Extended versus inpatient thromboprophylaxis with heparins following major open abdominopelvic surgery for malignancy: a systematic review of efficacy and safety

B Heijkoop,S Nadi,G Kiroff,D Spernat

doi:10.1186/s13741-020-0137-8

Abstract

BackgroundPatients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; however, optimum duration in this population remains unknown. Our objective was to conduct a systematic review of contemporary literature on the use of heparin thromboprophylaxis following major open pelvic surgery for malignancy, comparing the efficacy and safety of extended duration to inpatient treatment.MethodsA study protocol describing search strategy and inclusion and exclusion criteria was developed and registered with PROSPERO. A literature review was conducted in accordance with the protocol.ResultsLiterature review identified only 4 studies directly comparing extended and inpatient duration prophylaxis, with a combined population of 3198 and 3135 patients for VTE rate and bleeding events, respectively. Despite many studies reporting lower VTE rates in patients receiving extended prophylaxis, no statistically significant difference in rates of postoperative VTE (p = 0.18) or bleeding complications (p = 0.43) was identified between patients receiving extended duration prophylaxis and those receiving inpatient only prophylaxis.ConclusionOn the review of contemporary literature, no significant difference was found in rates of postoperative VTE or bleeding complications between patients receiving extended duration heparin VTE prophylaxis and those receiving inpatient prophylaxis after open abdominopelvic surgery for malignancy.This raises the question of how extended duration prophylaxis has become common practice in this population, and whether this needs to be re-evaluated.

Highlights

Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE)
Despite consensus that the risk of VTE extends for a significant period postoperatively, to date, literature reviews have found insufficient evidence to determine an exact time frame for this, and have not been able to make an evidence-based recommendation for the optimum duration of prophylaxis (Violetti et al 2016)
- Only 3 randomized controlled trials identified - Heterogeneity from inclusion of different types of surgeries, 3 studies allowed inclusion laparoscopic interventions - Insufficient data on specific cancer types and stages; individualized recommendations cannot be derived from data - Open label nature of some included studies; associated bias in patient symptom reporting and physician suspicion of VTE

Summary

Introduction

Patients undergoing open abdominopelvic procedures for malignancy are at high risk of postoperative venous thromboembolism (VTE). This risk can be mitigated with prophylaxis; optimum duration in this population remains unknown. A major risk factor for VTE is type of surgery, with patients undergoing major oncological surgery or pelvic surgery being at significant risk (Violetti et al.2016) These patients frequently have additional non-modifiable risk factors for VTE including advanced age, limited mobility, previous VTE, or hereditary prothrombotic disorders. These risks can be mitigated by using prophylaxis. There does not appear to be a consistent pattern of the use of postoperative pharmacological VTE prophylaxis in pelvic oncological surgery patients

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