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Zhang W, Wei X, Yang S, Du C, Hu B. Unfractionated heparin or low-molecular-weight heparin for venous thromboembolism prophylaxis after hepatic resection: A meta-analysis. Medicine (Baltimore) 2022; 101:e31948. [PMID: 36401460 PMCID: PMC9678573 DOI: 10.1097/md.0000000000031948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Two systematic reviews summarized the efficacy and safety of pharmacological prophylaxis for venous thromboembolism (VTE) after hepatic resection, but both lacked a discussion of the differences in the pharmacological prophylaxis of VTE in different ethnicities. Therefore, we aimed to evaluate the efficacy and safety of low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) for VTE prophylaxis in Asian and Caucasian patients who have undergone hepatic resection. METHODS We searched PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Data, and VIP databases for studies reporting the primary outcomes of VTE incidence, bleeding events, and all-cause mortality from January 2000 to July 2022. RESULTS Ten studies involving 4318 participants who had undergone hepatic resection were included: 6 in Asians and 4 in Caucasians. A significant difference in VTE incidence was observed between the experimental and control groups (odds ratio [OR] = 0.39, 95% confidence interval [CI]: 0.20, 0.74, P = .004). No significant difference in bleeding events and all-cause mortality was observed (OR = 1.29, 95% CI: 0.80, 2.09, P = .30; OR = 0.71, 95% CI: 0.36, 1.42, P = .33, respectively). Subgroup analyses stratified by ethnicity showed a significant difference in the incidence of VTE in Asians (OR = 0.16, 95% CI: 0.06, 0.39, P < .0001), but not in Caucasians (OR = 0.69, 95% CI: 0.39, 1.23, P = .21). No significant differences in bleeding events were found between Asians (OR = 1.60, 95% CI: 0.48, 5.37, P = .45) and Caucasians (OR = 1.11, 95% CI: 0.58, 2.12, P = .75). The sensitivity analysis showed that Ejaz's study was the main source of heterogeneity, and when Ejaz's study was excluded, a significant difference in VTE incidence was found in Caucasians (OR = 0.58, 95% CI: 0.36, 0.93, P = .02). CONCLUSION This study's findings indicate that the application of UFH or LMWH for VTE prophylaxis after hepatic resection is efficacious and safe in Asians and Caucasians. It is necessary for Asians to receive drug prophylaxis for VTE after hepatic resection. This study can provide a reference for the development of guidelines in the future, especially regarding the pharmacological prevention of VTE in different ethnicities.
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Affiliation(s)
- Wentao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai Province, China
| | - Xinchun Wei
- Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, Qinghai Province, China
| | - Shiwei Yang
- Organ Transplant Center and Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Changhong Du
- Department of Cardiology, The First People’s Hospital of Guangyuan, Guangyuan, Sichuan Province, China
| | - Baoyue Hu
- Department of Emergency, Pizhou Hospital of Traditional Chinese Medicine, Pizhou, Jiangsu Province, China
- * Correspondence: Baoyue Hu, Department of Emergency, Pizhou Hospital of Traditional Chinese Medicine, Pizhou 221300, Jiangsu Province, China (e-mail: )
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Hayashida K, Kawabata Y, Saito K, Fujita S, Choe H, Kato I, Takeyama M, Inaba Y. Prevalence and risk factors of preoperative venous thromboembolism in patients with malignant musculoskeletal tumors: an analysis based on D-dimer screening and imaging. Thromb J 2022; 20:22. [PMID: 35473949 PMCID: PMC9040225 DOI: 10.1186/s12959-022-00382-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/17/2022] [Indexed: 12/21/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a major complication in patients with malignant tumors and orthopedic disorders. Although it is known that patients undergoing surgery for malignant musculoskeletal tumor are at an increased risk of thromboembolic events, only few studies have investigated this risk in detail. Therefore, the aim of this study was to determine the prevalence and risk factors for preoperative VTE in malignant musculoskeletal tumors patients. Methods We retrospectively reviewed the medical records of 270 patients who underwent surgical procedures, including biopsy for malignant musculoskeletal tumor, have undergone measurements of preoperative D-dimer levels, and were subsequently screened for VTE by lower extremity venous ultrasonography and/or contrast-enhanced computed tomography scans. Statistical analyses were performed to examine the prevalence and risk factors for VTE. Receiver operating characteristic (ROC) analysis was performed to verify the D-dimer cutoff value for the diagnosis of VTE. Results Overall, 199 patients (103 with primary soft tissue sarcomas, 38 with primary bone sarcomas, 46 with metastatic tumors, and 12 with hematologic malignancies) were included. D-dimer levels were high in 79 patients; VTE was detected in 19 patients (9.5%). Multivariate analysis indicated that age ≥ 60 years (P = 0.021) and tumor location in the lower limbs (P = 0.048) were independent risk factors for VTE. ROC analysis showed that the D-dimer cutoff value for the diagnosis of VTE was 1.53 µg/mL; the sensitivity and specificity were 89.5% and 79.4%, respectively. Conclusions Our study indicated that age and tumor location in the lower limbs were independent risk factors for preoperative VTE in malignant musculoskeletal tumors patients. D-dimer levels were not associated with VTE in the multivariate analysis, likely because they are affected by a wide variety of conditions, such as malignancy and aging. D-dimer is useful for exclusion diagnosis because of its high sensitivity, but patients with high age and tumor location in the lower limbs are a high-risk group and should be considered for imaging evaluation such as ultrasonography regardless of D-dimer levels. Trial registration Our study was approved by the institutional review board. The registration number is B200600056. The registration date was July 13, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00382-2.
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Affiliation(s)
- Kenta Hayashida
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yusuke Kawabata
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Keiju Saito
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Shintaro Fujita
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Ikuma Kato
- Department of Molecular Pathology, Yokohama City University, Yokohama, Japan
| | - Masanobu Takeyama
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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When to operate after SARS-CoV-2 infection? A review on the recent consensus recommendation of the DGC/BDC and the DGAI/BDA. Langenbecks Arch Surg 2022; 407:1315-1332. [PMID: 35307746 PMCID: PMC8934603 DOI: 10.1007/s00423-022-02495-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 02/07/2023]
Abstract
Since the eruption of the worldwide SARS-CoV-2 pandemic in late 2019/early 2020, multiple elective surgical interventions were postponed. Through pandemic measures, elective operation capacities were reduced in favour of intensive care treatment for critically ill SARS-CoV-2 patients. Although intermittent low-incidence infection rates allowed an increase in elective surgery, surgeons have to include long-term pulmonary and extrapulmonary complications of SARS-CoV-2 infections (especially “Long Covid”) in their perioperative management considerations and risk assessment procedures. This review summarizes recent consensus statements and recommendations regarding the timepoint for surgical intervention after SARS-CoV-2 infection released by respective German societies and professional representatives including DGC/BDC (Germany Society of Surgery/Professional Association of German Surgeons e.V.) and DGAI/BDA (Germany Society of Anesthesiology and Intensive Care Medicine/Professional Association of German Anesthesiologists e.V.) within the scope of the recent literature. The current literature reveals that patients with pre- and perioperative SARS-CoV-2 infection have a dramatically deteriorated postoperative outcome. Thereby, perioperative mortality is mainly caused by pulmonary and thromboembolic complications. Notably, perioperative mortality decreases to normal values over time depending on the duration of SARS-CoV-2 infection.
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Lee KE, Lim F, Colombel JF, Hur C, Faye AS. Cost-effectiveness of Venous Thromboembolism Prophylaxis After Hospitalization in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 28:1169-1176. [PMID: 34591970 PMCID: PMC9890631 DOI: 10.1093/ibd/izab246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have a 2- to 3-fold greater risk of venous thromboembolism (VTE) than patients without IBD, with increased risk during hospitalization that persists postdischarge. We determined the cost-effectiveness of postdischarge VTE prophylaxis among hospitalized patients with IBD. METHODS A decision tree compared inpatient prophylaxis alone vs 4 weeks of postdischarge VTE prophylaxis with 10 mg/day of rivaroxaban. Our primary outcome was quality-adjusted life years (QALYs) over 1 year, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (in 2020 $USD), incremental cost-effectiveness ratios (ICERs) and number needed to treat (NNT) to prevent 1 VTE and VTE death were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS Prophylaxis with rivaroxaban resulted in 1.68-higher QALYs per 1000 persons compared with no postdischarge prophylaxis at an incremental cost of $185,778 per QALY. The NNT to prevent a single VTE was 78, whereas the NNT to prevent a single VTE-related death was 3190. One-way sensitivity analyses showed that higher VTE risk >4.5% and decreased cost of rivaroxaban ≤$280 can reduce the ICER to <$100,000/QALY. Probabilistic sensitivity analyses favored prophylaxis in 28.9% of iterations. CONCLUSIONS Four weeks of postdischarge VTE prophylaxis results in higher QALYs compared with inpatient prophylaxis alone and prevents 1 postdischarge VTE among 78 patients with IBD. Although postdischarge VTE prophylaxis for all patients with IBD is not cost-effective, it should be considered in a case-by-case scenario, considering VTE risk profile, costs, and patient preference.
