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Tikkinen KAO, Cartwright R, Jensen AG, Violette PD. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 12: Urology. Eur J Anaesthesiol 2024; 41:618-621. [PMID: 38957030 PMCID: PMC11224558 DOI: 10.1097/eja.0000000000002012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Kari A O Tikkinen
- From the Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki (KAOT), Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland (KAOT), Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada (KAOT, PDV), Departments of Gynaecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust (RC), Department of Epidemiology and Biostatistics, Imperial College London, London, UK (RC), Department of Anesthesiology, Odense University Hospital, Odense, Denmark (AGJ), Department of Surgery, Woodstock Hospital, Woodstock, Ontario, Canada (PDV) and European Association of Urology (EAU), Arnhem, The Netherlands (KAOT, RC, PDV)
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2
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Kawachi R, Okano T, Awano N, Matsumoto M, Hosokawa J, Takita A, Oba MS, Kunitoh H. Venous thromboembolism in patients undergoing surgery for lung cancer: a post hoc analysis of the Cancer-VTE Registry. Jpn J Clin Oncol 2024:hyae090. [PMID: 39037954 DOI: 10.1093/jjco/hyae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024] Open
Abstract
The relationship between lung cancer surgery and venous thromboembolism (VTE) in Japan has not been elucidated. This was a post hoc analysis of the Cancer-VTE Registry. The 1057 patients who underwent surgery for lung cancer were divided into the surgery alone (SA) group (n = 598) and the surgery plus chemotherapy (SC) group (n = 459), and the 1-year incidences of VTE and cerebral ischemia were analyzed. In the SA and SC groups, composite VTE was observed in one (0.2%) and 15 (3.3%) patients, respectively, and cerebral ischemia was observed in eight (1.3%) and four (0.9%) patients, respectively. Lymph node metastasis was more common in patients with D-dimer >1.2 μg/ml (odds ratio: 1.781, P = .004). SA had a low risk of VTE but a high risk of cerebral ischemia. Chemotherapy increases the risk of VTE. The D-dimer level was related to VTE and advanced cancer.
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Affiliation(s)
- Riken Kawachi
- Department of Respiratory Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Tetsuya Okano
- Department of Respiratory Medicine, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-shi, Chiba 270-1694, Japan
| | - Nobuyasu Awano
- Department of Respiratory Medicine, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo 150-8935, Japan
| | - Masaru Matsumoto
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Jun Hosokawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi-honcho, Chuo-ku, Tokyo 103-8246, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-ku, Tokyo 140-8710, Japan
| | - Mari S Oba
- Department of Medical Statistics, Toho University, 5-21-16 Omorinishi, Ota-ku,Tokyo 143-8540, Japan
- Department of Clinical Data Science, Clinical Research & Education Promotion Division, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi-cho, Kodaira-shi, Tokyo 187-8551, Japan
| | - Hideo Kunitoh
- Department of Medical Oncology, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo 150-8935, Japan
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3
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Lavikainen LI, Guyatt GH, Luomaranta AL, Cartwright R, Kalliala IEJ, Couban RJ, Aaltonen RL, Aro KM, Cárdenas JL, Devereaux PJ, Galambosi PJ, Ge FZ, Halme ALE, Haukka J, Izett-Kay ML, Joronen KM, Karjalainen PK, Khamani N, Oksjoki SM, Pourjamal N, Singh T, Tähtinen RM, Vernooij RWM, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic cancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:403-416. [PMID: 37827272 DOI: 10.1016/j.ajog.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice. STUDY ELIGIBILITY CRITERIA Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin <70 g/L. METHODS Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty. RESULTS We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was <1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and >2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1% to 1.3%. Median risks of bleeding requiring reintervention were <1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures. CONCLUSION Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rufus Cartwright
- Department of Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Riikka L Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jovita L Cárdenas
- Direction of Health Technology Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada; Outcomes Research Consortium, Cleveland, OH
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kirsi M Joronen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Children's Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Negar Pourjamal
- Laboratory of Molecular Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland.
