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Edwards MA, Hussain MWA, Spaulding AC, Brennan E, Colibaseanu D, Stauffer J. Venous thromboembolism and bleeding after hepatectomy: role and impact of risk adjusted prophylaxis. J Thromb Thrombolysis 2023; 56:375-387. [PMID: 37351821 DOI: 10.1007/s11239-023-02847-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/24/2023]
Abstract
Venous thromboembolism (VTE) occurs in 2-6% of post-hepatectomy patients and is associated with increased mortality and morbidity. The use of VTE risk assessment models in hepatectomy cases remains unclear. Our study aimed to determine the use and impact of Caprini guideline indicated VTE prophylaxis following hepatectomy. Hepatectomy cases performed during 2016-2021 were included. Caprini score and VTE prophylaxis were determined retroactively, and VTE prophylaxis was categorized as appropriate or inappropriate. The primary outcome was the receipt of appropriate prophylaxis, and secondary outcomes were postoperative VTE and bleeding. Statistical analyses included Fisher Exact test, Kruskal-Wallis, Pearson Chi-Square test, and multivariate regression models. R Statistical software was used for analysis. A p-value < 0.05 or 95% Confidence Interval (CI) excluding 1 was considered significant. A total of 1955 hepatectomy cases were analyzed. Patient demographics were similar between study cohorts. Inpatient, 30- and 90-day VTE rates were 1.28%, 0.56%, and 1.24%, respectively. By Caprini guidelines, 59% and 4.3% received appropriate in-hospital and discharged VTE prophylaxis, respectively. Inpatient VTE (4.5-fold) and mortality (9.5-fold) were lower in patients receiving appropriate prophylaxis. All discharged VTE and mortality occurred in patients not receiving appropriate prophylaxis. Inpatient, 30- and 90-day bleeding rates were 8.4%, 0.62%, and 0.68%, respectively. Appropriate prophylaxis did not increase postoperative bleeding. Increasing Caprini score inversely correlated with receiving appropriate prophylaxis (OR 0.38, CI 0.31-0.46) at discharge, and appropriate prophylaxis did not correlate with bleeding risk (OR 0.79, CI 0.57-1.12). Caprini guideline indicated prophylaxis resulted in reduced VTE complications without increasing bleeding risk.
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Affiliation(s)
- Michael A Edwards
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA.
- Department Surgery, Mayo Clinic Alix School of Medicine, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Md Walid Akram Hussain
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Emily Brennan
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Dorin Colibaseanu
- Division of Colorectal Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John Stauffer
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, 32224, USA
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A Propensity-Matched Analysis of the Postoperative Venous Thromboembolism Rate After Pancreatoduodenectomy Based on Operative Approach. J Gastrointest Surg 2022; 26:623-634. [PMID: 34757511 DOI: 10.1007/s11605-021-05191-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/23/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of minimally invasive approaches for pancreatoduodenectomy has increased in recent years, but the risk of postoperative VTE is undefined. We aimed to compare venous thromboembolism (VTE) rates after open and minimally invasive pancreatoduodenectomy using an administrative dataset. METHODS Patients who underwent pancreatoduodenectomy within the National Surgical Quality Improvement Program targeted pancreatectomy database (2016-2018) were identified. VTE was compared between patients who underwent open or minimally invasive pancreatoduodenectomy directly and after propensity score matching 1:1 for demographics, comorbidities, and peri-/intra-operative factors. RESULTS A total of 12,227 patients underwent pancreatoduodenectomy during the study period (open: n = 11,217; minimally invasive: n = 1010). Before matching, the VTE rate was higher among patients who underwent minimally invasive pancreatoduodenectomy (5.2% vs. 3.8%, p = 0.033), and minimally invasive resection was independently associated with VTE (OR = 1.46, 95%CI = 1.09-2.06). After matching, there were 916 patients per group without differences in demographics or comorbidities. Patients who underwent minimally invasive pancreatoduodenectomy had longer median operative times (422 vs. 348 min). The VTE rate remained higher following minimally invasive pancreatoduodenectomy after matching (5.1% vs. 2.9%, p = 0.018), mainly driven by a higher DVT rate (3.9% vs. 1.7%, p = 0.005). CONCLUSIONS Minimally invasive pancreatoduodenectomy is associated with a higher postoperative VTE rate compared to open pancreatoduodenectomy.