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Affiliation(s)
- Kate E Lee
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francesca Lim
- Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Adam S Faye
- Address correspondence to: Adam S. Faye, MD MS, Assistant Professor of Medicine & Population Health, NYU Langone Division of Gastroenterology, New York University, New York, NY, USA, 303 East 33rd Street, New York, NY 10016, USA ()
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Lelkes V, Ippolito J, Thomson J, Beebe K, Patterson F, Benevenia J. IVC filter placement in patients undergoing surgical treatment of bone or soft-tissue tumors. J Surg Oncol 2021; 124:1485-1490. [PMID: 34368956 DOI: 10.1002/jso.26640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 06/26/2021] [Accepted: 08/01/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with cancer to bone or soft tissues undergoing orthopedic procedures may be unable to receive pharmacologic prophylaxis for venous thromboembolism (VTE). Inferior vena cava (IVC) filters may be an effective method to prevent fatal pulmonary embolism (PE) in these patients. METHODS Retrospective chart review performed for patients surgically treated for malignant disease of bone or soft tissue who had IVC filter placement. Type of surgery, anatomic region, and development of wound complications requiring repeat surgery were analyzed. RESULTS From 2007 to 2018, 286 patients received IVC filters. Ten (3.5%) patients suffered deep vein thrombus (DVT) postoperatively. There was no acute fatal PE. Two patients suffered PE at 2 and 99 days postoperatively. Risk of DVT was comparable following surgery with endoprosthesis versus open reduction and internal fixation (p = 0.056) and with soft tissue versus bone involvement (p = 0.620). Three filter-related complications occurred. Patients disease at the femur had the highest rate of DVT. CONCLUSIONS Following treatment of malignant disease of bone or soft-tissues, two patients with IVC filter placement experienced nonfatal PE and three patients experienced filter-related complications. No patients in this series experienced a fatal PE.
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Affiliation(s)
- Valdis Lelkes
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Joseph Ippolito
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jennifer Thomson
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kathleen Beebe
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Francis Patterson
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Joseph Benevenia
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 402] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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Venous Thromboembolism Prophylaxis and Thrombotic Risk Stratification in the Varicose Veins Surgery-Prospective Observational Study. J Clin Med 2020; 9:jcm9123970. [PMID: 33297575 PMCID: PMC7762368 DOI: 10.3390/jcm9123970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background: An invasive phlebological treatment is still not free from complications such as thrombosis. As in other surgical populations, not only the treatment modality, but also patient condition-related venous thromboembolism (VTE) risk factors matter. The current protocols used in varicose vein surgery centers are based mostly on individual risk assessment as well as on an implementation and extrapolation of general surgery VTE prophylaxis guidelines. In the presented study, the efficacy of routine VTE pharmacological thromboprophylaxis in patients undergoing saphenous varicose vein surgery was prospectively evaluated. In the result assessment, VTE risk factor evaluation and Caprini score results were included; however, due to the limited size of the projected study group, as well as expected limited deep vein thrombosis (DVT) prevalence in this clinical scenario, it was not possible to perform the validation of the Caprini model efficacy in the projected study model. Methods: In the study, 141 patients undergoing saphenous vein stripping and miniphlebectomy in spinal anesthesia were included. In all of the patients, VTE risk factors (including Caprini score evaluation) were assessed, and the routine thromboprophylaxis with enoxaparin 40 mg for 10 days was used. The venous ultrasounds were undertaken before the surgery and on the 10th and 30th day after surgery. The study endpoint was the presence of symptomatic or asymptomatic DVT confirmed in the imaging study. The study safety endpoint was major bleeding occurrence intraoperatively or within 30 days after surgery. Results: The presence of a postoperative DVT was diagnosed in five cases (3.5%) In all of these cases, only distal DVT was confirmed. Despite extensive saphenous varicose vein surgery with stripping and miniphlebectomy performed in nontumescent but spinal anesthesia, no proximal lower leg episode was diagnosed. Three out of five DVT cases were diagnosed on day 10 postoperative control, while a further two were confirmed in the ultrasound examination performed 30 days after procedure. No clinically documented pulmonaly embolism (PE) as well as no bleeding episodes were noticed. Among the factors related to the statistically significant higher DVT occurrence, the results of the Caprini score were identified with odds ratio (OR) = 2.04 (95% CI = (0.998; 4.18)). Another factor that became statistically significant in terms of the higher postoperative DVT prevalence was the reported Venous Clinical Severity Score (VCSS) results (OR = 1.98; 95% CI (1.19; 3.26)). In the multiple logistic regression analysis, the patient age (OR = 0.86; 95% CI (0.75–0.99)), Caprini score evaluation results (OR = 4.04; 95% CI (1.26–12.9)) and VCSS results (OR = 2.4; 95% CI (1.23–4.7)) were of statistical significance as predictors for postoperative DVT occurrence, with a p value of 0.029 for age, and p = 0.017 and p = 0.009 for Caprini score results and VCSS results, respectively. Due to the confirmed limited number of the DVT events in our study cohort, as well as the descriptive and explorative nature of the achieved results, the final clinical potential and significance of the identified parameters, including Caprini score rate and VCSS rate, should be interpreted with caution and studied in the further trials in these clinical settings. Conclusion: All the patients undergoing varicose vein surgery should undergo VTE risk evaluation based on the individual assessment. In VTE risk evaluation, patient and surgical procedure characteristics based on the factors included into the Caprini score but also on specific chronic venous disease-related factors should be taken into consideration. Further studies are needed to propose an objective and validated VTE risk assessment model, as well as a validated antithrombotic prophylaxis protocol in this particular patient group.
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Obitsu T, Tanaka N, Oyama A, Ueno T, Saito M, Yamaguchi T, Takagi A, Rikiyama T, Unno M, Naitoh T, Shimamura H, Suto T, Saijo F, Yamauchi J, Miura K. Efficacy and Safety of Low-Molecular-Weight Heparin on Prevention of Venous Thromboembolism after Laparoscopic Operation for Gastrointestinal Malignancy in Japanese Patients: A Multicenter, Open-Label, Prospective, Randomized Controlled Trial. J Am Coll Surg 2020; 231:501-509.e2. [DOI: 10.1016/j.jamcollsurg.2020.08.734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 11/28/2022]
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Wang Q, Ding J, Yang R. The venous thromboembolism prophylaxis in patients receiving thoracic surgery: A systematic review. Asia Pac J Clin Oncol 2020; 17:e142-e152. [PMID: 33009716 DOI: 10.1111/ajco.13386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) is a significant and preventable cause of mortality and morbidity in thoracic surgery. It usually deep venous thromboembolism (DVT) and pulmonary thromboembolism (PE). We conducted this article to perform a systematic review on prophylaxis of perioperative VTE in patients undergoing thoracic surgery especially lung surgery and esophageal surgery and to identify potential areas for future research. METHODS The systematic review we conducted included studies of patients undergoing thoracic surgery especially lung surgery and esophageal surgery RESULTS: The study identified 2621 references. Finally, 22 trials with a total of 9072 patients were included. Only six studies declared that they continued a follow-up after the discharge of the patients. (range: 1-3 months); three studies reported on major bleeding events as an outcome measure, and the incidence varied from 0.8% to 1.6%. Total 346 VTEs occurred, and the overall mean risk of VTE was estimated at 3.8% (range: 0.77-27%). CONCLUSIONS The evidence for using thromboprophylaxis in thoracic surgery is limited and controversial, predominantly based on clinical consensus. Future research is needed to focus on identifying risk of VTE and providing sufficient evidence with high quality to support clinical strategies concerning the prophylaxis for VTE.
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Affiliation(s)
- Qin Wang
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
| | - Jiefang Ding
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
| | - Rusong Yang
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
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Kabashneh S, Alkassis S, Shanah L, Alkofahi AA. Venous Thromboembolism in Patients With Brain Cancer: Focus on Prophylaxis and Management. Cureus 2020; 12:e8771. [PMID: 32714708 PMCID: PMC7377668 DOI: 10.7759/cureus.8771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Patients with primary and metastatic brain tumors are predisposed to thromboembolism. This review of the literature explores the high prevalence of venous thromboembolism and its negative impact on patients with brain cancer. It outlines the recommended prophylactic strategies to prevent venous thrombosis and analyzes the benefit versus risk of anticoagulation in this population, with a focus on the risk of intracranial bleeding associated with it. Additionally, it explores the exceedingly high prevalence of venous thromboembolism in the setting of brain cancer surgeries and provides guidance on the best methods used for prophylaxis in this setting and discusses the safety of each method perioperatively. Lastly, this review article provides guidance on how to manage venous thromboembolism in patients with brain cancer and discusses the use of vena cava filters in this population.
