A Summary of the Key Aspects of Perioperative Care for Women Undergoing MIS for Gynecological Oncology

Abstract

A minimally invasive surgery (MIS) is the standard of care for surgical treatment in gynecological oncology. Robotic surgery is increasingly being used in this domain. Anesthetic considerations are related to the specific procedure, robotic approach per se, adjuvant chemotherapy, radiotherapy, and patient-specific concerns. Evidence-based practices encompass a balance of preoperative, intraoperative, and postoperative evidence-based goals. A summary of these key aspects of perioperative care for women undergoing MIS can enhance surgical outcomes in gynecological oncology.

Introduction

A thorough preoperative evaluation, airway and systemic examination, organ function tests, and assessment of functional capacity are crucial for successful postoperative outcomes.

Assessment of comorbidities, particularly severe cardiopulmonary disease, intracranial pathology, and advanced glaucoma are essential¹ if adverse effects on the respiratory, cardiovascular, and cerebral systems are to be avoided without losing sight of the potential advantages of a minimally invasive surgery (MIS).

Prehabilitation

By considering the patient holistically, prehabilitation aims to preemptively prepare the patient for the impending physiological and psychological insult of cancer treatment and surgery. It has been defined as “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient’s health to reduce the incidence and the severity of current and future impairments.”²

Prehabilitation uses aerobic and resistance exercises to improve physical function, body composition, and cardiorespiratory fitness; dietary interventions to support exercise-induced anabolism and treatment-related malnutrition; and psychological interventions to reduce stress, support behavior change, and encourage overall well-being.³

Anemia

The prevalence of preoperative anemia, defined as hemoglobin <12 g/dL in endometrial cancer, is >26%. Preoperative anemia is associated with prolonged hospitalization, increased morbidity, and mortality. It is a predictor of poor survival outcomes in patients with endometrial cancer.⁴ Not surprisingly, preoperative anemia is a strong predictor of perioperative blood transfusion. Red blood cell transfusion is, in turn, associated with poor 5-year progression-free survival and 5-year overall survival.⁵

Evidence supports the preoperative correction of iron deficiency anemia (IDA) with oral iron in elective, non-urgent cases and intravenous (IV) iron for a more severe and timely correction. IV iron infusion should ideally be given more than 2 weeks before surgery to achieve a clinically significant increase in preoperative hemoglobin concentration.⁶ Perioperative IV iron is associated with a reduced need for blood transfusion, shorter hospital stays, enhanced restoration of iron stores, and higher mean hemoglobin concentration 4 weeks after surgery.^7,8 In addition, preoperative erythropoietin (EPO) therapy has been used successfully to treat anemia of chronic disease and malignancy and IDA unresponsive to iron therapy alone.⁹

Hyperglycemia

A total of 38% of the adult U.S. adult population is prediabetic (defined as HbA1c 5.7–6.4; fasting blood sugar [FBS] 100–125 mg/dL), and 11% is diabetic (HbA1c ≥ 6.5; FBS >125 mg/dL).¹⁰ Poor perioperative glycemic control is associated with adverse clinical outcomes and increased mortality rates. Hyperglycemia is an easily identifiable, modifiable risk factor in optimizing patients for surgery. Better outcomes are achieved by initiating the optimization pathway during initial surgical referral.

Smoking and alcohol cessation

At least 3–4 weeks before surgery is associated with reduced morbidity and mortality.^11,12 Varenicline can increase abstinence from smoking with no increase in serious adverse events.¹³ Alcohol cessation for 4–8 weeks before surgery reduces the number of postoperative complications.¹⁴

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is associated with an increased risk of perioperative morbidity and mortality.¹⁵ Early identification of patients at risk for OSA using one of the screening tools allows for greater patient safety and improved quality of care. STOP-Bang Questionnaire has been well studied in the perioperative setting.¹⁶ Other tools include Berlin Questionnaire, American Society of Anesthesiologists checklist, and P-SAP (Perioperative Sleep Apnea Prediction) score.

