Rationalizing post‐operative prophylactic anticoagulation in reconstructive head and neck cancer patients: a review

Abstract

Microsurgical reconstructive head and neck cancer patients are at high risk of venous thromboembolism. The use of anticoagulation can reduce their risk; however, this also increases their bleeding risk. It is not clear whether the benefits of treatment outweigh the risks, and whether a specific post-operative anticoagulation regime is superior. The aim of this review is to evaluate the evidence pertaining to the risks and benefits of post-operative anticoagulation and to provide a rationale for its use in head and neck cancer patients receiving free flaps. The secondary aim was to determine the optimal post-operative anticoagulation regimen. A search was conducted in the PubMed and EMBASE databases identifying studies reporting venous thromboembolism rates in reconstructive head and neck cancer patients undergoing free flaps. These studies were reviewed for their eligibility. Outcomes measured were rates of venous thromboembolism, bleeding-related and microsurgical complications. A total of 306 studies were found from the search with another seven studies identified from citations of key articles. After assessment, nine studies were included. Venous thromboembolism rates ranged from 0.5% to 7% and the rates of bleeding-related complications ranged from 2.4% up to 29%. Anticoagulation appears to lower the risk of venous thromboembolism in this patient group, but also increases the bleeding risk. Risk stratification using the Caprini risk assessment model can help surgeons make decisions. For patients with cancer, low molecular weight heparin appears to be superior to heparin given twice daily but equal to heparin given three times daily and the bleeding risk of each medication appears similar.

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

“…[39][40][41] As anticoagulation must be finely balanced with bleeding risk, use of anticoagulants must be tailored to suit unique patient needs, and risk stratification models exist to help providers make this decision. 42 Patients with coexisting coagulopathies (ie, hemophilia, von Willebrand's disease, thrombocytopenia, liver disease) may therefore benefit from an individualized approach to treatment.…”

Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery

“…60 On the other hand, Cevik et al, in a review of 306 studies and meta-analysis of nine studies of head and neck microsurgical patients showed that anticoagulation lowers the risk of VTE in this patient group, but also increases the bleeding risk, necessitating risk stratification using the Caprini RAM to make decisions. 61 Based on their metaanalysis, LMWH appeared to be superior to heparin when was given twice daily but equal to heparin three times daily with similar complication profile in cancer patients. 61 Chien et al in a retrospective study on 216 patients who underwent head and neck microvascular reconstruction showed that combination of SQH (5,000 U twice daily) and ASA (325 mg orally daily) does not have significant effect on hematoma rate (5.6% vs. 5.3%).…”

“…61 Based on their metaanalysis, LMWH appeared to be superior to heparin when was given twice daily but equal to heparin three times daily with similar complication profile in cancer patients. 61 Chien et al in a retrospective study on 216 patients who underwent head and neck microvascular reconstruction showed that combination of SQH (5,000 U twice daily) and ASA (325 mg orally daily) does not have significant effect on hematoma rate (5.6% vs. 5.3%). 62 In a prospective study Ambani et al studied 90-day postoperative VTE and bleeding events in 78 patients who underwent free tissue reconstruction following tumor resection for head and neck or breast cancer.…”

“…60 On the other hand, Cevik et al, in a review of 306 studies and meta-analysis of nine studies of head and neck microsurgical patients showed that anticoagulation lowers the risk of VTE in this patient group, but also increases the bleeding risk, necessitating risk stratification using the Caprini RAM to make decisions. 61 Based on their meta-analysis, LMWH appeared to be superior to heparin when was given twice daily but equal to heparin three times daily with similar complication profile in cancer patients. 61…”

“…61 Based on their meta-analysis, LMWH appeared to be superior to heparin when was given twice daily but equal to heparin three times daily with similar complication profile in cancer patients. 61…”