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Beyond the boundaries of cardiology: Still untapped anticancer properties of the cardiovascular system-related drugs. Pharmacol Res 2019; 147:104326. [DOI: 10.1016/j.phrs.2019.104326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023]
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Hiyoshi M, Nozawa H, Inada K, Koseki T, Nasu K, Seyama Y, Wada I, Murono K, Emoto S, Kaneko M, Sasaki K, Shuno Y, Nishikawa T, Tanaka T, Hata K, Kawai K, Maeshiro T, Miyamoto S, Ishihara S. Cecal cancer with essential thrombocythemia treated by laparoscopic ileocecal resection: a case report. Surg Case Rep 2019; 5:101. [PMID: 31227949 PMCID: PMC6588662 DOI: 10.1186/s40792-019-0660-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/12/2019] [Indexed: 11/20/2022] Open
Abstract
Background Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by thrombocytosis and a propensity for both thrombotic and hemorrhagic events. ET rarely occurs simultaneously with colorectal cancer. Here, we report a case of colorectal cancer in an ET patient treated using laparoscopic ileocecal resection. Case presentation A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction. She had been previously diagnosed with ET; aspirin and anagrelide had been prescribed. Subsequent examination at our hospital revealed cecal cancer. Distant metastasis was absent; laparoscopic ileocecal resection was performed. Anagrelide was discontinued only on the surgery day. She was discharged on the seventh postoperative day without thrombosis or hemorrhage. However, when capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia; thus, anagrelide was discontinued. Five days later, her platelet count recovered. Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy. Her liver function normalized gradually in 4 months. One-year post operation, she is well without tumor recurrence or new metastasis. Conclusions To our knowledge, this is the first report of laparoscopic colectomy performed on an ET patient receiving anagrelide. Our report shows that complications such as bleeding or thrombosis can be avoided by anagrelide administration. Contrastingly, thrombocytopenia due to anagrelide intake should be considered when chemotherapy that could cause bone marrow suppression is administered.
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Affiliation(s)
- Masaya Hiyoshi
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kentaro Inada
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takayoshi Koseki
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Keiichi Nasu
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yasuji Seyama
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Ikuo Wada
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasutaka Shuno
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tsuyoshi Maeshiro
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Sachio Miyamoto
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medical Sciences, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Venous Thromboembolism in Minimally Invasive Gynecologic Surgery: A Systematic Review. J Minim Invasive Gynecol 2019; 26:186-196. [DOI: 10.1016/j.jmig.2018.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 01/05/2023]
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[Evidence-based perioperative medicine]. Chirurg 2019; 90:357-362. [PMID: 30627766 DOI: 10.1007/s00104-018-0776-1] [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: 10/27/2022]
Abstract
Perioperative medical interventions are an integral part of modern surgical management. In addition to the main manual aspects of surgical interventions, surgeons must also be familiar with preoperative and postoperative medical interventions. This ranges from the indications for perioperative anticoagulation, handling of drainage, adjusting the perioperative analgesia, prescribing an antibiotic prophylaxis to deciding whether a preoperative bowel preparation is necessary. Therefore, this article exemplifies some areas in perioperative medicine. Based on the best available evidence, it should always be critically assessed whether these perioperative interventions really contribute to the success of the treatment.
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[Venous thromboembolism and urological cancer: Epidemiology and therapeutically management]. Prog Urol 2018; 29:1-11. [PMID: 30316671 DOI: 10.1016/j.purol.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/01/2018] [Accepted: 09/06/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Active cancer is a risk factor in the occurrence of venous thromboembolism (VTE). This is the second cause of death for these patients. In onco-urology, some cancers are associated with an increased risk of VTE. The aim of this study was to propose a focus of epidemiology and VTE therapy management. MATERIAL AND METHODS A systematic analysis of the PubMed® database was performed through the PRISMA methodology using the followings keywords : "neoplasm", "venous thromboembolism", "prophylaxis", "pulmonary embolism", "urology". The original papers were included with a priority on: meta-analyzes, literature reviews, randomized controlled trials and good-level proof cohort studies. Only publications in English or French have been selected. RESULTS The incidence of VTE was more important in case of renal carcinomas (3.5%/year). When surgery was proposed cystectomy was the riskiest procedure (2.6 to 11.6% VTE). Chemotherapy alone was an important risk factor increasing by a factor of six the occurrence of VTE. Hormonotherapy also increased this risk by induced hypogonadism. The curative treatment for VTE associated with cancers has to be performed through the injection of low molecular weight heparin. The implantation of a prophylactic treatment was not systematic among patients diagnosed with urological cancer. CONCLUSION The understanding of mechanisms associated with the occurrence of VTE among these patients has enabled to improve patient management, especially those suffering from urological cancer. Undeniably, frequency of VTE is probably underestimated by urologists during clinical practice.
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Matar CF, Kahale LA, Hakoum MB, Tsolakian IG, Etxeandia‐Ikobaltzeta I, Yosuico VED, Terrenato I, Sperati F, Barba M, Schünemann H, Akl EA. Anticoagulation for perioperative thromboprophylaxis in people with cancer. Cochrane Database Syst Rev 2018; 7:CD009447. [PMID: 29993117 PMCID: PMC6389341 DOI: 10.1002/14651858.cd009447.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The choice of the appropriate perioperative thromboprophylaxis for people with cancer depends on the relative benefits and harms of different anticoagulants. OBJECTIVES To systematically review the evidence for the relative efficacy and safety of anticoagulants for perioperative thromboprophylaxis in people with cancer. SEARCH METHODS This update of the systematic review was based on the findings of a comprehensive literature search conducted on 14 June 2018 that included a major electronic search of Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 6), MEDLINE (Ovid), and Embase (Ovid); handsearching of conference proceedings; checking of references of included studies; searching for ongoing studies; and using the 'related citation' feature in PubMed. SELECTION CRITERIA Randomized controlled trials (RCTs) that enrolled people with cancer undergoing a surgical intervention and assessed the effects of low-molecular weight heparin (LMWH) to unfractionated heparin (UFH) or to fondaparinux on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, and thrombocytopenia. DATA COLLECTION AND ANALYSIS Using a standardized form, we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, PE, symptomatic venous thromboembolism (VTE), asymptomatic DVT, major bleeding, minor bleeding, postphlebitic syndrome, health related quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE Handbook). MAIN RESULTS Of 7670 identified unique citations, we included 20 RCTs with 9771 randomized people with cancer receiving preoperative prophylactic anticoagulation. We identified seven reports for seven new RCTs for this update.The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.63 to 1.07; risk difference (RD) 9 fewer per 1000, 95% CI 19 fewer to 4 more; moderate-certainty evidence), PE (RR 0.49, 95% CI 0.17 to 1.47; RD 3 fewer per 1000, 95% CI 5 fewer to 3 more; moderate-certainty evidence), symptomatic DVT (RR 0.67, 95% CI 0.27 to 1.69; RD 3 fewer per 1000, 95% CI 7 fewer to 7 more; moderate-certainty evidence), asymptomatic DVT (RR 0.86, 95% CI 0.71 to 1.05; RD 11 fewer per 1000, 95% CI 23 fewer to 4 more; low-certainty evidence), major bleeding (RR 1.01, 95% CI 0.69 to 1.48; RD 0 fewer per 1000, 95% CI 10 fewer to 15 more; moderate-certainty evidence), minor bleeding (RR 1.01, 95% CI 0.76 to 1.33; RD 1 more per 1000, 95% CI 34 fewer to 47 more; moderate-certainty evidence), reoperation for bleeding (RR 0.93, 95% CI 0.57 to 1.50; RD 4 fewer per 1000, 95% CI 22 fewer to 26 more; moderate-certainty evidence), intraoperative transfusion (mean difference (MD) -35.36 mL, 95% CI -253.19 to 182.47; low-certainty evidence), postoperative transfusion (MD 190.03 mL, 95% CI -23.65 to 403.72; low-certainty evidence), and thrombocytopenia (RR 3.07, 95% CI 0.32 to 29.33; RD 6 more per 1000, 95% CI 2 fewer to 82 more; moderate-certainty evidence). LMWH was associated with lower incidence of wound hematoma (RR 0.70, 95% CI 0.54 to 0.92; RD 26 fewer per 1000, 95% CI 39 fewer to 7 fewer; moderate-certainty evidence). The meta-analyses found the following additional results: outcomes intraoperative blood loss (MD -6.75 mL, 95% CI -85.49 to 71.99; moderate-certainty evidence); and postoperative drain volume (MD 30.18 mL, 95% CI -36.26 to 96.62; moderate-certainty evidence).In addition, the meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with Fondaparinux for the following outcomes: any VTE (DVT or PE, or both; RR 2.51, 95% CI 0.89 to 7.03; RD 57 more per 1000, 95% CI 4 fewer to 228 more; low-certainty evidence), major bleeding (RR 0.74, 95% CI 0.45 to 1.23; RD 8 fewer per 1000, 95% CI 16 fewer to 7 more; low-certainty evidence), minor bleeding (RR 0.83, 95% CI 0.34 to 2.05; RD 8fewer per 1000, 95% CI 33 fewer to 52 more; low-certainty evidence), thrombocytopenia (RR 0.35, 95% CI 0.04 to 3.30; RD 14 fewer per 1000, 95% CI 20 fewer to 48 more; low-certainty evidence), any PE (RR 3.13, 95% CI 0.13 to 74.64; RD 2 more per 1000, 95% CI 1 fewer to 78 more; low-certainty evidence) and postoperative drain volume (MD -20.00 mL, 95% CI -114.34 to 74.34; low-certainty evidence) AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH and LMWH compared with fondaparinux in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in people with cancer. There was a lower incidence of wound hematoma with LMWH compared to UFH.