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Cordova-Cassia C, Wong D, Cotter MB, Cataldo TE, Poylin VY. Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study. Surg Endosc 2021; 36:267-273. [PMID: 33495879 DOI: 10.1007/s00464-020-08271-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe. METHODS This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30 days of enoxaparin. Safety of use and patient compliance were examined. RESULTS Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance. CONCLUSION Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.
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Affiliation(s)
- Carlos Cordova-Cassia
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Daniel Wong
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Mary B Cotter
- HMFP Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Thomas E Cataldo
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Vitaliy Y Poylin
- Gastrointestinal and Oncologic Surgery, Feinberg School of Medicine, Northwestern Medical Group, Arkes Family Pavilion, 676 North St Clair Street, Suite 650, Chicago, IL, 60611, USA.
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Ong CT, Leung E, Shah AP. Improving prescribing of extended prophylaxis for venous thromboembolism at discharge in patients who underwent surgery for colorectal cancer. Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 33263480 DOI: 10.12968/hmed.2020.0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS/BACKGROUND Prophylaxis at discharge is important in mitigating venous thromboembolism events from colorectal cancer and major abdominopelvic surgery, both of which are risk factors for venous thromboembolism. Foundation doctors frequently rotate between departments, and so rely on departmental induction and/or handing down of knowledge to prescribe extended venous thromboembolism prophylaxis upon discharge. METHODS A retrospective audit of all patients who underwent surgery for colorectal cancer at The County Hospital, Hereford, between 1 August 2018 and 31 August 2019, was undertaken to assess departmental compliance with guidance from the National Institute for Health and Care Excellence. RESULTS A total of 181 patients underwent elective surgery and 29 patients had emergency surgery. The initial audit revealed a cyclical 4-monthly decline that coincided with foundation doctors' rotations. Six multidisciplinary interventions were implemented. Reaudit demonstrated 100% compliance with prescribing of extended venous thromboembolism prophylaxis at discharge. No venous thromboembolism events 30 days post operation were noted. CONCLUSIONS A multidisciplinary approach involving educating health professionals about the importance of extended venous thromboembolis prophylaxis in patients who have undergone surgery for colorectal cancer can be effective in improving compliance with prescribing practices at discharge.
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Affiliation(s)
- Chea Tze Ong
- Department of Surgery, The County Hospital, Hereford, UK
| | - Edmund Leung
- Department of Surgery, The County Hospital, Hereford, UK
| | - Adarsh P Shah
- Department of Surgery, The County Hospital, Hereford, UK.,School of Surgery, Health Education England West Midlands, Birmingham, UK
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Leeds IL, Canner JK, DiBrito SR, Safar B. Justifying Total Costs of Extended Venothromboembolism Prophylaxis After Colorectal Cancer Surgery. J Gastrointest Surg 2020; 24:677-687. [PMID: 30945086 PMCID: PMC6776724 DOI: 10.1007/s11605-019-04206-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current guidelines recommend extended venothromboembolism (VTE) prophylaxis for most patients following colorectal cancer surgery, but provider uptake has been limited. The purpose of this study was to identify thresholds for when such extended prophylaxis (ePpx) may be value-appropriate. METHODS All colorectal cancer postoperative discharges were identified within a private payer administrative database (MarketScan® 2010-2014, IBM Truven Health Analytics). Outcomes of interest were VTE event rate, mortality, and overall costs of care. The data along with published literature were used as parameter estimations for a decision analysis model with probabilistic sensitivity analysis. RESULTS We identified 22,463 colorectal cancer surgical patients (4.0% with ePpx) that served as the parameter estimates for the decision model with a VTE event rate of 0.2%. Decision analysis demonstrated that prescribing ePpx was dominated by usual practice with the former having higher probability-adjusted incremental costs ($1078.68 per person) and lower probability-adjusted benefits (- 0.000098 quality adjusted life years). Broad sensitivity analysis found that probability of a VTE event, bleeding case fatality rate, and probability of an ePpx-associated bleeding event were the primary effectors of the model. VTE event rates of greater than 3.0% benefited from prescribing ePpx to all patients. CONCLUSIONS Very few patients are discharged on ePpx following colorectal cancer surgery despite its endorsement by national guidelines. A decision analysis model does not support the use of ePpx except in cases of markedly high VTE rates. Clinical guidance could be improved by further recognizing the role of risk stratification in the determination of high-risk patients requiring ePpx.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Felder S, Rasmussen MS, King R, Sklow B, Kwaan M, Madoff R, Jensen C. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2019; 8:CD004318. [PMID: 31449321 PMCID: PMC6709764 DOI: 10.1002/14651858.cd004318.pub5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis, which approached significance (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.