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Halme ALE, Roshanov PS, Tornberg SV, Lavikainen LI, Devereaux PJ, Tikkinen KAO. Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery. JAMA Netw Open 2024; 7:e244581. [PMID: 38564217 PMCID: PMC10988355 DOI: 10.1001/jamanetworkopen.2024.4581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/31/2024] [Indexed: 04/04/2024] Open
Abstract
Importance Although 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. Objective To determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery. Design, Setting, and Participants This 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. Exposure Noncardiac surgery requiring overnight hospital admission. Main Outcomes and Measures The 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. Results Among 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 Relevance In 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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Affiliation(s)
| | - Pavel S. Roshanov
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sara V. Tornberg
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - P. J. Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Outcomes Research Consortium, Cleveland, Ohio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kari A. O. Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Lavikainen LI, Guyatt GH, Kalliala IEJ, Cartwright R, Luomaranta AL, Vernooij RWM, Tähtinen RM, Tadayon Najafabadi B, Singh T, Pourjamal N, Oksjoki SM, Khamani N, Karjalainen PK, Joronen KM, Izett-Kay ML, Haukka J, Halme ALE, Ge FZ, Galambosi PJ, Devereaux PJ, Cárdenas JL, Couban RJ, Aro KM, Aaltonen RL, Tikkinen KAO. Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:390-402. [PMID: 38072372 DOI: 10.1016/j.ajog.2023.11.1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries. DATA SOURCES We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis. STUDY ELIGIBILITY CRITERIA Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L. METHODS A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty. RESULTS We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures. CONCLUSION The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ilkka E J Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Rufus Cartwright
- Chelsea Centre for Gender Surgery, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom; Department of Epidemiology & Biostatistics, Imperial College London, London, United Kingdom
| | - Anna L Luomaranta
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robin W M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Riikka M Tähtinen
- Department of Obstetrics and Gynecology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Nadina Khamani
- Department of Obstetrics and Gynecology, Institute of Childrens' Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Kirsi M Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Finland
| | - Matthew L Izett-Kay
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Jari Haukka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Alex L E Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Päivi J Galambosi
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Outcomes Research Consortium, Cleveland, OH
| | - Jovita L Cárdenas
- National Center for Health Technology Excellence (CENETEC), Direction of Health Technologies assessment, Mexico City, Mexico
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Karoliina M Aro
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka L Aaltonen
- Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.
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Björklund J, Rautiola J, Zelic R, Edgren G, Bottai M, Nilsson M, Vincent PH, Fredholm H, Falconer H, Sjövall A, Nilsson PJ, Wiklund P, Aly M, Akre O. Risk of Venous Thromboembolic Events After Surgery for Cancer. JAMA Netw Open 2024; 7:e2354352. [PMID: 38306100 PMCID: PMC10837742 DOI: 10.1001/jamanetworkopen.2023.54352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024] Open
Abstract
Importance The risks and benefits of thromboprophylaxis therapy after cancer surgery are debated. Studies that determine thrombosis risk after cancer surgery with high accuracy are needed. Objectives To evaluate 1-year risk of venous thromboembolic events after major cancer surgery and how these events vary over time. Design, Setting, and Participants This register-based retrospective observational matched cohort study included data on the full population of Sweden between 1998 and 2016. All patients who underwent major surgery for cancer of the bladder, breast, colon or rectum, gynecologic organs, kidney and upper urothelial tract, lung, prostate, or gastroesophageal tract were matched in a 1:10 ratio with cancer-free members of the general population on year of birth, sex, and county of residence. Data were analyzed from February 13 to December 5, 2023. Exposure Major surgery for cancer. Main Outcomes and Measures The main outcome was incidence of venous thromboembolic events within 1 year after the surgery. Crude absolute risks and risk differences of events within 1 year and adjusted time-dependent cause-specific hazard ratios (HRs) of postdischarge events were calculated. Results A total of 432 218 patients with cancer (median age, 67 years [IQR, 58-75 years]; 68.7% women) and 4 009 343 cancer-free comparators (median age, 66 years [IQR, 57-74 years]; 69.3% women) were included in the study. The crude 1-year cumulative risk of pulmonary embolism was higher among the cancer surgery population for all cancers, with the following absolute risk differences: for bladder cancer, 2.69 percentage points (95% CI, 2.33-3.05 percentage points); for breast cancer, 0.59 percentage points (95% CI 0.55-0.63 percentage points); for colorectal cancer, 1.57 percentage points (95% CI, 1.50-1.65 percentage points); for gynecologic organ cancer, 1.32 percentage points (95% CI, 1.22-1.41 percentage points); for kidney and upper urinary tract cancer, 1.38 percentage points (95% CI, 1.21-1.55 percentage points); for lung cancer, 2.61 percentage points (95% CI, 2.34-2.89 percentage points); for gastroesophageal cancer, 2.13 percentage points (95% CI, 1.89-2.38 percentage points); and for prostate cancer, 0.57 percentage points (95% CI, 0.49-0.66 percentage points). The cause-specific HR of pulmonary embolism comparing patients who underwent cancer surgery with matched comparators peaked just after discharge and generally plateaued 60 to 90 days later. At 30 days after surgery, the HR was 10 to 30 times higher than in the comparison cohort for all cancers except breast cancer (colorectal cancer: HR, 9.18 [95% CI, 8.03-10.50]; lung cancer: HR, 25.66 [95% CI, 17.41-37.84]; breast cancer: HR, 5.18 [95% CI, 4.45-6.05]). The hazards subsided but never reached the level of the comparison cohort except for prostate cancer. Similar results were observed for deep vein thrombosis. Conclusions and Relevance This cohort study found an increased rate of venous thromboembolism associated with cancer surgery. The risk persisted for about 2 to 4 months postoperatively but varied between cancer types. The increased rate is likely explained by the underlying cancer disease and adjuvant treatments. The results highlight the need for individualized venous thromboembolism risk evaluation and prophylaxis regimens for patients undergoing different surgery for different cancers.
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Affiliation(s)
- Johan Björklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Juhana Rautiola
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Renata Zelic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Gustaf Edgren
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Per Henrik Vincent
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Fredholm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falconer
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Annika Sjövall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Per J. Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Markus Aly
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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7
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Lavikainen LI, Guyatt GH, Sallinen VJ, Karanicolas PJ, Couban RJ, Singh T, Lee Y, Elberkennou J, Aaltonen R, Ahopelto K, Beilmann-Lehtonen I, Blanker MH, Cárdenas JL, Cartwright R, Craigie S, Devereaux P, Garcia-Perdomo HA, Ge FZ, Gomaa HA, Halme AL, Haukka J, Karjalainen PK, Kilpeläinen TP, Kivelä AJ, Lampela H, Mattila AK, Najafabadi BT, Nykänen TP, Pandanaboyana S, Pourjamal N, Ratnayake CB, Raudasoja A, Vernooij RW, Violette PD, Wang Y, Xiao Y, Yao L, Tikkinen KAO. Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery. Ann Surg 2024; 279:213-225. [PMID: 37551583 PMCID: PMC10782937 DOI: 10.1097/sla.0000000000006059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
OBJECTIVE To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. BACKGROUND The 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 postsurgery, 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 among 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 a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and 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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Affiliation(s)
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ville J. Sallinen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J. Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rachel J. Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tino Singh
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Yung Lee
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Riikka Aaltonen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaisa Ahopelto
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ines Beilmann-Lehtonen
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marco H. Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jovita L. Cárdenas
- Direction of Health Technologies Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico
| | - Rufus Cartwright
- Departments of Gynecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Samantha Craigie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P.J. Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Anesthesiology, Perioperative Medicine, and Surgical Research Group, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, USA
| | - Herney A. Garcia-Perdomo