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Affiliation(s)
- Charbel F Matar
- American University of Beirut Medical CenterDepartment of Internal MedicineRiad El SolhBeirutLebanon1107 2020
| | - Lara A Kahale
- American University of BeirutFaculty of MedicineBeirutLebanon
| | - Maram B Hakoum
- American University of BeirutFamily MedicineBeirutLebanon1107 2020
| | | | - Itziar Etxeandia‐Ikobaltzeta
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact and of Medicine1280 Main Street WestHamiltonONCanadaL8S 4K1
| | | | - Irene Terrenato
- Regina Elena National Cancer InstituteBiostatistics‐Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Francesca Sperati
- Regina Elena National Cancer InstituteBiostatistics‐Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Maddalena Barba
- IRCCS Regina Elena National Cancer InstituteDivision of Medical Oncology 2 ‐ Scientific DirectionVia Elio Chianesi 53RomeItaly00144
| | - Holger Schünemann
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact and of Medicine1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Elie A Akl
- American University of Beirut Medical CenterDepartment of Internal MedicineRiad El SolhBeirutLebanon1107 2020
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The Impact of Epidural Analgesia on the Rate of Thromboembolism without Chemical Thromboprophylaxis in Major Oncologic Surgery. Am Surg 2018. [DOI: 10.1177/000313481808400631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with abdominopelvic cancers are at increased risk of venous thromboembolism (VTE) due to their malignancy. We evaluated outcomes and the rate of VTE in patients undergoing abdominopelvic surgery for malignancy with preoperative epidural analgesia without postoperative chemical VTE prophylaxis. A retrospective review between 2009 and 2015 identified 285 patients with malignancy who underwent abdominopelvic surgery by a single surgeon (AWS). Lower extremity venous duplex scans (VDS) were performed preoperatively and before discharge. Demographics, procedures, and VTE outcomes were reviewed. The median age was 66 years. The average operative time was 315 minutes. All patients ambulated on postoperative day (POD) one or two. Epidural catheters (ECs) were removed on postoperative day four or five. No patient received VTE prophylaxis while an epidural catheter was in place. Preoperative lower extremity VDS revealed above-knee deep vein thrombosis (DVT) in seven patients (2.5%). Postoperative lower extremity VDS revealed acute DVT in 24 patients (8.4%): nine (3.2%) above-knee and 15 (5.2%) below-knee. The nine patients with above-knee DVT were anticoagulated after epidural removal. No patient developed a pulmonary embolism. Our data suggest that patients undergoing major open operations with epidural analgesia have low rates of DVT and may obviate the need for chemical prophylaxis. However, larger studies are required to determine the overall effects of epidural analgesia on the development of DVTs postoperatively.
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Li H, Jiang G, Bölükbas S, Chen C, Chen H, Chen K, Chen J, Cui X, Fang W, Gao S, Gilbert S, Fu J, Fu X, Hida Y, Li S, Li X, Li Y, Li H, Li Y, Liu D, Liu L, He J, He J, Marulli G, Oizumi H, de Perrot M, Petersen RH, Shargall Y, Sihoe A, Tan Q, Wang Q, Xu S, Yang M, Yang Y, Yu Z, Zhang L, Zhang X, Zhao H, Zhi X. The Society for Translational Medicine: the assessment and prevention of venous thromboembolism after lung cancer surgery. J Thorac Dis 2018; 10:3039-3053. [PMID: 29997971 PMCID: PMC6006068 DOI: 10.21037/jtd.2018.05.38] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/20/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital of Tongji University, Shanghai 200433, China
| | - Servet Bölükbas
- Department of Thoracic Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fujian 350001, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Cancer Hospital, Fudan University, Shanghai 200032, China
| | - Keneng Chen
- Department of Thoracic Surgery, Beijing University Cancer Center, Beijing 100142, China
| | - Jun Chen
- Department of Thoracic Surgery, Genernal Hospital of Tianjin Medical University, Tianjin 300052, China
| | - Xiangli Cui
- Department of Pharmacology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University Medical School, Shanghai 200030, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jianhua Fu
- Department of Thoracic Surgery, San Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yasuhiro Hida
- Cardiovascular and Thoracic Surgery, Hokkaido University, Sapporo, Japan
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medicine, Beijing 100005, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi’an 710000, China
| | - Yin Li
- Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijing Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, Beijing 100730, China
| | - Deruo Liu
- Department of Thoracic Surgery, China and Japan Friendship Hospital, Beijing 100029, China
| | - Lunxu Liu
- Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Giuseppe Marulli
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Hiroyuki Oizumi
- Department of Surgery II (Cardiovascular, Thoracic and Pediatric Surgery), Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, 9N-961, University Health Network, Toronto, Canada
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yaron Shargall
- Division of Thoracic Surgery, McMaster University and Service of Thoracic Surgery, St Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Alan Sihoe
- Department of Surgery, The University of Hong Kong Division of Thoracic Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen 518054, China
| | - Qunyou Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Qun Wang
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Shun Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Mei Yang
- Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhentao Yu
- Department of Esophageal Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin 300060, China
| | - Lanjun Zhang
- Department of Thoracic Surgery, San Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Xun Zhang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin 300051, China
| | - Heng Zhao
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University Medical School, Shanghai 200030, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
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Shargall Y, Litle VR. European perspectives in Thoracic Surgery, the ESTS venous thromboembolism (VTE) working group. J Thorac Dis 2018; 10:S963-S968. [PMID: 29744223 DOI: 10.21037/jtd.2018.04.70] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Venous thromboembolism (VTE), composed of deep vein thrombosis (DVT) and PE is a well-recognized cause for significant perioperative morbidity and mortality. While in orthopedic surgery and general oncology surgery there are well established guidelines regarding VTE prophylaxis, based on carefully conducted high level studies, in thoracic surgery the level of evidence and overall knowledge in the field is still lacking, The European Society of Thoracic Surgeons have established an international working group in 2016, whose task was the define contemporary best practice, coordinate research efforts and eventually define best practice guidelines. This collaboration has matured into a multi-organizational effort, with participation of the American Association for Thoracic Surgery, the International Society on Thrombosis and Haemostasis and Chinese and Japanese thoracic societies. Two major projects (International practice survey and an expert group Delphi process re best practice and VTE risk factors) have been completed so far. For 2018, the working group goals will be to establish VTE prophylaxis guidance in Thoracic Surgery.
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Affiliation(s)
- Yaron Shargall
- Division of Thoracic Surgery, McMaster University, St. Joseph's Healthcare, Hamilton, Canada
| | - Virginia R Litle
- Division of Thoracic Surgery, Department of Surgery, Boston University, Boston, MA, USA
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Hashimoto D, Nakagawa S, Umezaki N, Yamao T, Kitano Y, Yamamura K, Kaida T, Arima K, Imai K, Yamashita YI, Chikamoto A, Baba H. Efficacy and safety of postoperative anticoagulation prophylaxis with enoxaparin in patients undergoing pancreatic surgery: A prospective trial and literature review. Pancreatology 2017; 17:464-470. [PMID: 28366422 DOI: 10.1016/j.pan.2017.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Enoxaparin is low-molecular-weight heparin that is used for postoperative thromboprophylaxis. The purpose of this study was to evaluate the efficacy and safety of enoxaparin after pancreatic resection. We additionally carried out a literature review regarding venous thromboembolism (VTE) and postoperative bleeding mainly after hepatobiliary-pancreatic surgery. METHODS This was a prospective, single-arm study. Patients aged 20-79 years who planned to undergo pancreatic resection followed by postoperative anticoagulation therapy with enoxaparin were enrolled from 2013 to 2016. The exclusion criteria were low renal function, active bleeding, clinical signs of VTE at screening, or evidence of thromboembolic disease before surgery. The primary endpoint was the incidence of postoperative VTE. The secondary endpoint was the incidence of postoperative complications. For the literature review, PubMed was searched for relevant articles and the PRISMA guidelines were used. RESULTS In total, 103 patients were analyzed. Two patients (1.9%) developed asymptomatic VTE, and no patients developed symptomatic VTE. No in-hospital mortality occurred. Morbidities (Clavien-Dindo grade ≥ IIIa) occurred in 29 patients (28.1%). Three patients (2.9%) developed intra-abdominal hemorrhage due to pseudoaneurysm formation after pancreaticoduodenectomy or distal pancreatectomy. The literature review included nine articles, and all indicated that the results of this study were feasible. CONCLUSION This is the first prospective trial to focus on pharmacologic prophylaxis with enoxaparin after pancreatic surgery. Postoperative anticoagulant therapy with enoxaparin was used in patients who underwent pancreatic surgery with a low incidence of VTE and no increase in postoperative bleeding events compared with existing evidence.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoki Umezaki
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takanobu Yamao
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yuki Kitano
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kensuke Yamamura
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takayoshi Kaida
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kota Arima
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Clinical and histopathological effects of presurgical treatment with sunitinib for renal cell carcinoma with inferior vena cava tumor thrombus at a single institution. Anticancer Drugs 2016; 27:1038-43. [PMID: 27557138 PMCID: PMC5049971 DOI: 10.1097/cad.0000000000000422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To evaluate the clinical and histopathological effects of presurgical treatment with sunitinib on inferior vena cava (IVC) tumor thrombus. Between 2010 and 2014, we treated seven patients with renal cell carcinoma and IVC tumor thrombus presurgically with sunitinib. We retrospectively evaluated primitive tumor size, the level of tumor thrombus according to Novick’s classification, its distance above the renal vein, thrombus diameter at its widest segment, and histopathological change after sunitinib treatment. Three patients were diagnosed histologically. Percutaneous biopsy of the renal mass before sunitinib treatment was performed in two patients. One patient was diagnosed after sunitinib treatment following nephrectomy. The primitive tumors shrank upon sunitinib therapy in four cases; however, although the caval thrombus was downstaged (from level II to I) in one patient, the level of caval thrombus did not change in five patients and increased in one patient (from level III to IV). We evaluated the histopathological effects in two patients. In one patient, the IVC tumor thrombus was mostly replaced with necrotic tissue, but its thrombus level was not downstaged. In the other patient, the IVC tumor thrombus was downstaged, but tumor thrombus was not replaced with necrotic tissue and viable tumor cells remained. Presurgical treatment with sunitinib for renal cell carcinoma with IVC tumor thrombus appears to have limited effect on IVC tumor thrombus, in contrast to its effects on primitive tumor shrinkage. In the absence of evidence of presurgical benefits from prospective studies, this treatment may not be systematically advisable.