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Affiliation(s)
- Seth Felder
- Moffitt Cancer CenterDepartment of Gastrointestinal OncologyTampaFloridaUSA
| | - Morten Schnack Rasmussen
- H:S Bispebjerg HospitalSurgical gastroenterology dept. K23 Bispebjeg BakkeCopenhagenDenmarkDK 2400
| | - Ray King
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNMinnesotaUSAMN 55105
| | - Bradford Sklow
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNMinnesotaUSAMN 55105
| | - Mary Kwaan
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNMinnesotaUSAMN 55105
| | - Robert Madoff
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNMinnesotaUSAMN 55105
| | - Christine Jensen
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNMinnesotaUSAMN 55105
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Dabigatran (Pradaxa) Is Safe for Extended Venous Thromboembolism Prophylaxis After Surgery for Pancreatic Cancer. J Gastrointest Surg 2019; 23:1166-1171. [PMID: 30187331 DOI: 10.1007/s11605-018-3936-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Chest Physicians and American Hepato-Pancreato-Biliary Association recommend using low-molecular-weight heparin for 28 days postoperatively for venous thromboembolism prophylaxis after cancer surgery. Dabigatran is a once daily oral anticoagulant that is FDA approved for venous thromboembolism prophylaxis after orthopedic surgery, uses fixed dosing, and has an antidote. METHODS Patients undergoing surgery for malignant pancreatic tumors (neuroendocrine excluded) from January 2017 to January 2018 were converted to dabigatran 220 mg daily on discharge until postoperative day 28; patients with medical or insurance contraindications were converted to enoxaparin or another direct oral anticoagulant. The primary endpoint was bleeding complications through 90 days. RESULTS A total of 134 patients were considered for this study (median age 67 ± 10; 58.9% male). Eighty-seven (82.9%) patients received dabigatran and 18 (17.1%) received another form of anticoagulation. There were 19 (4.2%) patients not prescribed dabigatran due to medical or inpatient contraindications. Four patients experienced bleeding complications after discharge while on dabigatran. Two (2%) were major bleeds (Clavien-Dindo IV and V), and 2 (2%) were minor (Clavien-Dindo I). Patient compliance was excellent, with 93% of prescribed patients fully completing their prophylaxis. There were 2 patients that developed symptomatic deep vein thrombosis. CONCLUSION The use of a direct oral anticoagulant as extended venous thromboembolism prophylaxis after major gastrointestinal surgery has not been studied to date. These results show dabigatran to be a safe alternative to low-molecular-weight heparin for extended venous thromboembolism prophylaxis with regard to bleeding complications.
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Marchocki Z, Norris L, O'Toole S, Gleeson N, Saadeh FA. Patients' experience and compliance with extended low molecular weight heparin prophylaxis post-surgery for gynecological cancer: a prospective observational study. Int J Gynecol Cancer 2019; 29:ijgc-2019-000284. [PMID: 30992328 DOI: 10.1136/ijgc-2019-000284] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Gynaecological cancer patients have a high risk of developing venous thromboembolism (VTE). There is limited information on patient experience and compliance with an extended low molecular weight heparin prophylaxis in this setting. The aim of this study was to assess patient compliance, satisfaction and experience with the extended low molecular weight heparin prophylaxis after major surgery for gynaecological cancer. METHODS This was a prospective observational study conducted in a large tertiary center for gynaecological cancer between July 2017-March 2018. Consecutive patients undergoing surgery for gynaecological cancer who received low molecular weight heparin prophylaxis for four weeks following surgery were recruited. All participants received a log book to record all injections, side effects, and questionnaire to be completed at the end of the study. RESULTS A total of 106 patients completed and returned the VTE prophylaxis logbook and questionnaire. Sixty-six (62%) patients received low molecular weight heparin for 28 days, twenty-five (24%) for 26-27 days, and 15 (14%) for less than 26 days. The median number of days of therapy was 28 days (range; 12-28 days). Reasons for missed or stopped injections included: forgetfulness(n=12), medical procedures (n=6), pain (n=5), incorrect prescription (n=4), patient choice (n=3), cost (n=2), physician request (n=2), non-availability of person administering the injections (n=1) or unknown (n=5). Sixty-one (58%) patients self-administered the injections. Patients who had the injection performed by a third person were twice as likely to experience pain compared to patients who self-administered (OR 2.81, p=0.003). Eighty-nine (84%) patients self-reported side effects during low molecular weight heparin prophylaxis including: bruising (75%), pain after injections (49%), itchiness (9%), swelling (9%) or other (8%). Although 83 (78%) patients were satisfied with injections, 91 (86%) admitted they would much prefer a tablet form. CONCLUSIONS Compliance with standard recommended regimen of 28-days prophylaxis was completed by 62% of patients. Majority of patients (86%) reported a preference for a tablet form, if one was available.