Postoperative nausea and vomiting prophylaxis

Postoperative nausea and vomiting prophylaxis (PONV) is a significant risk factor for patients undergoing gynecological surgery. Ineffective PONV prophylaxis is one of the leading causes of unplanned hospital admission and poor patient satisfaction. Using validated scoring systems such as the Apfel risk score and multimodal antiemetic prevention is essential. Currently available prophylactic medications include Nk-1 receptor antagonists, 5-HT3 receptor antagonists corticosteroids, butyrophenones, antihistamines, anticholinergic, and phenothiazines, among others.^17,18

Preoperative IV dexamethasone 8 mg has been found to enhance post-discharge recovery quality and reduce nausea, pain, and fatigue.¹⁹

Bowel preparation, preoperative fasting, and CHO loading

Routine preoperative bowel preparation does not decrease postoperative morbidity and should not be used before minimally invasive or open laparotomy in gynecological oncology, especially within an established enhanced recovery after surgery (ERAS) pathway.³

Patients should be encouraged to eat a light meal until 6 hours and consume clear fluids, including oral carbohydrate drinks, until 2 hours before initiation of anesthesia. Patients with delayed gastric emptying should fast overnight or 8 hours before surgery. Oral carbohydrates reduce insulin resistance, improve well-being, and should be used routinely (extrapolated from nongynecological surgery data). There are insufficient data to make recommendations for patients with diabetes.³

Venous thromboembolism prophylaxis

Venous thromboembolism (VTE) is a significant risk in gynecological oncology patients. Chemotherapy leads to a six-fold increase in this risk. History of VTE prophylaxis, hereditary thrombophilia, hormonal therapy, and higher body mass index also increase the risk. Caprini or a modified Caprini score (using a cutoff of ≥8), validated in other surgical sites, can be used for risk stratification of VTE in MIS to determine which patients would need extended prophylaxis.²⁰ Patients at increased risk should receive dual mechanical and chemoprophylaxis with either low molecular weight heparin or unfractionated heparin. Prophylaxis should be initiated preoperatively and continued postoperatively. Extended chemoprophylaxis (28 days postoperative) should be prescribed to patients who meet high-risk criteria.

Enoxaparin 40 mg subcutaneous (SC) daily is most used; however, there is emerging evidence that the direct oral anticoagulant apixaban is a potentially safe alternative for postoperative DVT prophylaxis.²¹ Apixaban has higher patient compliance²² and a significantly lower risk of major bleeding compared with Enoxaparin.²³

Surgical site infection prevention

Surgical site infections (SSIs) are defined as infections of the surgical incision or organ space that develop within 30 days of surgery. SSIs adversely affect outcomes and increase morbidity and mortality among patients with cancer. SSI bundles rather than a single intervention have been demonstrated to decrease the risk of developing an SSI additively.²⁴ SSI bundle elements include antimicrobial prophylaxis, skin preparation, avoiding hypothermia, avoiding surgical drains, and reducing perioperative hyperglycemia.

The following measures are recommended³:

Weight-based dosing of first-generation cephalosporins should be the first choice, with the addition of metronidazole for anaerobic coverage in pelvic cancer surgery or bowel surgery. It should be given 1 hour before skin incision. Redosing should be performed depending on surgical duration and blood loss.

Skin preparation should include showering before surgery with a chlorhexidine-based antimicrobial soap and a chlorhexidine alcohol skin preparation in the operating room before surgery.

The Centers for Disease Control and Prevention endorses perioperative normothermia as a class 1A recommendation to prevent SSI.²⁵

Peritoneal and subcutaneous drains and nasogastric tubes should be avoided or removed as soon as possible after surgery.

Perioperative glucose levels should be maintained under 200 mg/dL in diabetics and nondiabetics. All surgical patients should be screened for diabetes. Hypoglycemia should also be avoided as it is associated with higher mortality risk.

Hypothermia prevention

Prolonged hypothermia has been linked to an increased risk of SSI, impaired drug metabolism, adverse effects on coagulation, increased bleeding, and cardiac events. Methods to avoid intraoperative hypothermia include forced air blanket devices, under-body warming mattresses, and warmed IV fluid administration. In addition to intraoperative warming, additional warming 2 hours before and after surgery is associated with a significantly reduced rate of SSI in major abdominal surgery.²⁶ Temperature monitoring should always be used.

Effects of adjuvant therapy

Adjuvant therapies are used in combination or by themselves depending on the stage of cancer. Common side effects of the currently utilized adjuvant treatments are listed in Table 1.

Table 1.