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Zwischenberger BA, Tzeng CWD, Ward ND, Zwischenberger JB, Martin JT. Venous Thromboembolism Prophylaxis For Esophagectomy: A Survey of Practice Patterns Among Thoracic Surgeons. Ann Thorac Surg 2016; 101:489-94. [DOI: 10.1016/j.athoracsur.2015.07.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/22/2015] [Accepted: 07/09/2015] [Indexed: 12/21/2022]
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Aloia TA, Geerts WH, Clary BM, Day RW, Hemming AW, D'Albuquerque LC, Vollmer CM, Vauthey JN, Toogood GJ. Venous Thromboembolism Prophylaxis in Liver Surgery. J Gastrointest Surg 2016; 20:221-9. [PMID: 26489742 DOI: 10.1007/s11605-015-2902-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND At a recently concluded Americas Hepato-Pancreato-Biliary Association Annual Meeting, a Clinical Practice Guidelines Conference Series was convened with the topic focusing on Venous Thromboembolism (VTE) Prophylaxis in Liver Surgery. The symposium brought together hepatobiliary surgeons from three continents as well as medical experts in hematology and coagulation. METHODS The content of the discussion included literature reviews, evaluation of multi-institutional VTE outcome data, and examination of practice patterns at multiple high-volume centers. RESULTS Literature review demonstrated that, within gastrointestinal surgery, liver resection patients are at particularly high-risk for VTE. Recent evidence clearly indicates a direct relationship between the magnitude of hepatectomy and postoperative VTE rates, however, the PT/INR does not accurately reflect the coagulation status of the post-hepatectomy patient. Evaluation of available data and practice patterns regarding the utilization and timing of anticoagulant VTE prophylaxis led to recommendations regarding preoperative and postoperative thromboprophylaxis for liver surgery patients. CONCLUSIONS This conference was effective in consolidating our knowledge of coagulation abnormalities after liver resection. Based on the expert review of the available data and practice patterns, a number of recommendations were developed.
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Nelson DW, Simianu VV, Bastawrous AL, Billingham RP, Fichera A, Florence MG, Johnson EK, Johnson MG, Thirlby RC, Flum DR, Steele SR. Thromboembolic Complications and Prophylaxis Patterns in Colorectal Surgery. JAMA Surg 2015; 150:712-20. [PMID: 26060977 DOI: 10.1001/jamasurg.2015.1057] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Venous thromboembolism (VTE) is an important complication of colorectal surgery, but its incidence is unclear in the era of VTE prophylaxis. OBJECTIVE To describe the incidence of and risk factors associated with thromboembolic complications and contemporary VTE prophylaxis patterns following colorectal surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP) linked to a statewide hospital discharge database. At 52 Washington State SCOAP hospitals, participants included consecutive patients undergoing colorectal surgery between January 1, 2006, and December 31, 2011. MAIN OUTCOMES AND MEASURES Venous thromboembolism complications in-hospital and up to 90 days after surgery. RESULTS Among 16,120 patients (mean age, 61.4 years; 54.5% female), the use of perioperative and in-hospital VTE chemoprophylaxis increased significantly from 31.6% to 86.4% and from 59.6% to 91.4%, respectively, by 2011 (P < .001 for trend for both). Overall, 10.6% (1399 of 13,230) were discharged on a chemoprophylaxis regimen. The incidence of VTE was 2.2% (360 of 16,120). Patients undergoing abdominal operations had higher rates of 90-day VTE compared with patients having pelvic operations (2.5% [246 of 9702] vs 1.8% [114 of 6413], P = .001). Those having an operation for cancer had a similar incidence of 90-day VTE compared with those having an operation for nonmalignant processes (2.1% [128 of 6213] vs 2.3% [232 of 9902], P = .24). On adjusted analysis, older age, nonelective surgery, history of VTE, and operations for inflammatory disease were associated with increased risk of 90-day VTE (P < .05 for all). There was no significant decrease in VTE over time. CONCLUSIONS AND RELEVANCE Venous thromboembolism rates are low and largely unchanged despite increases in perioperative and postoperative prophylaxis. These data should be considered in developing future guidelines.
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Affiliation(s)
| | - Daniel W Nelson
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
| | - Vlad V Simianu
- University of Washington, Department of Surgery, Seattle
| | | | | | | | | | - Eric K Johnson
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
| | - Morris G Johnson
- Skagit Valley Medical Center, Department of Surgery, Mount Vernon, Washington
| | - Richard C Thirlby
- Virginia Mason Medical Center, Department of Surgery, Seattle, Washington
| | - David R Flum
- University of Washington, Department of Surgery, Seattle
| | - Scott R Steele
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Washington
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Martin JT, Mahan AL, Ferraris VA, Saha SP, Mullett TW, Zwischenberger JB, Tzeng CWD. Identifying Esophagectomy Patients at Risk for Predischarge Versus Postdischarge Venous Thromboembolism. Ann Thorac Surg 2015; 100:932-8; discussion 938. [DOI: 10.1016/j.athoracsur.2015.04.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/31/2015] [Accepted: 04/06/2015] [Indexed: 12/21/2022]
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Yamashita YI, Bekki Y, Imai D, Ikegami T, Yoshizumi T, Ikeda T, Kawanaka H, Nishie A, Shirabe K, Maehara Y. Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer. Thromb Res 2014; 134:826-31. [PMID: 25156238 DOI: 10.1016/j.thromres.2014.07.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/05/2014] [Accepted: 07/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUNDS Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery. STUDY DESIGN A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n=228) and an enoxaparin (+) group (n=53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared. RESULTS In the enoxaparin (+) group, the patients' age (65 vs. 69 years; p=0.01) and BMI (22.9 vs. 24.4; p<0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p=0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p=0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49). CONCLUSIONS Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.
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Affiliation(s)
- Yo-Ichi Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yuki Bekki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Daisuke Imai
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tetsuo Ikeda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Akihiro Nishie
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Revels SL, Wong SL, Banerjee M, Yin H, Birkmeyer JD. Differences in perioperative care at low- and high-mortality hospitals with cancer surgery. Ann Surg Oncol 2014; 21:2129-35. [PMID: 24710775 DOI: 10.1245/s10434-014-3692-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate adherence to perioperative processes of care associated with major cancer resections. BACKGROUND Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes. METHODS There were 1,279 hospitals participating in the National Cancer DataBase (2005-2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics. RESULTS Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50-0.92 and aRR 0.80, 95 % CI 0.56-0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90-1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81-1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32-0.93). CONCLUSIONS HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.