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Affiliation(s)
- Zibi Marchocki
- Department of Gynaecological Oncology, St. James's Hospital, Dublin, Ireland
- Trinity College Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
| | - Lucy Norris
- Trinity College Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
| | - Sharon O'Toole
- Trinity College Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
| | - Noreen Gleeson
- Department of Gynaecological Oncology, St. James's Hospital, Dublin, Ireland
- Trinity College Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
| | - Feras Abu Saadeh
- Department of Gynaecological Oncology, St. James's Hospital, Dublin, Ireland
- Trinity College Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
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Felder S, Rasmussen MS, King R, Sklow B, Kwaan M, Madoff R, Jensen C. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2019; 3:CD004318. [PMID: 30916777 PMCID: PMC6450215 DOI: 10.1002/14651858.cd004318.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.
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Affiliation(s)
- Seth Felder
- Moffitt Cancer CenterDepartment of Gastrointestinal OncologyTampaUSA
| | - Morten Schnack Rasmussen
- H:S Bispebjerg HospitalSurgical gastroenterology dept. K23 Bispebjeg BakkeCopenhagenDenmarkDK 2400
| | - Ray King
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Bradford Sklow
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Mary Kwaan
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Robert Madoff
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Christine Jensen
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
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Laureano M, Ebraheem M, Crowther M. Extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery: a retrospective review. ACTA ACUST UNITED AC 2019; 26:e106-e110. [PMID: 30853816 DOI: 10.3747/co.26.4339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Extended prophylaxis against venous thromboembolism (vte) after abdominal or pelvic cancer surgery with low molecular weight heparin (lmwh) is recommended by multiple guidelines. The primary objective of the present study was to assess adherence to that guideline recommendation at tertiary care centres within Hamilton Health Sciences (hhs). Methods Given that an estimated 70% of the study population would be expected to receive extended prophylaxis, a sample size of 105 patients was calculated. Patients who had undergone abdominal or pelvic surgery for cancer from March 2012 to December 2015 were identified, and data were collected from electronic health records. The primary outcome was prescription of extended vte prophylaxis. Results Of 105 patients, only 3 received extended vte prophylaxis. Those 3 patients had serous carcinoma of the uterus, transitional cell carcinoma of the bladder, and cecal cancer. Of the 3 patients, 2 were followed by the thrombosis service while in hospital; none of the other 102 patients received any form of extended vte prophylaxis. Conclusions Based on multiple randomized controlled trials, guidelines suggest lmwh prophylaxis for up to 4 weeks after major abdominal or pelvic cancer surgery. Despite those recommendations, postoperative extended vte prophylaxis is not commonly prescribed at hhs facilities. Next steps will include identification of barriers and an examination of how those barriers could be addressed. Failure to use prophylaxis is not consistent with evidence-based guidelines and is placing patients at risk of vte.
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Affiliation(s)
- M Laureano
- Department of Medicine, McMaster University, Hamilton, ON
| | - M Ebraheem
- Department of Medicine, McMaster University, Hamilton, ON
| | - M Crowther
- Department of Medicine, McMaster University, Hamilton, ON
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Felder S, Rasmussen MS, King R, Sklow B, Kwaan M, Madoff R, Jensen C. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2018; 11:CD004318. [PMID: 30481366 PMCID: PMC6517131 DOI: 10.1002/14651858.cd004318.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery. OBJECTIVES To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE. SEARCH METHODS We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies. SELECTION CRITERIA We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation. DATA COLLECTION AND ANALYSIS Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis. MAIN RESULTS We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I2 = 28%; seven studies, n = 1728; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I2 = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I2 = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I2 = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (HM-H OR 1.10, 95% CI 0.67 to 1.81; I2 = 0%; seven studies, n = 2239; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity. AUTHORS' CONCLUSIONS Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.
