Thromboprophylaxis

• Less trauma/minimal invasive techniques

• Less surgical stress

• Intraoperative goal-directed fluid therapy

• Less postoperative complications

• Early mobilization

• Short hospital stay

Methodology

A literature search has been undertaken using the various terms for ERP given above combined with various terms for VTE and VTE prophylaxis. Most studies on ERP have not been made to analyze postoperative VTE, and there are therefore several problems related to the focus of this article (Table 9.2). As recently pointed out by Neville et al. [2] and Nicholson et al. [3], the large literature on ERP is skewed by poor study design and quality. When these authors performed systematic searches only between 1 and 2 % of the identified papers could be included for qualitative synthesis.

Table 9.2.

Problem concerning ERP and VTE when analyzing the literature.

• Few studies with direct focus on VTE

• Various diagnoses and definitions

• Few (if any) RCTs on VTE

• Too small sample sizes in RCTs to study VTE

• Historical controls, center comparisons

• Pulmonary and respiratory complications not always defined (PE?)

• Autopsy rate

• Thromboprophylaxis not mentioned or “up to the surgeon”

• Time for follow-up varies

Results

The frequency of VTE after ERP without prophylaxis is virtually unknown, especially as the use of prophylaxis is often not reported or used in an unsystematic way, i.e., at the discretion of the surgeon in charge. In a review on laparoscopic cholecystectomy, Lindberg et al. [4] identified 60 publications with 153,832 patients without or with various prophylactic measures. The incidence of clinically diagnosed deep vein thrombosis (DVT) was 0.03 %, the incidence of pulmonary embolism (PE) 0.06 %, the incidence of fatal pulmonary embolism (FPE) 0.02 %, and the mortality 0.08 %. These results have recently been updated and verified [5]. In a Cochrane review [6], analyzing the short-term benefit of laparoscopic colorectal resection, 25 studies were identified, in six of which DVT was registered. The frequency was 0.6 % in 545 laparoscopically treated patients compared with 1.1 % in 535 with conventional open surgery.

Until spring 2014 there were 17 studies with a total of 13,783 patients (18–4718) concerning ERP and with VTE mentioned, none of them being a randomized trial (RCT) and in 9 there was no information on thromboprophylaxis. In the remaining eight studies acetyl salicylic acid, low molecular weight heparin (LMWH), unfractionated heparin, rivaroxaban, or leg compression were used in “high-risk” patients, high risk only rarely being defined. The surgical procedures were colorectal (8), arthroplasty (4), cystectomy (2), liver surgery (2), and esophageal surgery (1). From these studies it is hardly possible to draw any conclusions on the use of prophylaxis.

Husted et al. [7] analyzed 1977 consecutive patients operated on with knee or hip joint arthroplasty (2004–2008). Thromboprophylaxis with LMWH started postoperatively and continued until discharge. The length of stay decreased from 7.3 days to 3.1 days during this period and simultaneously VTE and death decreased. The authors concluded that the risk of clinical VTE with the fast-track regimen and short duration of thromboprophylaxis compared favorably with extended prophylaxis after conventional surgery (up to 4 weeks). These findings were further verified in a recent prospective cohort study (4924 patients) on fast-track hip and knee arthroplasty, where prophylaxis (LMWH or factor Xa inhibition) was used during hospitalization when length of stay was shorter than 5 days [8]. Again the incidence of VTE was very low and there was only one FPE (0.02 %). In another large observational study (with historical control), there was no difference in VTE between conventional surgery and ERP after hip and knee replacement, but thromboprophylaxis also changed between the two periods (from mechanical/aspirin to extended tinzaparin) [9], again showing the difficulty drawing conclusions from non-RCT with several potential biases.

In a similar but small registry study on fast-track laparoscopic resection for rectal cancer (102 patients), thromboprophylaxis was given as a combination of preoperatively instituted tinzaparin and graded compression stockings [10]. No clinical VTE was seen, two patients developed pneumonia (differential diagnosis towards PE not clear), and three patients died, none of VTE.

Table 9.3 summarizes how recent guidelines deal with thromboprophylaxis. The use of prophylaxis recommended in the guidelines is basically extrapolated from knowledge based on studies on conventional surgical procedures for a similar diagnosis.

Table 9.3.

Recommendations in recent guidelines and consensus reviews on ERP and thromboprophylaxis.

• Rectal/pelvic surgery [14, 15]

– Compression stockings and LMWH (4 weeks when increased risk)

• Pancreaticoduodenectomy [16]

– LMWH for 4 weeks. Mechanical measures added in high-risk patients

• Cystectomy for bladder cancer [17, 18]

– Compression stockings and LMWH (4 weeks in patients at high risk)

• ACCP and NICE guidelines do not distinguish ERP from conventional surgery [1, 19]

Discussion

There are several problems worth mentioning in the context of VTE and ERP. The main ones are summarized in Table 9.1. There are data from various types of studies that the risk of VTE is probably low or very low. There could be several reasons why the incidence of DVT postoperatively is decreasing, the explanation probably being complex and not fully understood. So the proportion of DVT after total knee replacement decreased significantly between 1993 and 2005, warfarin being used throughout [11]. An important factor, common to all surgeries, is early mobilization, the importance of which clearly shown after knee arthroplasty [12]. Mobilizing patients less than 24 h postoperatively versus on the second postoperative day reduced the incidence of DVT from 27.6 to 1.0 %!

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue