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

Abstract

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.

Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery

“…Although prior work exists on procedure-specific risks of thrombosis and bleeding in surgery (with variable certainty evidence), 27 , 28 , 29 , 30 , 31 , 32 , 33 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). 34 , 35 This has contributed to substantial practice variation in thromboprophylaxis worldwide.…”

Venous thromboembolism incidence and association with overall survival in pancreatic cancer: A Finnish nationwide cohort study

“…Among patients undergoing RIS, both surgery and chemotherapy were previously reported risk factors for VTE. 29 , 30 Thus, the perioperative period is of special interest. In our data, postoperative VTE incidence at 3 months following surgery stood at 2.0%.…”

“…A recent meta‐analysis reported that the estimated four‐week postoperative risk of symptomatic VTE without thromboprophylaxis was 6.2% following an open pancreatoduodenectomy for benign and malignant indications; yet, that estimate was deemed to have a low level of certainty. 29 A US prospective single‐center study found that among pancreatic adenocarcinoma patients undergoing either curative or palliative surgery exhibited a 12% postoperative cumulative incidence of VTE at 3 months following surgery despite thromboprophylaxis lasting for 21 days post‐operatively. 30 While the specific stage distribution was not reported, 9% had metastatic disease and the pre‐operative chemotherapy rate of 14.5% was similar to our data.…”

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.

“… b Net benefit is equal to absolute reduction in VTE risk minus absolute increase in bleeding risk (with twice the weight for major bleeding as for VTE). Net benefit with prophylaxis assumes an approximately 50% decrease in VTE and an approximately 50% increase in major bleed based on meta-analysis by Gould et al 5 and updated by Lavikainen et al 6 …”

“…Explanation: High-quality evidence found that LMWHs significantly reduce the risk of VTE compared with no anticoagulation. 2 , 6 , 11 In the absence of direct comparisons between LMWH and DOAC, and between DOAC and no anticoagulation among patients undergoing urological surgery, evidence from a systematic review and network meta-analysis suggests the efficacy and safety of DOACs is comparable to LMWH. 11 Some caution may be considered among postoperative patients who are expected to have decreased gastric motility or ileus.…”