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Affiliation(s)
- Seth Felder
- Moffitt Cancer CenterDepartment of Gastrointestinal OncologyTampaUSA
| | - Morten Schnack Rasmussen
- H:S Bispebjerg HospitalSurgical gastroenterology dept. K23 Bispebjeg BakkeCopenhagenDenmarkDK 2400
| | - Ray King
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Bradford Sklow
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Mary Kwaan
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Robert Madoff
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
| | - Christine Jensen
- University of MinnesotaDepartment of Surgery, Division of Colorectal Surgery1055 Westgate Drive, Suite 190Minneapolis, MNUSAMN 55105
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Marley L, Navadgi S, Banting S, Fox A, Hii M, Knowles B. Safety, efficacy and compliance of extended thromboprophylaxis in hepatobiliary and upper gastrointestinal surgery. ANZ J Surg 2018; 89:357-361. [DOI: 10.1111/ans.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Leah Marley
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
| | - Suresh Navadgi
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
| | - Simon Banting
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Adrian Fox
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Michael Hii
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Brett Knowles
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
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Lemke M, Beyfuss K, Hallet J, Coburn NG, Law CHL, Karanicolas PJ. Patient Adherence and Experience with Extended Use of Prophylactic Low-Molecular-Weight Heparin Following Pancreas and Liver Resection. J Gastrointest Surg 2016; 20:1986-1996. [PMID: 27688212 DOI: 10.1007/s11605-016-3274-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective. METHODS An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH. RESULTS There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome. CONCLUSION Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines.
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Affiliation(s)
- Madeline Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Kaitlyn Beyfuss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Calvin H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Paul J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada.
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Venous thromboembolism after radical cystectomy: Experience with screening ultrasonography. Arab J Urol 2015; 14:37-43. [PMID: 26966592 PMCID: PMC4767786 DOI: 10.1016/j.aju.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/13/2015] [Accepted: 11/24/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To detect the incidence of immediate postoperative deep vein thrombosis (DVT) using screening lower extremity ultrasonography (US) in patients undergoing radical cystectomy (RC) and to determine the rate of symptomatic pulmonary embolism (PE) after RC and identify risk factors for venous thromboembolic (VTE) events in a RC population. PATIENTS AND METHODS We performed a retrospective review of prospective data collected on patients who underwent RC between July 2008 and January 2012. These patients underwent screening US at 2/3 days after RC to determine the rate of asymptomatic DVT. A chart review was completed to identify those who had a symptomatic PE. Univariate and multivariable analysis was used to identify risk factors associated with DVT, PE and total VTE events. RESULTS In all, 221 patients underwent RC and asymptomatic DVT was identified in 21 (9.5%) on screening US. Nine (4.5%) developed symptomatic PE at a median of 9 days, of which no patients had positive lower extremity US postoperatively. Increased length of hospital stay, increased estimated blood loss, and lower body mass index were linked to risk of PE, and only a previous history of DVT was associated with postoperative DVT. CONCLUSION Patients who undergo RC are at high-risk for thromboembolic events and multimodal prophylaxis should be administered. Clinicians should be especially vigilant in those who demonstrate factors associated with higher risk for VTE events.
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Variable support for ASCO recommendations for the prevention and treatment of cancer-associated venous thromboembolism. PHLEBOLOGIE 2015. [DOI: 10.12687/phleb2294-6-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryObjectives: To determine the attitude of physicians towards the ASCO evidence-based clinical practice guidelines for venous thromboembolism (VTE) prophylaxis and treatment in patients with cancer.Methods: The ASCO guideline was published in Jan. 2015. Two specialists in in the field assembled a list of arguments for and against each of the ASCO recommendations. ASCO recommendations and pro & con arguments were presented to physicians attending 3 educational seminars on hemostasis in cancer patients. After the presentation each attendee was asked to fill out a questionnaire on how much he agreed with the recommendations and the pro & con arguments.Results: A total of 89 physicians attended the three meetings. 56 questionnaires were returned. The ASCO recommendation with the highest degree of support was that patients undergoing major cancer surgery should receive prophylaxis for 7–10 days and for four weeks after major abdominal or pelvic surgery with high-risk features (84 % Pro). The recommendation with the lowest degree of support was that anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications (56 % Pro = indifference). Arguments based on A) the scientific evidence underlying each recommendation, B) on clinical practicability and patients’ preferences/adherence, C) on the desire to avoid toxicity, malpractice litigation, and cost concerns, ranked equally.Conclusion: The degree of support for ASCO guideline recommendations on prophylaxis and treatment of VTE in cancer is variable. For some key recommendations it is close to indifference. Scientific evidence for a recommendation is just one decision factor among others. Our study underscores the need to further promote educational activities on VTE prophylaxis and treatment in cancer patients particularly among all physicians caring for cancer patients.