Adjuvant Oncologic Therapy-Side Effects

Class	Agents	Side effects
Progesterone	Medroxyprogesterone acetate Megestrol acetate	Weight gain, nausea, constipation, dizziness, excessive sweating, fatigue, peripheral edema, headaches, insomnia, VTE, hypercalcemia, stroke
Taxanes	Paclitaxel Docetaxel	Peripheral neuropathy, cytopenia, acute MI, diarrhea
Platinum-based agents	Carboplatin Cisplatin	Neurotoxicity—neuropathy, ototoxicity, rhabdomyolysis
Aromatase inhibitors	Letrozole	Arthralgia, osteopenia/osteoporosis, hot flashes, weight gain, mood fluctuations
Anthracyclines	Doxorubicin	Cardiotoxicity—LV dysfunction, CHF Cardiomyopathy Pulmonary fibrosis
Multi-tyrosine kinase inhibitor	Lenvatinib	Cardiovascular: HTN, Peripheral edema GI: diarrhea, nausea cytopenia, hypothyroidism, fatigue
Unconjugated monoclonal antibody	Bevacizumab	Cytopenia, pulmonary infiltration Cardiotoxicity—CHF, HTN impaired wound healing, skin rash, renal insufficiency
Selective estrogen receptor modifiers	Tamoxifen Fulvestrant	Hot flashes, weight gain, cognitive dysfunction, VTE, stroke
Immune checkpoint inhibitor	Pembrolizumab	Immune-related adverse events, AKI Neurological: MG, GBS, meningoencephalitis endocrinopathies, arrythmias
Radiotherapy	HDR brachytherapy LDR brachytherapy External beam radiation therapy	Short-term: mucositis—skin changes, cytopenias; gastritis, cystitis, proctitis, vaginitis Long-term: vaginal stenosis, lymphedema, osteopenia, secondary m alignancy

VTE, venous thromboembolism; MG, Myasthenia gravis; GBS, Guillain-Barré syndrome; HDR, high-dose rate; LDR, low-dose rate.

Intraoperative Considerations

In addition to patient-specific concerns related to comorbidities, important concerns for robotic surgery include the following:

Patient positioning

These procedures require low lithotomy and steep Trendelenburg position (TP) (25°–40°) for optimal surgical exposure. Patient positioning is an essential step of robotic surgery. Once the robot is docked, the patient’s position cannot be changed. This results in restricted access to the patient. There is limited access to the chest for CPR and AED placement in emergencies. Proper precautions should be taken with endotracheal tube and IV and arterial lines.

There are many options to prevent cephalad sliding of the patient^27,28: •

Tape and foam crisscrossed across the chest may impede ventilation.

•

Shoulder brace can cause pressure on and increases the risk of brachial plexus injury.²⁹

•

Anti-skid mattress—the most preferred tool.

•

Full-length gel pads provide good contact between the patient and the table.

•

Bean-bag vacuum mat.

•

Friction or conforming pad—disposable anti-slip pad strapped to the table rail.

Pneumoperitoneum

Pneumoperitoneum (PP) is created by insufflating CO₂ with a Veress needle or placing a port through a small umbilical incision. Pressures of 12–15 mmHg are routinely used.

Cardiovascular, respiratory, and neurological effects of TP combined with PP are listed in Table 2. Other systemic effects are listed in Table 3.

Table 2.

Effects of Trendelenburg Position Combined with Pneumoperitoneum

	Mechanism	Physiological effect	Clinical implication	Prevention/Treatment
Cardiovascular		↑MAP, SVR ↑Right and left stroke work → myocardial O₂ demand. ↑CVP ↑PCWP	Preexisting impaired myocardial contractility →cardiac failure Supply demand ischemia Detrimental for patients with severe pulmonary HTN	Gradual positional change, slow insufflation
	IAP <15 mmHg	↑Preload from Splanchnic circulation	Cardiac failure with depressed myocardial contractility exacerbated by sudden Trendelenburg	Gradual Trendelenburg
	IAP >15 mmHg	Compression of IVC→↓Preload, ↓MAP		Keep IAP < 15 mmHg
	Hypercarbia	↑Sympathetic tone→↑SVR, ↑Cardiac contractility	Tachyarrhythmias	Monitor PH and PaCO₂
	Vagal stimulation	Caused by peritoneal expansion or stimulation, CO² embolism	↓HR, ↓BP, Bradyarrhythmias, asystole	Vigilant monitoring, Keep Atropine ready
Respiratory	Cephalad shift of diaphragm + abdominal contents push the diaphragm	↑Peak airway pressures, ↓Lung volumes, ↓Pulmonary compliance Inadvertent endobronchial migration of ETT	↑Atelectasis, ↓FRC→↑VQ mismatch→Hypoxemia Risk of barotrauma→Pneumothorax or Pneumoperitoneum	Recruitment maneuvers, low TV + PEEP, consider PCV ✓Equal bilateral ventilation regularly If cardiopulmonary compromise is seen, release pneumoperitoneum, place chest tube
Neurological	↑ICP	↑IAP→↓Venous return from lumbar venous plexus	Cerebral hypoperfusion due to ↓CO+↑Stasis ↑PaCO²→↑Pulmonary vasoconstriction and central venous HTN Could affect POCD and POD in elderly	Usually well tolerated. Careful preoperative assessment of coexisting neurological disease and cerebral tumors/mets Higher depth of anesthesia (BIS) Thresholds (around 60) may be protective

