Pre- vs. postoperative initiation of thromboprophylaxis in liver surgery

Abstract

Background: Thromboprophylaxis protocols in liver surgery vary greatly worldwide. Due to limited research, there is no consensus whether the administration of thromboprophylaxis should be initiated pre-or postoperatively. Methods: Patients undergoing liver resection in Helsinki University Hospital between 2014 and 2017 were reviewed retrospectively. Initiation of thromboprophylaxis was changed in the institution in the beginning of 2016 from postoperative to preoperative. Patients were classified into two groups for analyses: thromboprophylaxis initiated preoperatively (Preop-group) or postoperatively (Postop-group). The incidences of VTE and haemorrhage within 30 days of surgery were compared between these groups. Patients with permanent anticoagulation were excluded. Results: A total of 512 patients were included to the study (Preop, n = 253, Postop, n = 259). The incidence of VTE was significantly lower in the Preop-group compared to the Postop-group (3 (1.2%) vs. 25 (9.7%), P = <.0001), mainly due to a lower incidence of pulmonary embolisms in the Preop-group (3 (1.2%) vs. 24 (9.3%), P < .0001). The rates of posthepatectomy haemorrhage within 30 days of surgery were similar (Preop 38 (15.0%) vs. Postop 36 (13.9%), p = .719). Conclusion: Initiating thromboprophylaxis preoperatively may reduce the incidence of postoperative VTE without affecting the incidence of posthepatectomy haemorrhage in patients undergoing liver resection.

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

“… 18 Three studies involving patients post pancreatectomy, duodenectomy, and liver surgery have reported that rates of VTE is higher when chemoprophylaxis was given postoperatively than when it was commenced prior to surgery. 8 – 10 In contrast to our data, these studies reported on asymptomatic VTE, in smaller cohorts. This may explain their higher rates of VTE reported (10–20%) which is inconsistent with larger studies that describe symptomatic VTE.…”

“…These have largely focused on liver, pancreas, biliary, and colorectal operations 7 – 11 . However, these studies are typically single surgeon or single center in origin 8 – 10 and are underpowered to detect a true difference in the incidence of bleeding and/or VTE. 8 – 10 They include a heterogenous group of procedures with vastly different bleeding and VTE risk profiles 9 and often use asymptomatic VTE as an endpoint.…”

“…However, these studies are typically single surgeon or single center in origin 8 – 10 and are underpowered to detect a true difference in the incidence of bleeding and/or VTE. 8 – 10 They include a heterogenous group of procedures with vastly different bleeding and VTE risk profiles 9 and often use asymptomatic VTE as an endpoint. 7 One also includes the testing of an experimental agent that has not translated into use routine clinical practice.…”

Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis

“…Doughtie et al [ 47 ] found that peri-operative PTP reduced the incidence of VTE (1.1% vs 6.1%, p = 0.05), but at increased risk of post-operative bleeding (10.9% vs 3.1%, p = 0.026) requiring intervention (reoperation, angiographic embolization, or percutaneous drainage for hematoma) in complex HPB surgeries. In contrast, Ainoa et al [ 34 ] noted a significant reduction in VTE events (1.2% vs 9.7%, p < 0.0001), especially PE (1.2% vs. 9.3%, p < 0.0001), without any increase in hemorrhagic ( p = 0.7186) or overall complications ( p = 0.98) with pre-operative initiation of PTP.ERAS® society endorses initiation of LMWH or UFH 2–12 h before surgery, particularly in major hepatectomies [ 69 ].…”

Optimal Timing of Perioperative Chemoprophylaxis in Patients With High Thromboembolic Risk Undergoing Major Abdominal Surgery

“…In contrast, all other reports investigating timing of perioperative chemoprophylaxis are either underpowered for both endpoints, or powered only to detect differences in bleeding. [11][12][13][15][16][17][18][21][22][23] This is not surprising, as the incidence of bleeding is typically much higher than clinical VTE across general surgery cohorts. 1 However, without considering both sides of the equation, these reports could not confidently recommend an optimal window for commencing chemoprophylaxis in the perioperative period.…”