1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Mills AR, Astle K, Frazier CC. “Affirming” journey: Narrative review and practice considerations on gender affirming care. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Alex R. Mills
- Department of Pharmacy Practice University of Mississippi School of Pharmacy Jackson Mississippi USA
- Center for Gender and Sexual Minority Health, University of Mississippi Medical Center Jackson Mississippi USA
| | - Kevin Astle
- Department of Pharmacy Practice Auburn University Harrison School of Pharmacy Mobile Alabama USA
- Department of Family Medicine University of South Alabama College of Medicine Mobile Alabama USA
| | - Cheyenne C. Frazier
- Department of Pharmacotherapy Washington State University College of Pharmacy and Pharmaceutical Sciences Spokane Washington USA
- Mann‐Grandstaff Veterans Affairs Medical Center Spokane Washington USA
| |
Collapse
|
3
|
Tafler K, Kuriya A, Gervais N, Leyland N. Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:82-96.e1. [PMID: 33878456 DOI: 10.1016/j.jogc.2021.04.003] [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: 11/18/2022]
Abstract
OBJECTIVE The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery. TARGET POPULATION All patients undergoing gynaecological surgery for benign or malignant indications. BENEFITS, HARMS, AND COSTS The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis. EVIDENCE The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS Gynaecologists and other members of the surgical team. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
Collapse
|
4
|
Violette PD, Cartwright R, Devereaux PJ, Gross PL, Kaukonen KM, Sandset PM, Kilpeläinen TP, Lavikainen LI, Sallinen V, Horstia S, Guyatt GH, Tikkinen KAO. ARTS: A Large, International Trial of Thromboprophylaxis in Intra-abdominal, Gynecologic, and Urologic Surgery. Eur Urol Focus 2021; 7:1222-1225. [PMID: 34556452 DOI: 10.1016/j.euf.2021.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
ARTS will be the first trial to compare anticoagulation with a direct oral anticoagulant (apixaban) versus no anticoagulation among patients undergoing intra-abdominal, gynecologic, or urologic surgery at sufficiently similar risk of deep vein thrombosis or pulmonary embolism and major bleeding.
Collapse
Affiliation(s)
- Philippe D Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Surgery, Woodstock General Hospital, Woodstock, Canada
| | - Rufus Cartwright
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Department of Obstetrics and Gynaecology, LNWH NHS Trust, London, UK
| | - 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
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | - Kirsi-Maija Kaukonen
- Department of Diagnostics and Therapeutics, Anesthesiology and Intensive care, University of Helsinki, Helsinki, Finland; Pharmacovigilance Unit, Finnish Medicines Agency, Helsinki, Finland
| | - Per Morten Sandset
- Department of Haematology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Ville Sallinen
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Saana Horstia
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.
| |
Collapse
|
5
|
Tafler K, Kuriya A, Gervais N, Leyland N. Directive clinique no 417 : Prévention de la maladie thromboembolique veineuse en chirurgie gynécologique (In English : Prevention of Venous Thromboembolic Disease in Gynaecological Surgery). JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:97-113.e1. [PMID: 33887446 DOI: 10.1016/j.jogc.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
6
|
De Tromboprofilaxis En Cirugía Ginecológica GDDC, de Obstetricia Y Ginecología Fecolsog FC. Consensus on thromboprophylaxis in gynecological surgery. ACTA ACUST UNITED AC 2021; 72:53-68. [PMID: 33878814 PMCID: PMC8372767 DOI: 10.18597/rcog.3666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/15/2021] [Indexed: 01/08/2023]
Abstract
Objetivo: Sintetizar la evidencia disponible en torno a las intervenciones para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna, buscando reducir la morbi-mortalidad asociada a esta condición. Materiales y métodos: El grupo desarrollador estuvo integrado por profesionales de la salud, tomadores decisiones y un representante de las pacientes. Todos los participantes declararon sus conflictos de interés. Se construyeron preguntas clínicas contestables y se realizó la graduación de los desenlaces. Se elaboró la pesquisa de la información en Medline/PubMed, Embase, Epistemonikos y LILACS. La búsqueda también abarcó fuentes de literatura gris y se actualizó el 22 de septiembre de 2020 sin restricciones por fecha o idioma. Se implementó la aproximación GRADE (Grading of Recommendations Assessment, Development and Evaluation) para establecer la calidad de la evidencia y la fuerza de las recomendaciones, se realizó consenso formal acorde con la metodología RAND/UCLA. Previo a la publicación, el documento fue objeto de revisión por pares. Resultados: se presenta la versión corta del consenso "para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna", junto a su evidencia de soporte y respectivas recomendaciones. Conclusiones: como recomendaciones claves para la implementación, se proponen el uso de la escala de Caprini y el uso de intervenciones acorde con el nivel de riesgo perioperatorio de las pacientes.