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Godzik J, McAndrew CM, Morshed S, Kandemir U, Kelly MP. Multiple lower-extremity and pelvic fractures increase pulmonary embolus risk. Orthopedics 2014; 37:e517-24. [PMID: 24972431 DOI: 10.3928/01477447-20140528-50] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
The incidence of venous thromboembolism after major trauma has been estimated to be as high as 60%, despite appropriate prophylaxis. Pulmonary embolism is associated with deep venous thrombosis and also with significant rates of morbidity and mortality. This study examined risk factors for pulmonary embolism among patients with pelvic and lower-extremity fractures in the National Trauma Data Bank. Univariate analysis and multiple logistic regression were used to assess potential risk factors for pulmonary embolism during the index hospitalization period. A total of 199,952 patients with pelvic and lower-extremity fracture were identified. Of these patients, 918 (0.46%) had a pulmonary embolism and 117 (12%) of them died during hospitalization. The risk of pulmonary embolism was significantly increased in patients with multiple fractures (odds ratio, 1.89; P<.001) only. No significant relationship was found with fracture location (pelvis, femur, tibia). Other factors that were associated with increased rates of pulmonary embolism were obesity (body mass index >40 odds ratio, 3.38; P<.001), history of warfarin use (P=.009), hospital disposition (surgery odds ratio, 1.68; P<.001; intensive care unit odds ratio, 2.4; P<.001), and hospital setting (university odds ratio, 1.36; P<.001). Multiple pelvic or lower-extremity fractures, but not their anatomic locations, were associated with pulmonary embolism in the National Trauma Data Bank. As expected, obese patients and those with a history of warfarin therapy have higher rates of pulmonary embolism. This study offers guidance in identifying patients with musculoskeletal trauma who are at elevated risk for pulmonary embolism.
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Venous thromboembolism prophylaxis in patients undergoing abdominal or pelvic surgery for cancer – A real-world, prospective, observational French study: PRéOBS. Thromb Res 2014; 133:985-92. [DOI: 10.1016/j.thromres.2013.10.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/25/2013] [Accepted: 10/28/2013] [Indexed: 11/30/2022]
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Iannuzzi JC, Rickles AS, Kelly KN, Fleming FJ, Dolan JG, Monson JRT, Noyes K. Defining high risk: cost-effectiveness of extended-duration thromboprophylaxis following major oncologic abdominal surgery. J Gastrointest Surg 2014; 18:60-8. [PMID: 24101450 PMCID: PMC4652588 DOI: 10.1007/s11605-013-2373-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 09/21/2013] [Indexed: 01/31/2023]
Abstract
PURPOSE Extended-duration thromboprophylaxis (EDTPPX) is the practice of prescribing antithrombotic therapy for 21 days after discharge, commonly used in surgical patients who are at high risk for venothromboembolism (VTE). While guidelines recommend EDTPPX, criteria are vague due to a paucity of data. The criteria can be further informed by cost-effectiveness thresholds. This study sought to determine the VTE incidence threshold for the cost-effectiveness of EDTPPX compared to inpatient prophylaxis. METHODS A decision tree was used to compare EDTPPX for 21 days after discharge to 7 days of inpatient prophylaxis with base case assumptions based on an abdominal oncologic resection without complications in an otherwise healthy individual. Willingness to pay was set at $50,000/quality-adjusted life year (QALY). Sensitivity analyses were performed to assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE incidence. RESULTS EDTPPX was the dominant strategy when VTE probability exceeds 2.39 %. Given a willingness to pay threshold of $50,000/QALY, EDTPPX was the preferred strategy when VTE incidence exceeded 1.22 and 0.88 % when using brand name or generic medication costs, respectively. CONCLUSIONS EDTPPX should be recommended whenever VTE incidence exceeds 2.39 %. When post-discharge estimated VTE risk is 0.88-2.39 %, patient preferences about self-injections and medication costs should be considered.
