Morten S. Rasmussen

Prolonged thromboprophylaxis with Low Molecular Weight heparin for abdominal or pelvic surgery

BACKGROUNDnMajor abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low-molecular weight heparin (LMWH) administered during the in-hospital period is well documented, but the optimal duration of thromboprophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominal surgery benefit from prolongation of the thromboprophylaxis to 1 month after surgery. No systematic review on prolonged thromboprophylaxis after major abdominal or pelvic surgery has been published.nnnOBJECTIVESnTo evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 1 month after abdominal or pelvic surgery with thromboprophylaxis administered during the in-hospital period only in preventing late VTE.nnnSEARCH STRATEGYnElectronic searches were performed January 2008 in the Medline, Embase, Lilacs, and the Cochrane Central Register of Controlled Trials. Abstract books from major congresses addressing thromboembolism were hand searched, as were reference lists from studies of relevance.nnnSELECTION CRITERIAnWe assessed both randomised and non-randomised controlled clinical trials comparing prolonged thromboprophylaxis with any anti-thrombotic agent with placebo and/or thromboprophylaxis during the admission period only. The patient population in the trials were patients undergoing abdominal or pelvic surgery. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (ascending bilateral venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral CT scan or autopsy). Studies exclusively reporting on clinical diagnosis of VTE, without objective confirmation were excluded.nnnDATA COLLECTION AND ANALYSISnThe identification of studies and data extraction were performed by the authors. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcome were defined as bleeding complications and mortality within 3 months after surgery.nnnMAIN RESULTSnThe search exclusively detected trials evaluating prolonged thromboprophylaxis with LMWH as compared to control or placebo. 133 studies were found in the searches, of which only 4 were found eligible for inclusion, and 129 were excluded. The incidence of overall VTE after major abdominal or pelvic surgery was 14.3% (95% confidence interval 11.2% - 17.8%) in the control group as compared to 6.1% (95% CI 4.0% - 8.7%) in the patients receiving out-of-hospital LMWH. This difference was statistically significant, Peto Odds Ratio 0.41 (95% CI 0.26 -0.63), P < 0.0005. Prolonged thromboprophylaxis with LMWH was also associated with a statistically significant reduction of even the incidence of symptomatic VTE from 1.7% (95% CI 0.8% - 3.4%) in the control group to 0.2 % (95% CI 0.0% - 1.2%) in patients receiving prolonged thromboprophylaxis, Peto Odds ratio 0.22 (95% CI 0.06 -0.80), P = 0.02. The respective incidence of bleeding in the control and LMWH group were 3.7% (95% CI 2.4% -5.5%) and 4.1% (95% CI 2.7% - 6.0%), Peto Odds ratio 1.11 (95% CI 0.62 - 1.97), P = 0.73. There was no significant heterogeneity detected as regards to outcome parameters reported in the included trials.nnnAUTHORS CONCLUSIONSnProlonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery.

Heparins and mechanical methods for thromboprophylaxis in colorectal surgery.

BACKGROUNDnColorectal surgery implies higher risk of postoperative thromboembolic complications as deep venous thrombosis (DVT) and pulmonary embolism (PE) than general surgery. The best prophylaxis in general surgery is heparin and graded compression stockings. No systematic review on combination prophylaxis or on thrombosis prophylaxis in colorectal surgery has been published.nnnOBJECTIVESnTo compare the incidence of postoperative thromboembolism after colorectal surgery using prophylactic methods focussing on heparins and mechanical methods alone and in combinations.nnnSEARCH STRATEGYnElectronic searches was performed in MEDLINE, EMBASE back to 1970. Abstract books from major congresses were handsearched as were reference lists from previously performed reviews.nnnSELECTION CRITERIAnRCT or CCT comparing prophylactic interventions and/or placebo. Outcomes were ascending venography, 125 I-fibrinogen uptake test, ultrasound methods, pulmonary scintigraphy. Studies, using thermographic methods, other isotopic methods, plethysmographic methods, and purely clinical methods as the only diagnostic measure were excluded. 558 studies were identified - 477 were excluded. Only 3 of the identified studies focused exclusively on colorectal surgery. Studies of general surgery contain considerable numbers of colorectal patients. The authors of 66 studies in general and/or abdominal surgery were contacted for retrieving the results from the colorectal patients. Answers were received from very few. 19 studies entered this review.nnnDATA COLLECTION AND ANALYSISnAll studies and all data extraction were performed independently by at least two of the authors. Outcome was deep venous thrombosis and/or pulmonary embolism. Analysis of bleeding complications were unfeasible. 12 meaningful outcomes were analysed by means of the fixed effects model with Peto Odds Ratios.nnnMAIN RESULTSnHeparins versus no treatment: Any kind of heparincompared to no treatment or placebo (comparison 07.03, 11 studies). Heparin is better in preventing DVT and/or PE with a Peto Odds ratio at 0.32 (95% Confidence Interval 0.20-0.53) Unfractionated heparin versus low molecular weight heparin (comparison 08.03, 4 studies). The two treatments were found equally effective in preventing DVT and/or PE with a Peto Odds ratio 1.01 (95% Confidence Interval 0.67-1.52). Mechanical methods (comparison 10.3, 2 studies). The combination of graded compression stockings and LDH is better than LDH alone in preventing DVT and/or PE with a Peto Odds ratio at 4.17 (95% Confidence Interval 1.37-12.70).nnnREVIEWERS CONCLUSIONSnThe optimal prophylaxis in colorectal surgery is the combination of graduated compression stockings and low-dose unfractionated heparin. The unfractionated heparin can be replaced with low molecular weight heparin.

Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis

OBJECTIVEnTo study the incidence of late deep venous thrombosis (DVT), and to evaluate a regimen of prolonged thromboprophylaxis after general surgery.nnnDESIGNnRandomised, controlled, open trial, with blinded evaluation.nnnSETTINGnUniversity hospital, Denmark.nnnSUBJECTSn176 consecutive patients undergoing major elective abdominal or non-cardiac thoracic operations, of whom 118 were eligible for evaluation.nnnINTERVENTIONSnThromboprophylaxis with a low-molecular-weight heparin, tinzaparin, given for four weeks (n = 58), compared with one week (control group, n = 60).nnnMAIN OUTCOME MEASURESnPresence of DVT established by bilateral venography four weeks after the operation.nnnRESULTSnThe incidence of late DVT in the control group was 6/60 (10%, 95% confidence interval (CI) 4% to 21%). In the prophylaxis group it was 3/58 (5.2%, 95% CI 1% to 14%) (p = 0.49).nnnCONCLUSIONnProlonged thromboprophylaxis had no significant effect on the incidence of DVT occurring late after general surgery.

Preventing thromboembolic complications in cancer patients after surgery: a role for prolonged thromboprophylaxis

Patients undergoing major abdominal surgery for malignancy are at particularly high risk of developing VTE. Extra protection against this can be given to patients with cancer by using a higher dose of LMWH than normally used for prophylaxis, with no increase in bleeding complications. Despite thromboprophylaxis with high-dose LMWH for the first postoperative week, the rate of late VTE is estimated to be between 10% and 20%. A meta-analysis of two studies using dalteparin or enoxaparin has shown that prolonging thromboprophylaxis for a further 3 weeks significantly reduces the risk of late occurring VTE by 62%. Thromboprophylaxis with LMWH for at least one month should be considered in patients undergoing surgery for malignant disease.

Systematic review of thromboprophylaxis in colorectal surgery -- an update.

Objectiveu2002 The incidence of thromboembolism after colorectal surgery is higher than after general surgery. The aim of this paper is to update a systematic review addressing thrombosis prophylaxis in connection with colorectal surgery.

Does prolonged thromboprophylaxis improve outcome in patients undergoing surgery

Patients undergoing major abdominal surgery, particularly for malignancy, are at increased risk of venous thromboembolism. Haemostatic markers of coagulation are raised for several weeks after surgery. A higher dose of low-molecular-weight heparin than normally used for thromboprophylaxis is effective in preventing post-surgical VTE in patients with cancer with no compromise on bleeding. Four weeks of thromboprophylaxis with the LMWH dalteparin is significantly more effective than standard (1 week) thromboprophylaxis in preventing proximal DVT. A meta-analysis of studies comparing 4 weeks with 1 week of thromboprophylaxis showed that prolonged thromboprophylaxis with LMWH following major abdominal surgery for malignancy significantly reduces the risk of late occurring DVT.

No effect on survival of home psychosocial intervention in a randomized study of Danish colorectal cancer patients

Objective: We investigated whether regular home visits to persons with newly diagnosed colorectal cancer influenced their overall survival and selected immune parameters.

What is the role for antithrombotics in cancer care? Interactive session with panel discussion.

Two case scenarios presenting clinical conundrums in thrombosis management were outlined. Some of the clinical management issues discussed were voted on by the audience and then commented on by the panel. The first case addressed the use of thromboprophylaxis in surgical patients with cancer in the event of bleeding complications. The second case addressed issues in the treatment of venous thromboembolism (VTE) in patients with cancer.

Triage for selection to colonoscopy

Implementation of population screening for colorectal cancer by direct colonoscopy or follow-up colonoscopy after a positive fecal blood test has challenged the overall capacity of bowel examinations. Certain countries are facing serious colonoscopy capacity constraints, which have led to waiting lists and long-time latency of follow-up examinations. Various options for improvement are considered, including increased cut-off values of the fecal blood tests. Results from major clinical studies of blood-based, cancer-associated biomarkers have led to focus, however, on a triage concept for improved selection to colonoscopy. The triage test may include subject age, concentration of hemoglobin in a feces test and a combination of certain blood-based cancer associated biomarkers. Recent results have indicated that triage may reduce the requirements for colonoscopy by around 30%. Such results may be advantageous for the capacity, the heath budgets and in particular, the subjects, who do not need an unnecessary, unpleasant and risk-associated bowel examination.

Three years of colorectal cancer screening in Denmark

BACKGROUNDnThe Danish National Colorectal Cancer Screening Programme was implemented in March 2014 and is offered free of charge to all residents aged 50-74 years. The aim of this study is to compare performance indicators from the Danish National Colorectal Cancer Screening Programme to the recommendations from European Guidelines in order to assure the quality of the programme and to provide findings relevant to other population-based colorectal cancer screening programmes.nnnMETHODSnBased on data from the Danish Colorectal Cancer Screening Database, we evaluated all performance indicators for which the European Guidelines provided acceptable level, desirable level or the level from first screening rounds in population-based studies using FIT.nnnRESULTSnAll performance indicators were above the acceptable level and/or in line with the level from the first screening round in population-based studies using FIT. Whenever the European Guidelines provided a desirable level for a performance indicator, the Danish National Colorectal Cancer Screening Programme was close to or above this desirable level.nnnCONCLUSIONSnCompared to the European Guidelines, all performance indicators were above the acceptable level and close to the desirable level. Based on these findings, the implementation of the National Danish Colorectal Cancer Screening Programme is considered a success and the programme is hopefully in the process of reducing colorectal cancer morbidity and mortality in Denmark. This study provides relevant information for comparisons to other population-based public service colorectal cancer screening programmes as well as for future revisions of guidelines.