2006:Less infections in all groups!

Abdominal Laparoscopic Vaginal

Year 1996 2006 1996 2006 1996 2006

Infections all 10,5% 7,8% 13,0% 6,9% 9,0% 5,5%

Antibiotic prophylaxis

79% 96% 80% 98% 92% 97%

FINHYST 2006: Antibiotic prophylaxis

0 % 20 % 40 % 60 % 80 % 100 %

VAGINAL

LAPAROSCOPIC

ABDOMINALUNSPECIFIED

CEFUROXIME ALONE

METRONIDATZOLE ALONE

CEFU + METRO

OTHER COMBINATION

OTHER AB ALONE

Usage (%)

Abdominal 96TAH 96

SAH 93

Laparoscopic 98LH 98

LAVH 97

Vaginal 97

Reasons to NOT give routine prophylactic metronidatzol Interactions: Varfarin!! Bacterial resistance Costs

-> indicated only if bowel injury

Costs of prophylaxis (examples of hospital prices /dose) Klexane 40 mg 3.80€ Fragmin 5000 IU 3.60€ Kefuroksiimi 1.5: 1.80€ Metronidatsoli 500 mg 3.10€ Klindamysiini 600 mg 5.50€ Siprofloksasilliini 200 mg 14.00€ Vankomysiini 1 g 5.60€ Tobramysiini 120 mg6.40€ Netilmysiini 10 mg 7.00€

Postoperative treatment

Moller C et al 2001: Variation in recommendations for hysterectomy and vaginal surgery patients in Denmark

Sick leave: 4 w (1-8 w) work without heavy lifting, 6 w (2-12 w) work with heavy lifting

Lifting restrictions : 2-15 kg, 2-12 weeks No sex intercourse: 4 w (0-12 w)

SICK leave after hysterectomy

No evidence based medicine

Persson et al. 2006. Rand. multicenter trial

AH (n=56) vs. LH (n=63)

Sick leave 14 days

Final sick leave:

AH: 33.5vrk LH: 26vrk

FINHYST 2006: Convalescence period AH LH VH+prol VH

Post op hospital days (mean) 3,9 1,9 2,7 1,8

Sick leave days (mean) doctors 32,2 22,0 35,0 25,0

Sick leave days (mean) patients 36,2 25,3 38,3 28,0

Inadequate sick leave 38,6% 38,2% 26,5% 32,9%

Workers receiving extra days % 32,2% 30,9% 22,5% 25,4%

Number of extra days (mean) 11,1 11,0 11,9 11,9

Too long sick leave 0,8% 1,3% 0,7% 2,4%

Sick leave days (mean) if sick leave was reported adequate 32,6 21,7 36,8 25,8

FINHYST 1996: Sick leave (mean)

34,4 21,5 34,0

Postoperative recommendations (HUS, TAYS, TYKS, OYS, PKKS, KYS):

Sick leave: AH: 4 w LH: 2-3 w VH: 2-3 w VH+prolapse: 3-6 w

No sex intercourse: Postop. control or 4 w Postop. control: 4/6 Other very specific restrictions: Preop peräruiske

kaikille, istumakielto laskeumissa 2vi, ei saunaan 1vi, ei ammekylpyjä/uintia, ei kovia löylyjä, alapesu vähintään 2x/vrk, ei tampoonia, ei raskaita töitä 1-2 viikkoon, PAPA 5v välein, gyn tutkimus vuosittain, ei pyöräilyä ennen jt, ei autolla ajoa 2 viikkoon jne…

Sick leave after hysterectomy:GKS recommendations LH: 2-3 weeks AH: 4 weeks VH, no prolaps surgery: 2-3 weeks VH + prolaps surgery : 4 weeks

Hysterectomy: Other GKS recommendations No pubic hair shaving, shortening if

necessary No bowel preparation No routine abd. cavity drainage No lifting restrictions (no heavy work during

sick leave) No sexual intercourse during sick leave No other specific restrictions to patient

guidelines No routine postoperative control

KIITOS!