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Affiliation(s)
- Sha'Shonda L Revels
- Department of Surgery and Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI, USA
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Changolkar A, Menditto L, Shah M, Puto K, Farrelly E. Comparison of injectable anticoagulants for thromboprophylaxis after cancer-related surgery. Am J Health Syst Pharm 2014; 71:562-9. [DOI: 10.2146/ajhp120711] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Arun Changolkar
- SOAL Pharmatech Solutions, Inc., Philadelphia, PA; at the time of this study he was Manager, U.S. Health Outcomes, GlaxoSmithKline, Philadelphia
| | - Laura Menditto
- Laura A. Menditto LLC, Newtown, PA; at the time of this study she was Director, Cardiovascular, Metabolic, and Oncology U.S. Health Outcomes, GlaxoSmithKline
| | - Manan Shah
- Health Services and Outcomes Research, U.S. Medical, Bristol-Myers Squibb Company, Tampa, FL; at the time of this study he was Director, Health Economics and Outcomes Research, Xcenda, AmerisourceBergen Consulting Services, Palm Harbor, FL
| | - Katarzyna Puto
- Global Health Economics and Outcomes Research, Xcenda; at the time of this study she was Assistant Director, Medical Communications, Xcenda
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Tzeng CWD, Katz MHG, Lee JE, Fleming JB, Pisters PWT, Vauthey JN, Aloia TA. Predicting the risks of venous thromboembolism versus post-pancreatectomy haemorrhage: analysis of 13,771 NSQIP patients. HPB (Oxford) 2014; 16:373-83. [PMID: 23869628 PMCID: PMC3967890 DOI: 10.1111/hpb.12148] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/26/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The fear of an early post-pancreatectomy haemorrhage (PPH) may prevent surgeons from prescribing post-operative venous thromboembolism (VTE) chemoprophylaxis. The primary hypothesis of this study was that the national post-pancreatectomy early PPH rate was lower than the rate of VTE. The secondary hypothesis was that patients at high risk for post-discharge VTE could be identified, potentially facilitating the selective use of extended chemoprophylaxis. PATIENTS AND METHODS All elective pancreatectomies were identified in the 2005 to 2010 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Factors associated with 30-day rates of (pre- versus post-discharge) VTE, early PPH (transfusions > 4 units within 72 h) and return to the operating room (ROR) with PPH were analysed. RESULTS Pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) numbered 9140 (66.4%) and 4631 (33.6%) out of 13 771 pancreatectomies, respectively. Event rates included: VTE (3.1%), PPH (1.1%) and ROR+PPH (0.7%). PD and DP had similar VTE rates (P > 0.05) with 31.9% of VTE occurring post-discharge. Independent risk factors for late VTE included obesity [odds ratio (OR), 1.5], age ≥ 75 years (OR, 1.8), DP (OR, 2.4) and organ space infection (OR, 2.1) (all P < 0.02). CONCLUSIONS Within current practice patterns, post-pancreatectomy VTE outnumber early haemorrhagic complications, which are rare. The fear of PPH should not prevent routine and timely post-pancreatectomy VTE chemoprophylaxis. Because one-third of VTE occur post-discharge, high-risk patients may benefit from post-discharge chemoprophylaxis.
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Affiliation(s)
| | | | | | | | | | | | - Thomas A Aloia
- Correspondence Thomas A. Aloia, Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA. Tel: +1 713 563 0189. Fax: +1 713 745 1921. E-mail:
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Ogura K, Yasunaga H, Horiguchi H, Ohe K, Kawano H. Incidence and risk factors for pulmonary embolism after primary musculoskeletal tumor surgery. Clin Orthop Relat Res 2013; 471:3310-6. [PMID: 23690155 PMCID: PMC3773132 DOI: 10.1007/s11999-013-3073-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 05/13/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited information is available regarding the incidence, risk factors, and optimal prophylaxis in orthopaedic oncology patients, although malignancy and major orthopaedic surgery are associated with an increased pulmonary embolism (PE) risk. QUESTIONS/PURPOSES We aimed to investigate the incidence of PE after musculoskeletal tumor surgery in Japanese patients and analyze the potential risk factors for PE. METHODS We retrospectively identified 3750 patients (1981 males, 1769 females) who underwent musculoskeletal tumor surgery during 2007 to 2010 using the Japanese Diagnostic Procedure Combination administrative database. Data collected included sex, age, primary diagnosis, type of surgery, duration of anesthesia, and comorbidities that may affect PE incidence. Univariate logistic regression analyses were performed to examine the relationship of each factor with PE occurrence. RESULTS We identified 10 patients with PE during the survey period. A primary malignant bone tumor was associated with a significantly higher risk of PE than a primary malignant soft tissue tumor (odds ratio [OR], 5.58; 95% CI, 1.39-22.42). Bone tumor resection (OR, 7.94; 95% CI, 1.77-35.59) and prosthetic reconstruction (OR, 9.15; 95% CI, 1.52-55.07) were associated with a significantly higher risk of PE than soft tissue tumor resection. CONCLUSIONS Malignant bone tumors and bone tumor resections have a higher risk of PE than malignant soft tissue neoplasms and soft tissue resections. Both populations might require PE prophylaxis as it is likely that the risk is greater than with other major orthopaedic surgery, but data accumulation should continue, and further investigation should be done to clarify details of the incidence, risk factors, and optimal prophylaxis for PE. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Koichi Ogura
- />Department of Orthopaedic Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Hideo Yasunaga
- />Department of Health Management and Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiromasa Horiguchi
- />Department of Health Management and Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Ohe
- />Department of Medical Informatics and Economics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirotaka Kawano
- />Department of Orthopaedic Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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Tzeng CWD, Curley SA, Vauthey JN, Aloia TA. Distinct predictors of pre- versus post-discharge venous thromboembolism after hepatectomy: analysis of 7621 NSQIP patients. HPB (Oxford) 2013; 15:773-80. [PMID: 23869577 PMCID: PMC3791116 DOI: 10.1111/hpb.12130] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 04/15/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Hepatectomy patients are known to be at significant risk for venous thromboembolism (VTE), but previous studies have not differentiated pre- versus post-discharge events. This study was designed to evaluate the timing, rate and predictors of pre- ('early') versus post-discharge ('late') VTE. METHODS All patients undergoing elective hepatectomy during 2005-2010 and recorded in the American College of Surgeons National Surgical Quality Improvement Program participant use file were identified. Perioperative factors associated with 30-day rates of early and late VTE were analysed. RESULTS A total of 7621 patients underwent 4553 (59.7%) partial, 802 (10.5%) left, 1494 (19.6%) right and 772 (10.1%) extended hepatectomies. Event rates were 1.9% for deep venous thrombosis, 1.2% for pulmonary embolus and 2.8% for VTE. Of instances of VTE, 28.6% occurred post-discharge. The median time of presentation of late VTE was postoperative day 14. Multivariate analysis determined that early VTE was associated with age ≥75 years [odds ratio (OR) 1.92, P = 0.007], male gender (OR 1.87, P = 0.002), intraoperative transfusion (OR 2.49, P < 0.001), operative time of >240 min (OR 2.28, P < 0.001), organ space infection (OSI) (OR 2.60, P < 0.001), and return to operating room (ROR) (OR 3.25, P < 0.001). Late VTE was associated with operative time of >240 min (OR 2.35, P = 0.008), OSI (OR 3.78, P < 0.001) and ROR (OR 2.84, P = 0.011). CONCLUSIONS Late VTE events occur in patients with clearly identifiable intraoperative and postoperative risk factors. This provides a rationale for the selective use of post-discharge VTE chemoprophylaxis in high-risk patients.
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Affiliation(s)
- Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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The Timing of Preoperative Prophylactic Low-Molecular-Weight Heparin Administration in Breast Reconstruction. Plast Reconstr Surg 2013; 132:279-284. [DOI: 10.1097/prs.0b013e318295870e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol 2013; 31:517-21. [DOI: 10.1016/j.urolonc.2011.03.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 01/08/2023]
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Lyman GH, Khorana AA, Kuderer NM, Lee AY, Arcelus JI, Balaban EP, Clarke JM, Flowers CR, Francis CW, Gates LE, Kakkar AK, Key NS, Levine MN, Liebman HA, Tempero MA, Wong SL, Prestrud AA, Falanga A. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013; 31:2189-204. [PMID: 23669224 DOI: 10.1200/jco.2013.49.1118] [Citation(s) in RCA: 584] [Impact Index Per Article: 53.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was considered, as were treatment and use of anticoagulation as a cancer-directed therapy. METHODS A systematic review of the literature published from December 2007 to December 2012 was completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed evidence to determine which recommendations required revision. RESULTS Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized controlled trials. RECOMMENDATIONS Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low-molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE. Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient education about the signs and symptoms of VTE.
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Affiliation(s)
- Gary H Lyman
- Duke University and Duke Cancer Institute, Durham, NC, USA
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Current practice managements regarding thromboembolic prophylaxis within the pediatric sarcoma patient population. J Pediatr Hematol Oncol 2013; 35:28-31. [PMID: 22995922 DOI: 10.1097/mph.0b013e318266bf72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Children with cancer are approximately 600 times more likely to develop thromboses than the general pediatric population. Current management strategies for children have been extrapolated from adult studies and prophylaxis guidelines remain controversial. The purpose of this study is to survey the current thromboembolic prophylaxis practice methods of physicians treating pediatric sarcoma patients. METHODS Physicians involved in the care of sarcoma patients were surveyed using a 5-question survey designed to evaluate current clinical practices. RESULTS Of 107 responding physicians, 67 identified themselves as involved in the treatment of pediatric sarcoma patients. The providers most likely to use any form of deep vein thrombosis prophylaxis were orthopedic surgeons (60%), followed by general surgeons (45%), pediatric oncologists (30%), and medical oncologists (25%). Of the providers polled, 48% use mechanical forms, 20% use chemical forms, and 31% use a combination. CONCLUSIONS Currently, there is a lack of consensus regarding thromboembolic prophylaxis for pediatric sarcoma patients.