BIS, Bispectral index; IAP, intra-abdominal pressure; POCD, Postoperative Cognitive Dysfunction; POD, Postoperative Delirium.

Table 3.

Systemic Effects of Trendelenburg Position Combined with Pneumoperitoneum

Category	Systemic effect	Mechanism	Prevention
Ocular	Temporary or permanent vision loss	↑IOP, ION	Trendelenburg to lowest possible degree, dNMG. Consider TIVA and/or Dexmedetomidine gtt. Consider ophthalmology consultation in high-risk patients for risk stratification.
Ocular	Eye lid injuries, corneal damage	Chemosis or exposure keratopathy, mechanical compression	Padding, avoid equipment grazing orbital area prevent secretions and cleaning solution from entering eyes. Eye patching, lube, transparent occlusive dressings
Increased CO₂	SubQ emphysema, pneumothorax, pneumomediastinum	Inadvertently placed trocar, disruption in peritoneum. Congenital or acquired (caused by surgery) diaphragmatic injury, dissection through retroperitoneum, extension of subQ emphysema to pleura or mediastinum	Most cases are asymptomatic, monitoring and conservative treatment. If ↑peak airway pressure, ↓SpO₂, ↓BP or cardiac arrest— release pneumoperitoneum +place chest tube
Renal	↓RBF, ↓GFR, ↓UO	Direct compression of renal vasculature Activation of RAAS, ↑ADH, ↓CO	Adequate hydration before, during and after surgery. Low dose dopamine (2 mcg/kg/min) or nicardipine (0.5 mcg/kg/min)
Positioning	Injuries, neuropathies, compartment syndrome, rhabdomyolysis	Mechanical injury, prolonged compression due to inappropriate positioning or padding Ischemia due to compression	Identify at risk patients, patients with preexisting deformities such as RA and OA. Specialized cushions and gel pads. Intraop risk reduction measures like leg checks and leg rests
Edema	Facial, periorbital, conjunctival, pharyngeal, laryngeal airway edema	Prolonged Trendelenburg	Avoid prolonged Trendelenburg, fluid restriction Leak test, brief post op ventilation
Emergency	Delay in CPR and conversion to open surgery can be lethal	Limited access to patient	Simulation training and emergency undocking protocols can improve time of preparation and intervention
Surgical	Organ injury	Robotic intervention per se	dNMB, neuromuscular and depth of anesthesia monitors Avoid external forces on robot arms

Perioperative fluid management

Both hyper and hypovolemia are detrimental. Hypervolemia is associated with longer length of stay, PONV, delayed return of bowel function, and postoperative ileus.³⁰ Hypovolemia can cause an increased risk of acute kidney injury (AKI) and SSI.³¹ The absence of intraoperative oliguria is a good predictor for the absence of postoperative AKI. However, the converse cannot be implied.³² The goal should be to maintain euvolemia (zero balance), which is more easily attainable with ERAS protocols than with traditional surgical care owing to the protocolization of preoperative hydration and CHO loading, as well as perioperative fluid management. Buffered isotonic crystalloids should be used for intraoperative maintenance.

