Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety

Abstract

Background:Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment. Methods: A study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol. Results: Literature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis. Conclusion: On the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy. This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association

“…Even in patients at high risk for VTE, there is no net benefit in extended thromboprophylaxis compared with inpatient only strategy ( P =0.18 for VTE and P =0.43 for bleeding). 52,53…”

Extended chemothromboprophylaxis use in colorectal cancer surgery: a literature review

“…6 Asymptomatic DVT clinical relevance A recurrent limitation of the above RCTs has been the use of a surrogate test such as venography or ultrasonography to objectively diagnose VTE. 5 This method diagnoses many distal asymptomatic DVTs with limited potential to embolize or propagate; only 25% of untreated calf DVTs are expected to extend proximally. 4 Hence, the clinical relevance of a reduction in the number of these asymptomatic cases has been questioned in literature reviews.…”

“…4 Hence, the clinical relevance of a reduction in the number of these asymptomatic cases has been questioned in literature reviews. 5,14,22 The ENOXACAN II and CANBESURE studies have especially been criticized for including distal DVTs in their primary outcome. 5,14 However, in the post-operative state especially in the context of cancer, patients are highly thrombogenic.…”

“…5,14,22 The ENOXACAN II and CANBESURE studies have especially been criticized for including distal DVTs in their primary outcome. 5,14 However, in the post-operative state especially in the context of cancer, patients are highly thrombogenic. 23 It is possible that asymptomatic or distal DVT may have a larger potential to progress and embolize in these conditions versus in general populations.…”

“…4 These patients frequently also have additional nonmodifiable risk factors for VTE such as advanced age, limited mobility, previous VTE or hereditary prothrombotic disorders. 5 Furthermore, factors such as lithotomy position, prolonged procedure duration >2 h, bed rest >4 h, need for pelvic dissection and neoadjuvant therapy further increase the risk of VTE in colorectal surgery. [6][7][8] The risk of VTE appears to stay elevated for at least 3 months after abdominal and pelvic surgery, with cumulative incidence reaching up to 40%.…”