Global practice variation in pharmacologicthromboprophylaxis for general and gynaecologicalsurgery: systematic review

Pourjamal, Negar; Lavikainen, Lauri I; Halme, Alex L E; Cartwright, Rufus; Ahopelto, Kaisa; Guyatt, Gordon; Tikkinen, Kari A.O.

doi:10.1093/bjsopen/zrac129

Cited by 7 publications

(7 citation statements)

References 5 publications

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“…These reports, along with findings from two recent meta-analyses, one of randomized trials involving different surgical disciplines 22 , and the other of randomized trials and cohort studies involving major abdominal surgery 23 , demonstrated that postoperative chemical thromboprophylaxis did not diminish protection against VTE. Therefore, in the context of significant global variations in practice 4 , 24 , this study contributes to a growing body of evidence, spanning multiple specialties and procedural types, that postoperative chemical thromboprophylaxis is a safer approach for patients, resulting in a similar risk of VTE, but lower rates of bleeding.…”

Section: Discussionmentioning

confidence: 91%

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Liu,

Wong,

Goh

et al. 2023

BJS Open

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Background Although guidelines recommend the use of perioperative chemical thromboprophylaxis for antireflux surgery, the optimal timing for its initiation is unknown. The aim of this study was to investigate whether perioperative timing of chemical thromboprophylaxis affects bleeding, symptomatic venous thromboembolism, and complication rates in patients undergoing antireflux surgery. Methods This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Results Overall, chemical thromboprophylaxis was given early (before surgery or intraoperatively) in 1099 (25.6 per cent) patients, and after surgery in 3202 (74.4 per cent) patients, with comparable exposure doses between the two groups. Symptomatic venous thromboembolism risk was unrelated to chemical thromboprophylaxis timing (0.5 versus 0.6 per cent for early and postoperative chemical thromboprophylaxis respectively (odds ratio (OR) 0.97, 95 per cent c.i. 0.41 to 2.47, P = 1.000). Postoperative bleeding developed in 34 (0.8 per cent) patients, and 781 intraoperative adverse events were identified in 544 (12.6 per cent) patients. Both intraoperative bleeding and complications were associated with significantly higher postoperative morbidity affecting multiple organ systems. Importantly, compared with postoperative chemical thromboprophylaxis, early administration increased the risk of postoperative bleeding ((1.5 versus 0.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 2.94, 95 per cent c.i. 1.48 to 5.84, P = 0.002)) and intraoperative adverse events ((16.1 versus 11.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 1.48, 95 per cent c.i. 1.22 to 1.80, P < 0.001)), as well as independently predicted their occurrences. Conclusion Intraoperative adverse events and bleeding that occur during and after antireflux surgery are associated with significant morbidity. Compared with postoperative chemical thromboprophylaxis, early initiation of chemical thromboprophylaxis confers a significantly higher risk of intraoperative bleeding complications, without appreciable additional protection from symptomatic venous thromboembolism. Therefore, postoperative chemical thromboprophylaxis should be recommended for patients undergoing antireflux surgery.

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Section: Discussionmentioning

confidence: 91%

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Liu,

Wong,

Goh

et al. 2023

BJS Open

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“…Although prior work exists on procedure-specific risks of thrombosis and bleeding in surgery (with variable certainty evidence), the optimal starting time and duration of thromboprophylaxis remains unclear owing to insufficient statistical power of existing randomized trials in the field and the changing nature of surgery (eg, earlier mobilization and less-invasive surgery) . This has contributed to substantial practice variation in thromboprophylaxis worldwide . Because decisions regarding thromboprophylaxis in noncardiac surgery often represent a trade-off between decreased risk of VTE and increased risk of bleeding, an understanding of the postoperative timing of major bleeding plays a major role in assessing the risks and benefits associated with thromboprophylaxis.…”

