The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery

Fleming, Fergal J.; Gaertner, Wolfgang B.; Ternent, Charles A.; Finlayson, Emily; Herzig, Daniel O.; Paquette, Ian M.; Feingold, Daniel L.; Steele, Scott R.

doi:10.1097/dcr.0000000000000982

Cited by 97 publications

(106 citation statements)

References 38 publications

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Section: Resultsmentioning

confidence: 98%

“…The median length of follow‐up was 1 month. Importantly, IBD patients were at greatest risk of VTE in the first two postoperative weeks . In one of the included studies, 61% of the postdischarge VTEs occurred within 2 weeks following discharge [mean length of stay (LOS) 6.9 days] . How does the risk of VTE in patients undergoing colorectal surgery for IBD compare with that of patients undergoing colorectal surgery for other indications?Three studies showed higher postoperative VTE rates when colorectal surgery was performed for IBD than for diverticular disease (Fig.…”

Section: Resultsmentioning

confidence: 99%

“…They reported a significant increase in minor bleeding events postoperatively, but did not find an increase in major bleeding events, as defined by the International Society of Thrombosis and Hemostasis . As such, current recommendations from the American Society of Colon and Rectal Surgeons (ASCRS) indicate that patients at high risk of postoperative bleeding should not receive pharmacological thromboprophylaxis . Does extended pharmacological thromboprophylaxis following colorectal surgery for IBD influence the rate of postoperative mortality?Currently, there are no studies that specifically evaluate the impact of extended pharmacological thromboprophylaxis in postoperative IBD patients on mortality rates. However, this has been previously studied in CRC patients .…”

Section: Resultsmentioning

confidence: 99%

“…Currently, there is a significant gap in the literature. Although there are a large number of data suggesting that IBD patients undergoing colorectal surgery are at a high risk of postoperative VTE, no RCTs have assessed the effectiveness of extended pharmacological thromboprophylaxis in this population . No studies have evaluated the optimal drug, dose and duration.…”

Section: Discussionmentioning

confidence: 99%

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Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review

et al. 2019

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Aim Patients with inflammatory bowel disease (IBD) are at increased risk of postoperative venous thromboembolism (VTE) following major abdominal surgery. The pathogenesis is multifactorial and not fully understood. A combination of pathophysiology, patient and surgical risk factors increase the risk of postoperative VTE in these patients. Despite being at increased risk, IBD patients are not regularly prescribed extended pharmacological thromboprophylaxis following colorectal surgery. Currently, there is a paucity of evidence‐based guidelines. Thus, the aim of this review is to evaluate the role of extended pharmacological thromboprophylaxis in IBD patients undergoing colorectal surgery. Method A search of Ovid Medline, EMBASE and PubMed databases was performed. A qualitative analysis was performed using 10 clinical questions developed by colorectal surgeons and a thrombosis haematologist. The Newcastle–Ottawa Scale was utilized to assess the quality of evidence. Results A total of 1229 studies were identified, 38 of which met the final inclusion criteria (37 retrospective, one case–control). Rates of postoperative VTE ranged between 0.6% and 8.9%. Patient‐specific risk factors for postoperative VTE included ulcerative colitis, increased age and obesity. Surgery‐specific risk factors for postoperative VTE included open surgery, emergent surgery and ileostomy creation. Patients with IBD were more frequently at increased risk in the included studies for postoperative VTE than patients with colorectal cancer. The risk of bias assessment demonstrated low risk of bias in patient selection and comparability, with variable risk of bias in reported outcomes. Conclusion There is a lack of evidence regarding the use of extended pharmacological thromboprophylaxis in patients with IBD following colorectal surgery. As these patients are at heightened risk of postoperative VTE, future study and consideration of the use of extended pharmacological thromboprophylaxis is warranted.

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Section: Resultsmentioning

confidence: 98%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review

et al. 2019

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“…The increased risk in colorectal patients is thought to be due to pelvic dissections, patient positioning, and common patient cohort characteristics; specifically pre-existing inflammation due to malignancy or inflammatory bowel disease. 1 The American Society of Colon and Rectal Surgeons (ASCRS) recommends extended-duration pharmacological thromboprophylaxis in patients undergoing colorectal cancer resection. 1 Forty mg enoxaparin daily is most commonly prescribed.…”

Section: Introductionmentioning

confidence: 99%

One Size Does Not Fit All: Venous Thromboembolism Prophylaxis in Colorectal Cancer

