Safety and efficacy of fondaparinux for prophylaxis of venous thromboembolism after colorectal cancer resection: a propensity score matched analysis

Impact of the preoperative prognostic nutritional index as a predictor for postoperative complications after resection of locally recurrent rectal cancer

BACKGROUND

Local recurrence is common after curative resections for rectal cancer. Surgical intervention is among the best treatment choices. However, achieving a negative resection margin often requires extensive pelvic organ resections; thus, the postoperative complication rate is quite high. Recent studies have reported that the inflammatory index could predict postoperative complications. This study aimed to validate the correlation between clinical factors, including inflammatory markers, and severe complications after surgery for local recurrent rectal cancer.

METHODS

This retrospective study included 99 patients that underwent radical resections for local recurrences of rectal cancer. Postoperative complications were graded according to the Clavien-Dindo classification. Grades ≥3 were defined as severe complications. Risk factors for severe complications were identified with univariate and multivariate logistic regression models and assessed with receiver-operating characteristic curves.

RESULTS

Severe postoperative complications occurred in 38 patients (38.4%). Analyses of correlations between inflammatory markers and severe postoperative complications revealed that the strongest correlation was found between the prognostic nutrition index and severe postoperative complications. The receiver-operating characteristic analysis showed that the optimal prognostic nutrition index cut-off value was 42.2 (sensitivity: 0.790, specificity: 0.508). In univariate and multivariate analyses, a prognostic nutrition index ≤44.2 (Odds ratio: 3.007, 95%CI:1.171-8.255, p = 0.02) and a blood loss ≥2850 mL (Odds ratio: 2.545, 95%CI: 1.044-6.367, p = 0.04) were associated with a significantly higher incidence of severe postoperative complications.

CONCLUSIONS

We found that a low preoperative prognostic nutrition index and excessive intraoperative blood loss were risk factors for severe complications after surgery for local recurrent rectal cancer.

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

BACKGROUND

Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer.

CONCLUSIONS

Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.

Efficacy and safety of anticoagulant prophylaxis for prevention of postoperative venous thromboembolism in Japanese patients undergoing laparoscopic colorectal cancer surgery

AIM

To investigate the efficacy and safety of anticoagulant prophylaxis to prevent postoperative venous thromboembolism (VTE) during laparoscopic colorectal cancer (CRC) surgery, which is unknown in Japanese patients.

METHODS

We conducted this randomized controlled trial at nine institutions in Japan from 2011 to 2015. It included 302 eligible patients aged 20 years or older who underwent elective laparoscopic surgery for CRC. Patients were randomly assigned to an intermittent pneumatic compression (IPC) therapy group or to an IPC + anticoagulation therapy group. Anticoagulation therapy comprised fondaparinux or enoxaparin for postoperative VTE prophylaxis. Postoperative VTE was diagnosed based on enhanced multi-detector helical computed tomography. The primary endpoint was VTE incidence, including asymptomatic cases, the secondary endpoint was incidence of major bleeding, and we conducted an intention-to-treat analysis. This study is registered in UMINCTR (UMIN000008435).

RESULTS

Postoperative VTE incidence was 5.10% with IPC therapy (n = 157) and 2.76% with IPC + anticoagulant therapy (n = 145; P = .293). We identified no symptomatic VTE cases. The major bleeding rates were 1.27% with IPC alone and 1.38% with the combination (P = .936). The overall bleeding rates were 7.69% for enoxaparin and 13.6% for fondaparinux (P = .500), and there were no bleeding-related deaths.

CONCLUSION

Anticoagulant prophylaxis did not reduce the incidence of VTE and the incidence of major bleeding was comparable between the two groups. Usefulness of perioperative anticoagulation was not demonstrated in this study. Pharmacological prophylaxis must be restricted in Japanese patients with higher risk of VTE.

The impact of pharmacological thromboprophylaxis and disease-stage on postoperative bleeding following colorectal cancer surgery

Background

Pharmacological thromboprophylaxis after colorectal cancer (CRC) surgery is internationally recommended for venous thromboembolism (VTE) prevention. The aim of this retrospective study was to evaluate the risk factors of postoperative bleeding after elective surgery for patients with primary CRC receiving pharmacological thromboprophylaxis of fondaparinux or enoxaparin.

Methods

We experienced consecutive 266 patients who underwent elective surgery for CRC during the study period. Finally, the medical records of 218 patients with CRC administrated fondaparinux or enoxaparin following surgery were retrospectively reviewed to evaluate symptomatic VTE until 28 days and postoperative bleeding comparing perioperative D-dimer levels.

Results

The significant differences in TNM classification staging and type of thromboprophylaxis were observed between postoperative bleeding-negative and bleeding-positive group. There was no statistical significance among other backgrounds of patients between the two groups. One case (0.46%) of symptomatic VTE and total 11 cases (5%) of postoperative bleeding were observed. In the univariate analysis, fondaparinux thromboprophylaxis and early disease-stage CRC (stages 0 and I) were associated with risk for postoperative bleeding. Multivariate analysis revealed that fondaparinux thromboprophylaxis was identified as an independent risk factor of postoperative bleeding. Moreover, preoperative levels of D-dimer in patients with stage IV CRC were significantly higher than those with the other stages. The significant elevation in preoperative D-dimer was also observed in patients with stage II CRC compared to those with stage I CRC. Perioperative levels of D-dimer in patients with advanced disease-stage CRC (stages II, III, and IV) were significantly higher than those in patients with early disease-stage CRC.

Conclusions

Fondaparinux administration and early disease-stage CRC appeared to be risk factors for postoperative bleeding in patients with pharmacological thromboprophylaxis undergoing surgical treatment for CRC. Patients’ hypercoagulative condition depending on disease progression of CRC might be related to the occurrence of postoperative bleeding following CRC surgery.

Venous thromboembolism in colorectal surgery: Incidence, risk factors, and prophylaxis

Colorectal surgery is associated with a high risk of perioperative venous thromboembolism (VTE), and this risk is especially high following colorectal cancer resection and surgery for inflammatory bowel disease. Previous analyses of large databases have reported the incidence of postoperative VTE in this population to be approximately 1.1%-2.5%. Therefore, to minimize this risk, patients should be offered appropriate prophylaxis, which may involve a combination of mechanical and pharmacologic prophylaxis with low-dose unfractionated heparin or low molecular weight heparin as recommended by several guidelines. Prior to initiation of treatment, appropriate risk stratification should be performed according to the patients' basic and disease-related as well as procedure-related risk factors, and post-operative factors. Furthermore, a risk-benefit calculation that takes into account patients' VTE and bleeding risk should be performed prior to starting pharmacologic prophylaxis and to help determine the duration of treatment.

Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis

BACKGROUND

The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery.

METHODS

We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE.

RESULTS

Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1-2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9-18.2) and lung cancer (8.1%, 95% CI 3.7-12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40-0.53; I² = 93.8%), radiation (OR 1.29, 95% CI 1.03-1.62; I² = 34.6%), transfusion (OR 1.96, 95% CI 1.48-2.59; I² = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07-1.16; I² = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07-30.56; I² = 92.0%).

CONCLUSIONS

The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.