- Department of Surgery, Division of Urology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Fang Zhou Ge
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Huda A. Gomaa
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Egypt
- Department of Medical Pharmacology, Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt
| | - Alex L.E. Halme
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Health Sciences, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Päivi K. Karjalainen
- Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti J. Kivelä
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Lampela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne K. Mattila
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Borna Tadayon Najafabadi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Negar Pourjamal
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Chathura B.B. Ratnayake
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Robin W.M. Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philippe D. Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Yuting Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Nursing and West China School of Nursing, West China Hospital and Sichuan University, Chengdu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kari A. O. Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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8
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Al-Juhani A, Sharaf GF, Aseri S, Alosaimi H, Alharkan SA, AlGhamdi JK, Hariri FS, Daak L, Daak I. The Role of Tranexamic Acid in Sleeve Gastrectomy: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54269. [PMID: 38496064 PMCID: PMC10944379 DOI: 10.7759/cureus.54269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Tranexamic acid (TXA) is an essential procoagulant drug used in various intra- and postoperative situations. Its efficacy and safety profile in obese cases undergoing laparoscopic sleeve gastrectomy (LSG) is still unresolved. Therefore, this meta-analysis evaluated and investigated the current intra- and postoperative effects and hazards of TXA on patients undergoing LSG. As for methodology, Web of Science, Cochrane Library, Scopus, and PubMed were thoroughly searched for relevant studies. Retrieved results were prepared for screening through Endnote, helping to identify eligible studies. Relevant patient characteristics and outcomes were extracted. The methodological quality of the relevant studies was appraised using the respected appraisal tool. Six studies of different designs were enrolled, comprising 753 cases that underwent LSG and administered TXA. Their mean BMI and age went from 37.3 to 56.25 kg/m2 and 33.5 to 43.25 years, respectively. Tranexamic acid significantly linked to reduction in intraoperative bleeding instances, operative blood loss, and operative duration, compared to placebo ((RR = 0.66, 95% CI [0.44, 0.98], P=0.04, I2 = 81%); (MD = -39.64, 95%CI [-75.49, -3.78], P=0.03, I2=94%); (MD=-5.84, 95%CI [-9.62, -2.05], P=0.003, I2=73%)). Tranexamic acid also significantly showed superiority regarding postoperative bleeding events and duration of hospitalization compared to the control group ((RR= 0.45, 95%CI [0.29, 0.69], P=0.0002, I2 =0%); (MD=-0.24, 95%CI [-0.32, -0.17], P< 0.0000, I2 =0%)). Moreover, follow-up of the enrolled patients for a minimum of three to six months resulted in no reported thromboembolic instances, suggesting a negligible risk for thromboembolism among patients undergoing LSG and receiving TXA. In conclusion, tranexamic acid demonstrates a robust safety and efficacy profile for its use in patients undergoing LSG, with no reported instances of thromboembolism. Variations in TXA administration regimens, bleeding definitions, procedural techniques, and potential confounding medications could not be accounted for, necessitating additional large-scale RCTs to address and bridge knowledge gaps.
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Affiliation(s)
| | | | - Saeed Aseri
- Psychiatry, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | | | - Faris S Hariri
- Medicine, Batterjee Medical College, King Abdulaziz University Hospital, Jeddah, SAU
| | - Lojain Daak
- Medicine and Surgery, Jazan University, Jazan, SAU
| | - Ikhlas Daak
- Medicine, Jazan College of Medicine and Medical Sciences, Jazan University, Jazan, SAU
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9
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Yang F. Comment on: Timing of symptomatic venous thromboembolism after surgery: meta-analysis. Br J Surg 2023; 110:1402. [PMID: 37343067 DOI: 10.1093/bjs/znad193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 06/23/2023]
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10
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Singh T, Haukka J, Ibrahim Q, Guyatt GH, Tikkinen KAO. Author response to: Comment on: Timing of symptomatic venous thromboembolism after surgery: meta-analysis. Br J Surg 2023; 110:1403. [PMID: 37406087 PMCID: PMC10480031 DOI: 10.1093/bjs/znad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Tino Singh
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kari A O Tikkinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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