Collapse
|
7
|
Kozato A, Fox GWC, Yong PC, Shin SJ, Avanessian BK, Ting J, Ling Y, Karim S, Safer JD, Pang JH. No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery. J Clin Endocrinol Metab 2021; 106:e1586-e1590. [PMID: 33417686 DOI: 10.1210/clinem/dgaa966] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Both surgery and exogenous estrogen use are associated with increased risk of venous thromboembolism (VTE). However, it is not known whether estrogen hormone therapy (HT) exacerbates the surgery-associated risk among transgender and gender nonbinary (TGNB) individuals. The lack of published data has contributed to heterogeneity in perioperative protocols regarding estrogen HT administration for TGNB patients undergoing gender-affirming surgery. METHODS A single-center retrospective chart review was performed on all TGNB patients who underwent gender-affirming surgery between November 2015 and August 2019. Surgery type, preoperative HT regimen, perioperative HT regimen, VTE prophylaxis management, outcomes, and demographic data were recorded. RESULTS A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days. CONCLUSIONS Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.
Collapse
Affiliation(s)
- Aki Kozato
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - G W Conner Fox
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick C Yong
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sangyoon J Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Bella K Avanessian
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Jess Ting
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Yiwei Ling
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Subha Karim
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Joshua D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - John Henry Pang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| |
Collapse
|
8
|
Stone R, Carey E, Fader AN, Fitzgerald J, Hammons L, Nensi A, Park AJ, Ricci S, Rosenfield R, Scheib S, Weston E. Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper. J Minim Invasive Gynecol 2020; 28:179-203. [PMID: 32827721 DOI: 10.1016/j.jmig.2020.08.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023]
Abstract
This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.
Collapse
Affiliation(s)
- Rebecca Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston).
| | - Erin Carey
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina (Dr. Carey)
| | - Amanda N Fader
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston)
| | - Jocelyn Fitzgerald
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr. Fitzgerald)
| | - Lee Hammons
- Allegheny Women's Health, Pittsburgh, Pennsylvania (Dr. Hammons)
| | - Alysha Nensi
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada (Dr. Nensi)
| | - Amy J Park
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio (Drs. Park and Ricci)
| | - Stephanie Ricci
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio (Drs. Park and Ricci)
| | | | - Stacey Scheib
- Department of Obstetrics and Gynecology, Tulane University, New Orleans, Louisiana (Dr. Scheib)
| | - Erica Weston
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston)
| |
Collapse
|
9
|
Trends in venous thromboembolism prophylaxis in gynecologic surgery for benign and malignant indications. Arch Gynecol Obstet 2020; 302:935-945. [PMID: 32728922 DOI: 10.1007/s00404-020-05678-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of perioperative morbidity and mortality. We analyzed the trends in use of VTE prophylaxis over time in women undergoing hysterectomy for both benign and malignant indications. METHODS The Premier Database was used to identify women who underwent hysterectomy from 2011 to 2017. Women were stratified by indication for surgery (benign or malignant) and route of hysterectomy. VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination (mechanical and pharmacologic). Trends in use of prophylaxis over time were analyzed. Multivariate models were developed to examine predictors of use of prophylaxis. RESULTS