Section: Discussionmentioning

confidence: 99%

Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery

Halme,

Roshanov,

Tornberg

et al. 2024

JAMA Netw Open

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ImportanceAlthough major bleeding is among the most common and prognostically important perioperative complications, the relative timing of bleeding events is not well established. This information is critical for preventing bleeding complications and for informing the timing of pharmacologic thromboprophylaxis.ObjectiveTo determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery.Design, Setting, and ParticipantsThis is a secondary analysis of a prospective cohort study. Patients aged 45 years or older who underwent inpatient noncardiac surgery were recruited in 14 countries between 2007 and 2013, with follow-up until December 2014. Data analysis was performed from June to July 2023.ExposureNoncardiac surgery requiring overnight hospital admission.Main Outcomes and MeasuresThe primary outcome (postoperative major bleeding) was a composite of the timing of the following bleeding outcomes: (1) bleeding leading to transfusion, (2) bleeding leading to a postoperative hemoglobin level less than 7 g/dL, (3) bleeding leading to death, and (4) bleeding associated with reintervention. Each of the components of the composite primary outcome (1-4) and bleeding independently associated with mortality after noncardiac surgery, which was defined as a composite of outcomes 1 to 3, were secondary outcomes.ResultsAmong 39 813 patients (median [IQR] age, 63.0 [54.8-72.5] years; 19 793 women [49.7%]), there were 5340 major bleeding events (primary outcome) in 4638 patients (11.6%) within the first 30 days after surgery. Of these events, 42.7% (95% CI, 40.9%-44.6%) occurred within 24 hours after surgery, 77.7% (95% CI, 75.8%-79.5%) by postoperative day 7, 88.3% (95% CI, 86.5%-90.2%) by postoperative day 14, and 94.6% (95% CI, 92.7%-96.5%) by postoperative day 21. Within 48 hours of surgery, 56.2% of major bleeding events, 56.2% of bleeding leading to transfusion, 56.1% of bleeding independently associated with mortality after noncardiac surgery, 51.8% of bleeding associated with hemoglobin less than 7 g/dL, and 51.8% of bleeding associated with reintervention had occurred.Conclusions and RelevanceIn this cohort study, of the major postoperative bleeding events in the first 30 days, more than three-quarters occurred during the first postoperative week. These findings are useful for researchers for the planning future clinical research and for clinicians in prevention of bleeding-related surgical complications and in decision-making regarding starting of pharmacologic thromboprophylaxis after surgery.

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“…The wide variability in the use of thromboprophylaxis in general abdominal, colorectal, UGI, and HPB surgeries, both within and between countries, centers, and surgeons, reflects a lack of consensus regarding optimal practice. 12,19,20,22,23,56 As no systematic reviews of procedure-specific risks of VTE and bleeding for general abdominal, colorectal, UGI, and HPB surgeries have heretofore been available, this variability is unsurprising. 12,[15][16][17] Summaries presented-and visually summarized in Infographics (Figs.…”

Section: Implications Of the Findingsmentioning

confidence: 99%

“…General abdominal, colorectal, upper gastrointestinal (UGI), and hepatopancreatobiliary (HPB) surgery guidelines have failed to provide patient and procedure-specific guidance on pharmacological thromboprophylaxis, 7,12–17 at least in part due to uncertainty regarding baseline risks that vary with patient and procedure-specific factors 18 . The absence of procedure-specific recommendations contributes to substantial practice variation within and between centers and countries 12,19–25 . To provide risk estimates of VTE and major bleeding for general abdominal, colorectal, UGI, and HPB procedures, and thus to fill this knowledge gap, we conducted a series of systematic reviews 12 …”

mentioning

confidence: 99%

“…18 The absence of procedurespecific recommendations contributes to substantial practice variation within and between centers and countries. 12,[19][20][21][22][23][24][25] To provide risk estimates of VTE and major bleeding for general abdominal, colorectal, UGI, and HPB procedures, and thus to fill this knowledge gap, we conducted a series of systematic reviews. 12…”

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confidence: 99%

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Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper-Gastrointestinal and Hepatopancreatobiliary Surgery

Lavikainen,

Guyatt,

Sallinen

et al. 2023

Annals of Surgery

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Objective: To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding following abdominal surgery. Summary Background Data: Use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain. Methods: We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery; adjusted the reported estimates for thromboprophylaxis and length of follow-up; and estimated cumulative incidence at 4 weeks post-surgery, stratified by VTE risk groups; and rated evidence certainty. Results: After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper-gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially between procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection; in colorectal from 0.3% in minimally-invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy; and in upper-gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer. Conclusions: VTE thromboprophylaxis provides net benefit through VTE reduction with small increase in bleeding in some procedures (e.g., open colectomy, open pancreaticoduodenectomy), whereas the opposite is true in others (e.g., laparoscopic cholecystectomy, elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

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Global practice variation in pharmacologicthromboprophylaxis for general and gynaecologicalsurgery: systematic review

Cited by 7 publications

References 5 publications

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper-Gastrointestinal and Hepatopancreatobiliary Surgery

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