Program to reduce venous thromboembolism rates after surgery

Program to reduce venous thromboembolism rates after surgery | Image Credit: © rh2010 - © rh2010 - stock.adobe.com.

According to a recent study published in the American Journal of Obstetrics & Gynecology, prophylactic heparin and extended venous thromboembolism are safe for use in gynecologic surgeries.

Venous thromboembolism, a severe and potentially life-threatening condition, is seen in 3% to 38% of women with gynecologic malignancy and 1% to 17% of women after complex gynecologic surgery. Treatment of subcutaneous unfractionated heparin or low-molecular-weight heparin (LMWH), as well as mechanical prophylaxis and early return to ambulation, may reduce venous thromboembolism risk.

To increase the speed of recovery after surgery, an Enhanced Recovery After Surgery (ERAS) program is often employed. Patients in an ERAS program reduce venous thromboembolism risk using mechanical and pharmacologic prophylaxes, and experience a shorter median time to return to mild or no interference with walking.

There is a lack of data on the rate of venous thromboembolism following gynecologic surgery through an ERAS program. Investigators conducted a study to determine the rate of venous thromboembolism in the 30 days following gynecologic surgery on an ERAS pathway.

Participants included women receiving an open and minimally invasive gynecologic surgery for malignant and benign indications from November 3, 2014, to March 31, 2021. All surgeries were performed under an ERAS pathway program. Exclusion criteria included receiving emergency surgery, surgery with multiple teams from different specialties, and therapeutic anticoagulation before surgery.

Data obtained from patient medical records included patient demographics and comorbidities, smoking status, oncologic diagnosis, preoperative hemoglobin and platelet values, preoperative venous thromboembolism prophylaxis receipt, ERAS preoperative pathway medications, and intraoperative outcomes. Prolonged surgery time was defined as a surgical time of 3 hours.

The Aletti score was used to calculate surgical complexity, with a score of 3 or less indicating low complexity, 4 to 7 medium complexity, and 8 or above high complexity. Both symptomatic and asymptomatic venous thromboembolisms were included, while arterial thrombosis was not included.

Surgeries were performed at The University of Texas MD Anderson Cancer Center, which began its ERAS program for open surgeries in 2014 and expanded it to include minimally invasive surgery in 2017. Subcutaneous heparin 5000 units was recommended before surgery for patients receiving open surgery, and ambulation was recommended on the same day as surgery.

Venous thromboembolism prophylaxis included subcutaneous LMWH of enoxaparin 40 mg daily and was given for 28 days to patients with malignancy who had a laparotomy. Sequential compression devices were recommended for all patients during surgery.

There were 3329 patients in the final analysis, 43.6% of which underwent a laparotomy, 43.8% a laparoscopy, and 10.8% a robotic procedure. Venous thromboembolism was seen in 0.8% of participants, 1.1% of the open approach group, and 0.3% of the minimally invasive approach group.

Venous thromboembolism rates were 0.9% for patients with malignancy, 0.3% for benign indications, and 0% for borderline histology. Among the 21 patients with venous thromboembolism, 22 deep venous thromboembolism or pulmonary embolism events were observed, with 59.1% being deep venous thromboses and 40.9% being pulmonary emboli.

Rates of venous thromboembolism did not differ based on surgery type in patients with benign indications. A standard prophylaxis with subcutaneous heparin prophylaxis was given to 94.3% of patients undergoing a laparotomyprior to surgery. Those who did not receive heparin had an unexpected conversion from minimally invasive surgery.

Of patients who received minimally invasive surgery, 35.9% spent at least 1 night in the hospital and 23.2% received subcutaneous LMWH during admission. Venous thromboembolism prophylaxis was not seen in patients who received minimally invasive surgery after discharge. Intraoperative blood transfusion was performed in 5.4% of patients.

These results indicated safety from using prophylactic heparin before surgery and extended venous thromboembolism prophylaxis after open surgery. Investigators recommended these risk factors be considered in the decision-making process.

Reference

Taylor JS, Iniesta MD, Zorrilla-Vaca A, Cain KE.Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery. American Journal of Obstetrics & Gynecology. 2023;229(2). doi:10.1016/j.ajog.2023.04.045