Among 920,477 patients identified, 579,824 (63.0%) received VTE prophylaxis, including 15.4% who received pharmacologic, 34.5% who received mechanical, and 13.1% who received combination prophylaxis. Overall use of prophylaxis declined annually from 68.1% in 2011 to 56.7% in 2017 (P < 0.001). Among patients with cancer, the use of prophylaxis declined from 84.5% in 2011 to 78.6% in 2017 (P < 0.001). A similar trend was noted among women with benign conditions, with rates of prophylaxis declining from 66.2 to 53.3% (P < 0.001). Additionally, use of prophylaxis declined for patients undergoing MIS hysterectomy from 65.4% in 2011 to 53.3% in 2017, and from 73.1 to 66.7% in patients who underwent abdominal hysterectomy. Among patients with cancer, rates of pharmacologic and combined prophylaxis was 70.9% in 2011 and 69.7% in 2017. However, among women with benign conditions, the rates of pharmacologic and combined prophylaxis rose from 19.4% in 2011 to 25.6% in 2017 (P < 0.001). Despite these changes in prophylaxis rates and methods, there was no significant change in the rate of VTE between 2011 and 2017 (P = 0.06). CONCLUSION Despite the lack of change in guidelines for VTE prophylaxis in gynecologic surgery, the overall rates of prophylaxis decreased over time independent of the indication or route of surgery. The rates of thromboembolic events did not significantly increase in response to the decreased use of VTE prophylaxis.
Collapse
|
10
|
Yu R, Nansubuga F, Yang J, Ding W, Li K, Weng D, Wu P, Chen G, Ma D, Wei J. Efficiency and safety evaluation of prophylaxes for venous thrombosis after gynecological surgery. Medicine (Baltimore) 2020; 99:e20928. [PMID: 32569239 PMCID: PMC7310966 DOI: 10.1097/md.0000000000020928] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND In this study, we investigate the incidence of venous thrombosis (VT), and evaluate the effectiveness and safety of 3 major thromboprophylaxes and the potential risk factors for VT in women undergoing surgery for a gynecological malignancy. METHODS We performed a randomized controlled trial of 307 patients undergoing laparoscopic surgery for gynecological malignancies at a single institution from January 2016 to October 2017. Patients were divided into 3 groups: one receiving a half dose of low-molecular-weight heparin sodium injection (FLUXUM, Alfa Wassermann, Italy) delivered by injection, one receiving a full dose of FLUXUM, and a third group receiving an Argatroban injection. RESULTS None of the patients in our study developed a pulmonary embolism, bleeding, or infectious complications. There were no statistical differences in the rate of deep venous thrombosis (DVT) (0%, 0%, and 2.38%) and the superficial venous thromboembolism (SVT) (15.66%, 8.97%, and 18.6%) among the 3 groups. None of the patients developed symptomatic VT. The effect of treatment on alanine aminotransferase and aspartate aminotransferase differed between the groups, with a minimal effect in the Argatroban group, and all 3 methods resulted in minimal impairment of renal function. Decreased hemoglobin, elevated levels of D-dimer, and prothrombin time were closely related to thrombogenesis. CONCLUSION In conclusion, the incidence of postoperative thrombosis in gynecological malignancy among these Chinese people is not as low as we had originally presumed. Argatroban is not more effective than Parnaparin as a direct thrombin inhibitor, but it has less influence on liver function, which is beneficial for patients undergoing chemotherapy. Hemoglobin, D-dimer, and prothrombin time may be used to predict or detect thrombogenesis.
Collapse
Affiliation(s)
- Ruidi Yu
- Department of Obstetrics and Gynecology
| | | | - Jun Yang
- Division of Vascular Surgery, Hepatic Surgery Center, Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | | | - Kezhen Li
- Department of Obstetrics and Gynecology
| | | | - Peng Wu
- Department of Obstetrics and Gynecology
| | - Gang Chen
- Department of Obstetrics and Gynecology
| | - Ding Ma
- Department of Obstetrics and Gynecology
| | | |
Collapse
|