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Affiliation(s)
- James C Iannuzzi
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY, 14642, USA,
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Iannuzzi JC, Young KC, Kim MJ, Gillespie DL, Monson JR, Fleming FJ. Prediction of postdischarge venous thromboembolism using a risk assessment model. J Vasc Surg 2013; 58:1014-20.e1. [DOI: 10.1016/j.jvs.2012.12.073] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 12/12/2012] [Accepted: 12/22/2012] [Indexed: 01/31/2023]
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Iannuzzi JC, Rickles AS, Kelly KN, Monson JRT, Fleming FJ. Prediction of venous thromboembolism after surgery for colorectal cancer: a prevention paradigm. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
SUMMARY Colorectal cancer patients are at elevated risk for venous thromboembolism, especially in the postsurgical setting. Many risk factors particular to colorectal patients have been identified including malignancy-associated hypercoagulability, colorectal cancer in its own right, chemotherapy, obesity and operative approach. While initiatives aimed at improving inpatient prophylaxis have been effective, the period of risk extends far beyond the inpatient episode suggesting that this approach is inadequate. The prolonged hypercoaguable state combined with the efficacy of extended-duration thromboprophylaxis has led to international consensus guidelines suggesting its implementation. International compliance is low, highlighting the need for greater educational efforts. Risk stratification using identified predictors of venous thromboembolism may improve guideline delivery through a more targeted approach.
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Affiliation(s)
- James C Iannuzzi
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY, USA.
| | - Aaron S Rickles
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY, USA
| | - Kristin N Kelly
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY, USA
| | - John RT Monson
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY, USA
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Cohen A, Chiu KM, Park K, Jeyaindran S, Tambunan KL, Ward C, Wong R, Yoon SS. Managing venous thromboembolism in Asia: Winds of change in the era of new oral anticoagulants. Thromb Res 2012; 130:291-301. [DOI: 10.1016/j.thromres.2012.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
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Bhagya Rao B, Kalayarasan R, Kate V, Ananthakrishnan N. Venous Thromboembolism in Cancer Patients Undergoing Major Abdominal Surgery: Prevention and Management. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/783214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cancer is an important risk factor for venous thrombosis. Venous thromboembolism is one of the most common complications of cancer and the second leading cause of death in these patients. Recent research has given insight into mechanism and various risk factors in cancer patients which predispose to thromboembolism. The purpose of this review is to summarize the current knowledge on the prophylaxis, diagnosis, and management of venous thromboembolism in these patients.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - R. Kalayarasan
- Department of Surgical Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Vikram Kate
- Department of General and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - N. Ananthakrishnan
- Department of Surgery, Mahatma Gandhi Medical College & Research Institute, Pondicherry 607402, India
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Prevention of venous thromboembolism in cancer patients: current approaches and opportunities for improvement. Oncol Rev 2011. [DOI: 10.1007/s12156-011-0079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Perre A, Markman M. Extended venous thromboembolism prophylaxis for high-risk patients undergoing surgery for malignancy. Case Rep Oncol 2011; 4:115-7. [PMID: 21475600 PMCID: PMC3072189 DOI: 10.1159/000324584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background In surgical patients with known malignancy, the odds ratio for an episode of a venous thromboembolism is approximately 6.5 compared to a group of patients without malignancy undergoing the same procedure [Heit et al.: Arch Intern Med 2000;160:809–815]. Case Report We present a case of a 46-year-old Caucasian male with a history of adenocarcinoma of the rectum. The patient received neoadjuvant treatment prior to low anterior resection with diverting colostomy. He received short-term prophylaxis for venous thrombosis, but unfortunately developed a blood clot in a lower extremity several weeks after surgery. Conclusion There is a well-defined role in carefully selected patients for the use of extended prophylaxis to prevent venous thromboembolic complications following cancer surgery.
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Affiliation(s)
- A Perre
- Cancer Treatment Centers of America, Eastern Regional Medical Center, Philadelphia, Pa., USA
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2010; 17:568-80. [PMID: 21030841 DOI: 10.1097/med.0b013e328341311d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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