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Dar TI, Wani KA, Ashraf M, Malik A, Ahmad S, Gojwari TA, Iqbal A. Low molecular weight heparin in prophylaxis of deep vein thrombosis in Asian general surgical patients: A Kashmir experience. Indian J Crit Care Med 2012; 16:71-4. [PMID: 22988360 PMCID: PMC3439781 DOI: 10.4103/0972-5229.99107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Deep vein thrombosis (DVT) occurs at a lower rate in Asia than in the rest of the world. We wanted to study the significance and efficacy of low molecular weight heparin (LMWH) in prophylaxis of DVT in major general surgical patients in the Kashmir Valley (India, Asia) so as to make it a routine in our patients. PATIENTS AND METHODS This was a prospective study in which the effect of LMWH was compared with no prophylaxis. RESULTS LMWHs are more effective than no prophylaxis in the prevention of DVT and pulmonary thromboembolism in highest-risk general surgical patients (odds ratio = 16.64; 95% confidence interval = 3.63-1130.03; P-value = 0.014). CONCLUSION LMWHs have a significant prophylactic effect on DVT in general surgical patients, with a higher benefit to risk ratio, and, in spite of the low incidence of DVT in Asia, its prophylaxis should routinely be considered in this part of the world as well, preferably in the form of LMWHs.
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Affiliation(s)
- Tanveer Iqbal Dar
- Department of General Surgery, SKIMS Soura, and SKIMS Medical College, Srinagar, J and K, India
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Tzeng CWD, Katz MHG, Fleming JB, Pisters PWT, Lee JE, Abdalla EK, Curley SA, Vauthey JN, Aloia TA. Risk of venous thromboembolism outweighs post-hepatectomy bleeding complications: analysis of 5651 National Surgical Quality Improvement Program patients. HPB (Oxford) 2012; 14:506-13. [PMID: 22762398 PMCID: PMC3406347 DOI: 10.1111/j.1477-2574.2012.00479.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Historically, liver surgeons have withheld venous thromboembolism (VTE) chemoprophylaxis due to perceived postoperative bleeding risk and theorized protective anticoagulation effects of a hepatectomy. The relationships between extent of hepatectomy, postoperative VTE and bleeding events were evaluated using the National Surgical Quality Improvement Program (NSQIP) database. METHODS From 2005 to 2009, all elective open hepatectomies were identified. Factors associated with 30-day rates of VTE, postoperative transfusions and returns to the operating room (ROR), were analysed. RESULTS The analysis included 5651 hepatectomies with 3376 (59.7%) partial, 585 (10.4%) left, 1134 (20.1%) right, and 556 (9.8%) extended. Complications included deep vein thrombosis (DVT) (1.93%), pulmonary embolism (PE) (1.31%), venous thromboembolism (VTE) (2.88%), postoperative transfusion (0.76%) and ROR with transfusion (0.44%). VTE increased with magnitude of hepatectomy (partial 2.13%, left 2.05%, right 4.15%, extended 5.76%; P < 0.001) and outnumbered bleeding events (P < 0.001). Other factors independently associated with VTE were aspartate aminotransferase (AST) ≥27 (P= 0.022), American Society of Anesthesiologists (ASA) class ≥3 (P < 0.001), operative time >222 min (P= 0.043), organ space infection (P < 0.001) and length of hospital stay ≥7 days (P= 0.004). VTE resulted in 30-day mortality of 7.4% vs. 2.3% with no VTE (P= 0.001). CONCLUSIONS Contrary to the belief that transient postoperative liver insufficiency is protective, VTE increases with extent of hepatectomy. VTE exceeds major bleeding events and is strongly associated with mortality. These data support routine post-hepatectomy VTE chemoprophylaxis.
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Affiliation(s)
- Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA
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Brown A. Preventing venous thromboembolism in hospitalized patients with cancer: improving compliance with clinical practice guidelines. Am J Health Syst Pharm 2012; 69:469-81. [PMID: 22382477 DOI: 10.2146/ajhp110187] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of anticoagulants for the prevention of venous thromboembolism (VTE) in hospitalized medical and surgical oncology patients is discussed. SUMMARY Hospitalized patients are often at risk for developing VTE, and risk is increased in patients who have cancer. Moreover, the incidence of VTE appears to be rising in hospitalized cancer patients, who have a 2.2-fold increased risk of mortality with a VTE compared with similar patients without VTE. The literature indicates that these patients are often inadequately anticoagulated, despite strong recommendations for prophylaxis. Although there are few studies that specifically address VTE prophylaxis in cancer patients, there are several large trials that have examined data in cancer subgroups. The trials have directly compared low-molecular-weight heparin (LMWH) with placebo, unfractionated heparin with LMWH, factor Xa inhibitor (fondaparinux) with placebo, and fondaparinux with LMWH. Three important guidelines provide current recommendations for VTE prophylaxis; the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American College of Chest Physicians (ACCP) recommend unfractionated heparin, LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications. Pharmacists can play an essential role in ensuring that VTE prophylaxis is appropriate for individual patients. Interventions to improve compliance with guidelines are particularly important now due to financial incentives from quality-focused organizations whose mandate is to decrease preventable mortality events in hospitals. CONCLUSION Hospitalized patients with cancer often do not receive appropriate thromboprophylaxis. Guidelines from ASCO, ACCP, and NCCN recommend unfractionated heparin, an LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications to such therapy.
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Blackburn T, Java K, Lowe D, Brown J, Rogers S. Safety of a regimen for thromboprophylaxis in head and neck cancer microvascular reconstructive surgery: non-concurrent cohort study. Br J Oral Maxillofac Surg 2012; 50:227-32. [DOI: 10.1016/j.bjoms.2011.03.265] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 03/22/2011] [Indexed: 11/25/2022]
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Reddy SK, Turley RS, Barbas AS, Steel JL, Tsung A, Marsh JW, Clary BM, Geller DA. Post-operative pharmacologic thromboprophylaxis after major hepatectomy: does peripheral venous thromboembolism prevention outweigh bleeding risks? J Gastrointest Surg 2011; 15:1602-10. [PMID: 21691924 DOI: 10.1007/s11605-011-1591-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Accepted: 06/10/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although standard of care after most abdominal surgeries, post-operative pharmacologic thromboprophylaxis after major hepatectomy is commonly withheld due to bleeding risks. The objective of this retrospective study is to evaluate the benefits and risks of post-operative pharmacologic thromboprophylaxis after major hepatectomy at two high volume academic centers. METHODS Demographics, clinicopathologic data, treatments, and post-operative outcomes from patients who underwent major hepatectomy were reviewed. RESULTS From 2005 to 2010, 419 patients underwent major hepatectomy; 275 (65.6%) were treated with pharmacologicthromboprophylaxis beginning a median of 1 day after resection. Post-operative symptomatic venous thromboembolism (VTE) occurred in 15 (3.6%) patients. Patients treated with pharmacologic thromboprophylaxis had lower rates of symptomatic VTE (2.2% vs. 6.3%, p = 0.03) and post-operative red blood cell (RBC) transfusion (16.7% vs. 26.4%, p = 0.02) with similar rates of overall RBC transfusion (35.0% vs. 30.6%, p = 0.36) compared to untreated patients. Specifically, isolated deep venous thrombosis (0% vs. 2.1%, p = 0.04) and pulmonary embolism (2.2% vs. 4.2%, p = 0.35) occurred less often in treated patients. Analysis of demographics, clinicopathologic data, and treatment factors revealed that pharmacologic thromboprophylaxis was the only variable associated with post-operative VTE. CONCLUSIONS Post-operative pharmacologic thromboprophylaxis lowers the incidence of symptomatic VTE after major hepatectomy without increasing the rate of RBC transfusion.
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Affiliation(s)
- Srinevas K Reddy
- University of Pittsburgh Medical Center, Liver Cancer Center, UPMC Montefiore 7 South, Pittsburgh, PA 15213, USA.