Goal-directed fluid therapy guided by noninvasive or minimally invasive cardiac output (CO) and stroke volume variation (SVV) monitors to optimize end-organ perfusion, especially in high-risk patients and surgeries, provides the best outcomes.^3,33

Multimodal analgesia

Acute pain management reduces perioperative morbidity and improves patient satisfaction. Multimodal analgesia combines different analgesics that act by different mechanisms and at different sites in the nervous system resulting in additive or synergistic pain control. Multimodal analgesic regimens for MIS rely on nonopioid pharmacologic agents, including NSAIDs, acetaminophen, and dexamethasone. Gabapentin and pregabalin have also been shown to decrease opioid consumption.

Preoperative

Oral acetaminophen, celebrex, gabapentinoids, IV dexamethasone are important adjuncts in multimodal analgesic regimens.

For acetaminophen, there is no evidence to support IV over oral administration, especially in minimally invasive hysterectomy (MIH).

Administration of dexamethasone preoperatively has led to less postoperative opioid consumption and significantly less overall pain. Timing of administration may be an essential factor influencing the intensity of postoperative pain because the onset of action of dexamethasone is 45–60 minutes. Dosing immediately before surgical incision may be less effective in attenuating inflammatory and pain pathways. A potential limitation of preoperative administration is that it can cause perineal pain when given rapidly in low volumes. This effect can be avoided if the dose is diluted in 50 mL saline and infused over 10 minutes.³⁴

In a recent RCT, adding a single dose of gabapentin (600 mg) to acetaminophen and celecoxib in patients undergoing MIH did not reduce opioid use. The U.S. Food and Drug Administration (FDA) has warned about serious, life-threatening, and fatal respiratory depression with gabapentinoids, particularly when taken concomitantly with other central nervous system depressants such as opioids and benzodiazepines, resulting in the discontinuation of gabapentinoids from several ERAS protocols.

Intraoperative

MIGS: Minimally invasive gynecological surgery (MIGS) is currently the standard approach for treating benign and malignant gynecological conditions. Minimally invasive laparoscopic and robotic surgery have substantially improved patient outcomes by decreasing intraoperative blood loss, length of stay, and analgesic requirements and improving return of bowel function and return to normal daily activities.^35,36 Oncological outcomes are equivalent in women undergoing MIS and open procedures for endometrial cancer.³⁷ Patients undergoing MIS reported less pain, interference with walking, and fatigue than women undergoing open surgery on an ERAS pathway.³⁸

Ketorolac: Current consensus expert opinion is to administer ketorolac 30 minutes before the end of the case to delay its antiplatelet effects till this point and achieve postoperative analgesia. The analgesic efficacy of a 10 mg dose is similar to that of 15 and 30 mg for treating postoperative or cancer pain and acute pain in the ER.^39,40 There is evidence of improved acute pain control when ketorolac is combined with local anesthetic port-site infiltration compared with either singular intervention during MIH.⁴¹

Dexmedetomidine: This is a direct sedative-analgesic, which also reduces opioid consumption, nausea, and MAC levels for inhalational anesthetics.⁴²

Ketamine: This is a helpful adjunct in opioid-tolerant patients. However, due to the neuropsychiatric adverse effects, it should not be used routinely as a part of multimodal pain management regimens for MIGS.

Regional anesthesia: Neuraxial and regional blocks, including thoracic epidural analgesia (TEA), intrathecal morphine, TAP, rectus sheath, and ilioinguinal–iliohypogastric, should be considered in open procedures but are not recommended for routine use in laparoscopic procedures owing to a lack of consistent evidence in reduction of postoperative pain scores and opioid requirements,⁴³ especially in the setting of other available multimodal analgesics.

Magnesium: This is a N-methyl-D-aspartate (NMDA) receptor antagonist. It can be part of a multimodal analgesic strategy to reduce postoperative opioid requirements and pain scores without serious side effects. It is essential to ensure the adequate reversal of neuromuscular block due to the potentiating effects of magnesium on nondepolarizing neuromuscular blocking agents.⁴⁴

IV lidocaine: This may facilitate the return of gastrointestinal function and provide analgesia, especially in open transabdominal hysterectomy. It should be considered an adjunct for opioid-tolerant patients but is not routinely recommended for patients undergoing MIGS. Care must be taken to avoid systemic lidocaine toxicity when multiple sources of local anesthetics are used, for example, port-site infiltration.⁴⁵

Port-site injection: With short-acting local anesthetic agents (bupivacaine), a port-site injection has minimal risk, low cost, and has been shown to decrease pain perception among patients requiring MIGS. Compared with short-acting bupivacaine, liposomal bupivacaine has not reduced postoperative opioid use in laparoscopic and open procedures.⁴⁶ The weight of current data supports the use of incisional injection over tap blocks or thoracic epidural analgesia.³