Perrotti

Sadri

Fassler

et al. 2020

JSLS

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Background and Objectives: Venous thromboembolisms (VTEs) in patients who have undergone a colorectal cancer operation increases morbidity and mortality, lengthens recovery time, and are costly. The current common standard is a 28-day prophylactic regimen of 40 mg enoxaparin daily. This study aims to examine the variability in prophylaxis discharge prescriptions at one institution, report 30-day postoperative incidence of venous thromboembolisms and bleeding, and to offer a new protocol for VTE prophylaxis in postoperative patients. Methods: This retrospective case series occurred at Abington-Jefferson Health Hospital in Abington, PA. The electronic medical record was searched for patients who underwent an operation for colorectal cancer from October 2019 to mid-March 2020 and all discharge prophylaxis regimens were recorded and patient demographics were analyzed. Outcomes were measured by rate of VTEs and postoperative complications such as bleeding, transfusions, re-admission, and intensive care admission in the 30-day postoperative period. Results: Eighteen of 57 patients received a medication besides 40 mg of enoxaparin daily. These 18 patients were divided into six different subgroups of various prophylaxis regimens. No patients developed a venous thromboembolism. Four of 18 patients experienced postoperative bleeding complications. Conclusions: Patients with similar pre-operative comorbidities have various venous thromboembolism perioperative prophylaxis regimens prescribed. Despite prescription variations, VTE rates remain negligible. Patients with different comorbid conditions may require alterations to the traditionally prescribed 40 mg enoxaparin daily. Upon discharge, aspirin 81 mg with 40 mg of enoxaparin daily for high-risk patients shows benefits, but requires further investigation.

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Assessment of Anti–Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis

et al. 2019

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IMPORTANCE Between 4% and 12% of patients undergoing colorectal surgery and receiving enoxaparin, 40 mg per day, have a postoperative venous thromboembolism (VTE) event. An improved understanding of why "breakthrough" VTE events occur despite guideline-compliant prophylaxis is an important patient safety question. OBJECTIVE To determine the proportion of patients undergoing colorectal surgery who received adequate anticoagulation based on peak anti-factor Xa (aFXa) levels while receiving enoxaparin at 40 mg per day. DESIGN, SETTING, AND PARTICIPANTS This prospective, nonrandomized clinical trial was conducted between February 2017 and July 2018 with 90-day follow-up at a quaternary academic medical center in the Intermountain West and included patients undergoing colorectal surgery who had surgery after receiving general anesthesia, were admitted for at least 3 days, and received enoxaparin, 40 mg once daily. INTERVENTIONS All patients had aFXa levels measured after receiving enoxaparin 40 mg per day. Patients whose aFXa level was out of range entered the trial's interventional arm where real-time enoxaparin dose adjustment and repeated aFXa measurement were performed. MAIN OUTCOMES AND MEASURES Primary outcome: in-range peak aFXa levels (goal range, 0.3-0.5 IU/mL) with enoxaparin, 40 mg per day. Secondary outcomes: (1) in-range trough aFXa levels (goal range, 0.1-0.2 IU/mL) and (2) the proportion of patients with in-range peak aFXa levels from enoxaparin, 40 mg once daily, vs the real-time enoxaparin dose adjustment protocol. RESULTS Over 16 months, 116 patients undergoing colorectal surgery (65 women [56.0%]; 99 white individuals [85.3%], 13 Hispanic or Latino individuals [11.2%], and 4 Pacific Islander individuals [3.5%]; mean [range] age, 52.1 [18-85] years) were enrolled. Among 106 patients (91.4%) whose peak aFXa level was appropriately drawn, 72 (67.9%) received inadequate anticoagulation (aFXa < 0.3 IU/mL) with enoxaparin, 40 mg per day. Weight and peak aFXa levels were inversely correlated (r 2 = 0.38). Forty-seven patients (77%) had a trough aFXa level that was not detectable (ie, most patients had no detectable level of anticoagulation for at least 12 hours per day). Real-time enoxaparin dose adjustment was effective. Patients were significantly more likely to achieve an in-range peak aFXa with real-time dose adjustment as opposed to fixed dosing alone (85.4% vs 29.2%, P < .001). CONCLUSIONS AND RELEVANCE This study supports the finding that most patients undergoing colorectal surgery receive inadequate prophylaxis from enoxaparin, 40 mg once daily. These findings may explain the high rate of "breakthrough" VTE observed in many clinical trials. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02704052

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The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery

Cited by 97 publications

References 38 publications

Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review

Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review

One Size Does Not Fit All: Venous Thromboembolism Prophylaxis in Colorectal Cancer

Assessment of Anti–Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis

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