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Mohn AC, Egge J, Rokke O. Low Risk of Thromboembolic Complications After Fast-Track Abdominal Surgery With Thrombosis-Prophylaxis Only During Hospital Stay. Gastroenterology Res 2011; 4:107-113. [PMID: 27942324 PMCID: PMC5139815 DOI: 10.4021/gr320e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2011] [Indexed: 11/14/2022] Open
Abstract
Background Subcutaneous low molecular weight heparin (LMWH) reduces the risk of thromboembolic complications after abdominal surgery. With enhanced recovery after surgery (ERAS), median hospital stay after abdominal surgery may be as short as 3 - 4 days. The aim of our study was to investigate whether thrombosis prophylaxis during the short hospital stay was sufficient to maintain a low frequency of thromboembolic complications. Methods Ninety-eight patients, median age 67 years, were enrolled in a prospective two-center observational study of colorectal resections following the ERAS principles. Seventy-seven patients (78.6%) were resected for colonic cancer, the rest for benign colonic diseases. Fifty percent of the patients were discharged from hospital within three days after surgery. Follow-up examinations took place at 8 and 30 days after surgery with clinical examination for thromboembolism. The patients enrolled at one of the centers were also scheduled for a routine venography at day 8. Seventeen of these were evaluated. Results Clinical follow-up at day 8 of 72 patients (73.5%) revealed no venous thromboembolism (VTE), and the 17 venograms did not show any thromboses. Clinical follow-up at day 30 of 74 patients (75.5%) showed no deep venous thrombosis (DVT), whereas pulmonary embolus (PE) was suspected and verified in one patient (1.3%) with pulmonary metastases and pneumonia. Conclusions Prophylaxis until full mobilization seems to be sufficient following major surgery in patients treated with the principles of ERAS who remain in hospital for 3 - 4 days.
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Affiliation(s)
| | - Jon Egge
- Department of Radiology, Haugesund Hospital, Haugesund, Norway
| | - Ola Rokke
- Department of Surgery, Akershus University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
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Lesselroth BJ, Yang J, McConnachie J, Brenk T, Winterbottom L. Addressing the sociotechnical drivers of quality improvement: a case study of post-operative DVT prophylaxis computerised decision support. BMJ Qual Saf 2011; 20:381-9. [PMID: 21209144 PMCID: PMC3088464 DOI: 10.1136/bmjqs.2010.042689] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Quality improvement (QI) initiatives characterised by iterative cycles of quantitative data analysis do not readily explain the organisational determinants of change. However, the integration of sociotechnical theory can inform more effective strategies. Our specific aims were to (1) describe a computerised decision support intervention intended to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations; and (2) show how sociotechnical theory expressed in ‘Fit between Individuals, Task and Technology’ framework (FITT) can identify and clarify the facilitators and barriers to QI work. Methods A multidisciplinary team developed and implemented electronic menus with DVT prophylaxis recommendations. Stakeholders were interviewed and human factors were analysed to optimise integration. Menu exposure, order placement and clinical performance were measured. Vista tool extraction and chart review were used. Performance compliance pre-implementation was 77%. Results There were 80–110 eligible cases per month. Initial menu use rate was 20%. After barriers were classified and addressed using the FITT framework, use improved 50% to 90%. Tasks, users and technology issues in the FITT model and their interfaces were identified and addressed. Workflow styles, concerns about validity of guidelines, cycle times and perceived ambiguity of risk were issues identified. Conclusions DVT prophylaxis in a surgical setting is fraught with socio-political agendas, cognitive dissonance and misaligned expectations. These must be sought and articulated if organisations are to respond to internal resistance to change. This case study demonstrates that QI teams using information technology must understand the clinical context, even in mature electronic health record environments, in order to implement sustainable systems.
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Affiliation(s)
- Blake J Lesselroth
- Portland Oregon VA Medical Center, Oregon Health and Sciences University, Portland, Oregon, USA.
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Venous thromboembolism in the management of patients with musculoskeletal tumor. J Orthop Sci 2010; 15:810-5. [PMID: 21116900 DOI: 10.1007/s00776-010-1539-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 07/26/2010] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although patients with musculoskeletal tumors are at risk of venous thromboembolism (VTE), few detailed studies on the incidence, clinical course, and risk factors of this condition have been reported. METHODS A total of 299 patients with musculoskeletal tumors during the preceding 3 years were enrolled. D-dimer (DD) levels on admission and on postoperative days 1, 7, and 14 were routinely assessed. For patients who were receiving chemotherapy, an examination was performed every 2-3 days for the survey. Multidetector-row computed tomography (MDCT) was used for the detection of VTE in patients with DD levels > 10 μg/ml. The incidence of clinically detected VTE and the clinical courses of the patients with VTE were reviewed. The risk factors for VTE were analyzed. For statistical analysis, Fisher's exact test, the Mann-Whitney U-test, and logistic regression were used. RESULTS VTE was detected in eight cases (2.7%). Six cases were detected postoperatively, and the remaining two cases were detected during chemotherapy. Pulmonary embolism was evident in four cases. No VTE-related lethal events were detected during the study period. In the univariate analysis, malignancy (P = 0.003), chemotherapy (P = 0.004), plastic surgery (P = 0.006), tumor size (P = 0.008), and elevated DD levels at admission (P = 0.03) were found to be significant risk factors for VTE. Among these factors, the multivariate analysis indicated that tumor size (P = 0.00 006), plastic surgery (P 0. 01), and chemotherapy (P = 0.02) were independent risk factors. CONCLUSIONS The incidence and risk factors for VTE in the management of musculoskeletal tumor patients by screening DD levels combined with MDCT were analyzed. For patients at risk, prospective surveys for VTE should be considered in the future.
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Martin MJ, Blair KS, Curry TK, Singh N. Vena Cava Filters: Current Concepts and Controversies for the Surgeon. Curr Probl Surg 2010; 47:524-618. [DOI: 10.1067/j.cpsurg.2010.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Vivarelli M, Zanello M, Zanfi C, Cucchetti A, Ravaioli M, Gaudio MD, Cescon M, Lauro A, Montanari E, Grazi GL, Pinna AD. Prophylaxis for venous thromboembolism after resection of hepatocellular carcinoma on cirrhosis: Is it necessary? World J Gastroenterol 2010; 16:2146-50. [PMID: 20440855 PMCID: PMC2864840 DOI: 10.3748/wjg.v16.i17.2146] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the safety and effectiveness of prophylaxis for venous thromboembolism (VTE) in a large population of patients with hepatocellular carcinoma (HCC) on cirrhosis.
METHODS: Two hundred and twenty nine consecutive cirrhotic patients with HCC who underwent hepatic resection were retrospectively evaluated to assess whether there was any difference in the incidence of thrombotic or hemorrhagic complications between those who received and those who did not receive prophylaxis with low-molecular weight heparin. Differences and possible effects of the following parameters were investigated: age, sex, Child-Pugh and model for end-stage liver disease (MELD) score, platelet count, presence of esophageal varices, type of hepatic resection, duration of surgery, intraoperative transfusion of blood and fresh frozen plasma (FFP), body mass index, diabetes and previous cardiovascular disease.
RESULTS: One hundred and fifty seven of 229 (68.5%) patients received antithromboembolic prophylaxis (group A) while the remaining 72 (31.5%) patients did not (group B). Patients in group B had higher Child-Pugh and MELD scores, lower platelet counts, a higher prevalence of esophageal varices and higher requirements for intraoperative transfusion of FFP. The incidence of VTE and postoperative hemorrhage was 0.63% and 3.18% in group A and 1.38% and 1.38% in group B, respectively; these differences were not significant. None of the variables analyzed including prophylaxis proved to be risk factors for VTE, and only the presence of esophageal varices was associated with an increased risk of bleeding.
CONCLUSION: Prophylaxis is safe in cirrhotic patients without esophageal varices; the real need for prophylaxis should be better assessed.
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Abstract
Recent data suggest that patients with a malignancy have a seven-fold increased risk for venous thromboembolism (VTE) compared with those without cancer, suggesting that these patients may benefit from thromboprophylaxis. Mechanisms for the prevention of thromboembolism can be divided into two broad categories: mechanical and pharmacological. Although generally used in combination with pharmacotherapy, little evidence exists for the efficacy of mechanical modalities either in the broader population of patients at risk for VTE or for patients with cancer specifically. A recent study using graduated compression stockings (GCS) for thromboprophylaxis showed no support for the use of stockings in acute stroke patients. Established pharmacological modalities, including warfarin, unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and the factor Xa inhibitor fondaparinux, have been shown to reduce risk for VTE in general medical and surgical populations. In medical cancer patients, only limited data are available for the efficacy of thromboprophylaxis. In contrast, considerable evidence indicates that thromboprophylaxis is warranted in patients undergoing cancer surgery. The most recent evidence suggests that catheter-related thrombosis is not prevented by current pharmacological modalities. On 22 May 2009, a group of clinicians based in the United Kingdom (UK) met in London, UK, to evaluate recent data on cancer thrombosis. This article (the second of four) briefly reviews key data on the prevention of VTE in medical and surgical oncology patients, providing context for a brief transcript of the surrounding discussion and a consensus statement, developed by meeting attendees, on the implications of this information for UK clinical practice.
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Beyer-Westendorf J, Werth S, Halbritter K, Weiss N. Cancer in males and risk of venous thromboembolism. Thromb Res 2010; 125 Suppl 2:S155-9. [DOI: 10.1016/s0049-3848(10)70035-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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