Diagnosis of VTE postdischarge for major abdominal and pelvic oncologic surgery: implications for a change in practice

Abstract

Background: Extended thromboprophylaxis after hospital discharge following cancer surgery has been shown to reduce the incidence of venous thromboembolism (VTE); however, this practice has not been universally adopted. We conducted a populationbased analysis to determine the proportion of patients with symptomatic VTE diagnosed within 90 days after initial discharge following major abdominopelvic cancer surgery who might have benefited from extended thromboprophylaxis. Methods:We used the Manitoba Cancer Registry to identify patients who underwent major abdominopelvic cancer surgery between 2004 and 2009. The proportion in whom VTE was diagnosed during the initial hospital stay was determined by accessing the Hospital Separations Abstracts. The proportion in whom VTE was diagnosed after discharge was determined by examining repeat admissions within 90 days and by accessing Drug Programs Information Network records for newly prescribed anticoagulants. Detailed tumour and treatment-specific data allowed calculation of VTE predictors.Results: Of 6612 patients identified, 106 (1.60%) had VTE diagnosed during the in itial stay and 96 (1.45%) presented with VTE after discharge. Among patients in whom VTE developed after discharge, 33.3% had a pulmonary embolus, 24% had deep vein thrombosis, and 6.3% had both. Predictors of presenting with VTE after discharge within 90 days of surgery included advanced disease, presence of other complications, increased hospital resource utilization, primary tumours of noncolorectal gastrointestinal origin and age younger than 45 years. The development of VTE was an independent predictor of decreased 5-year overall survival. Conclusion:The cumulative incidence of VTE within 90 days of major abdominopelvic oncologic surgery was 3.01%, with about half (1.45%) having been diagnosed within 90 days after discharge.Contexte : La thromboprophylaxie prolongée après le congé hospitalier suite à une chirurgie pour cancer a permis de réduire l'incidence de la thrombo-embolie veineuse (TEV); or, cette pratique n'a pas été universellement adoptée. Nous avons procédé à une analyse de population afin de déterminer la proportion de patients qui ont reçu un diagnostic de TEV symptomatique dans les 90 jours suivant leur congé à la suite d'une chirurgie majeure pour cancer abdomino-pelvien et qui auraient pu bénéficier d'une thromboprophylaxie prolongée.

Facing the challenge of venous thromboembolism prevention in patients undergoing major abdominal surgical procedures for gastrointestinal cancer

“…However, the use of NOACs for VTE prophylaxis is certainly debatable. Potential drug interactions with chemotherapeutic components, GI abnormalities, and hepatic and renal insufficiency remain significant determinants of NOAC administration[ 43 - 45 ]. Therefore, bioavailability may not reach desirable levels[ 46 ].…”

Implementation of a Comprehensive Post-Discharge Venous Thromboembolism Prophylaxis Program for Abdominal and Pelvic Surgery Patients

“…16,21 The risk of VTE, however, extends beyond discharge: at least 30% to 50% of postoperative VTE events occur in the outpatient setting. 2,3,6,7 Patients with underlying malignancy or IBD are at particularly elevated risk. 3,6 Despite more than a decade of strong evidence to support its use, post-discharge prophylaxis remains under-used in practice.…”

“…4,5 Critically, however, at least 30% to 50% of VTEs occur after discharge for patients undergoing abdominal surgery for malignancy or IBD. 2,3,6,7…”

Thromboprophylaxis in Elderly Surgical Patients: Current State and Future Considerations

“…From observational/retrospective studies, it has been shown that the risk of thromboembolic events remains high for at least 30 days postoperatively and even up to 3 months after discharge. The ratio can be even 10-50 times higher compared to controls and a retrospective review of medical records for newly discharged surgical patients revealed that more patients presented to hospital with signs and symptoms of VTE in the first 3/12 after their discharge compared to the number of inpatients diagnosed (39,40). In another similar study the mean time to DVT was approximately 65 days after discharge (25).…”