Esmolol: This is an ultra-short β1 adrenoceptor antagonist. Several studies have investigated the antinociceptive effects of an intraoperative esmolol infusion. A recent meta-analysis demonstrates that intraoperative esmolol use reduces intraoperative and postoperative opioid consumption with no change in postoperative pain scores. The exact mechanism of action is unclear. Regulation of voltage-gated calcium channels that stimulate inhibitory G proteins in the cell membrane may control the release of neurotransmitters leading to a state of central analgesia similar to the mechanism of action of clonidine. Another proposed mechanism involves blocking hippocampal adrenergic activation, which attenuates pain perception.⁴⁷

Postoperative Considerations

Same-day discharge

Same-day discharge (SDD) is safe and feasible for MIS in gynecological oncology. It is associated with low complication and readmission rates and mortality. It requires a multidisciplinary team approach, patient education, implementing ERAS protocols, refining patient selection, and operating room scheduling. SDD significantly reduces the length of hospital stay and increases patient satisfaction.^48,49

Urinary retention

Postoperative urinary retention is a substantial problem in gynecological oncology patients, with a baseline rate close to 20%. It is one of the top reasons that prevent SDD. Risk factors include older age, anticholinergic medication use, baseline urinary dysfunction, and para-aortic lymphadenectomy.⁵⁰ Implementing a standardized voiding protocol significantly reduces the time to first void and catheter-associated urinary tract infection. Phenazopyridine (Pyridium) 200 mg is a relatively low-risk intervention that can be given preoperatively as a urogesic and has been shown to increase voiding trial success rates.⁵¹

Postoperative pain management

Control of postoperative pain is vital to facilitate early patient mobility and hastened recovery. Inadequate pain control is attributed to 30% of delayed discharges and might prevent SDD. Thoracic epidural analgesia (TEA) provides superior pain relief⁴⁶ with decreased venous thromboembolism (VTE) and pulmonary and respiratory complications⁴⁷ compared with systemic analgesia for complex open surgery. Neuraxial analgesia should be used with caution when co-administered with anticoagulation. Routine use of scheduled postoperative acetaminophen and NSAIDs is recommended. There are no robust data to recommend the routine usage of gabapentinoids and dextromethorphan. Although it is essential to limit the amount of opioids and opioid-related side effects, opioids still play a potentially vital role in pain management. They are recommended as rescue medications when all other non-opioid agents have failed to control pain adequately.⁴⁵

Prevention of postoperative ileus

Factors that influence the return of bowel function include but are not limited to exposure to opioids, fluid balance, the extent of peritoneal disease and complexity of surgery, receipt of transfusion, and postoperative abdominopelvic complications.⁵²

The primary mechanism of postoperative ileus is the inflammatory response to bowel manipulation. MIS reduces the rate of postoperative ileus; however, not all patients are candidates for MIS. Simple interventions that stimulate the enteric nervous system, such as early feeding, coffee consumption, and gum chewing, effectively decrease the time to bowel function return.⁵² Euvolemia, early ambulation, and minimization of opioids via multimodal analgesia have also been shown to decrease the rate of postoperative ileus by two- to fivefold in women undergoing high complexity open gynecological cancer surgery.⁵³

IV magnesium administered as a bolus of 40 mg/kg followed by an infusion of 10 mg/kg intraoperatively was studied in a trial that demonstrated a decrease in interval return of bowel function without any side effects.⁵⁴ In patients undergoing planned bowel resection, the peripherally acting mu receptor antagonist alvimopan, given pre- and postoperatively, has been shown to reduce time to bowel recovery and the incidence of postoperative ileus in multiple surgical specialties, including gynecological oncology.⁵⁵ It is only FDA-approved for patients undergoing planned bowel resection.

Footnotes

Authors’ Contributions

Conception and design: R.K., S.N., A.E., and M.H. Drafting the article: all authors. Critically revising the article: R.K. and A.E. Reviewed submitted version of article: all authors. Approved the final version of the article, on behalf of all authors: A.E. Administrative/technical/material support: R.K. and A.E.

Author Disclosure Statement

The authors declare no conflict of interest.

Funding Information

The article has received no funding.

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