Shaheel M. Sahebally

Aspirin in the primary prophylaxis of venous thromboembolism in surgical patients

INTRODUCTION Venous thromboembolism (VTE) is a common complication in surgical patients, especially those undergoing lower limb orthopaedic procedures as well as oncological resectional surgery. Numerous studies have evaluated the role of acetylsalicylic acid (ASA, aspirin) in primary VTE prevention, with contradictory results reflected in divergent guidelines. We reviewed current evidence for ASA as primary VTE prophylaxis. METHODS English language studies meeting our inclusion criteria were retrieved from PubMed, EMBASE and Cochrane databases. Six studies (3 meta-analyses and 3 randomized trials) comparing ASA with placebo and 7 studies (1 meta-analysis, 5 randomized trials, and 1 prospective) comparing ASA with other anticoagulants were included in the final analysis. Retrospective studies and case reports were excluded. RESULTS ASA is more effective than placebo in primary VTE prevention. Although there is clinical equipoise when ASA is compared with other anticoagulants, studies specific to orthopaedic surgery suggest that ASA appears as effective as low molecular weight heparin (LMWH) and may reduce bleeding risk. Extended prophylaxis up to 4 weeks post surgery reduces VTE episodes. CONCLUSIONS ASA may be considered as a potential strategy in primary VTE prophylaxis in orthopaedic patients at high-risk of bleeding complications. Further studies comparing ASA with LMWH/oral anticoagulants in primary thromboprophylaxis following non-orthopaedic surgery are warranted.

Metastatic breast cancer presenting as a gallstone ileus

Metastatic breast cancer to the small bowel (SB) presenting as gallstone ileus and resulting in SB obstruction has not been described previously. A 76-year-old woman with previous metastatic breast cancer to the axial spine and hips presented with abdominal pain and bilious vomiting. CT scanning revealed SB obstruction consistent with gallstone ileus. The patient underwent two segmental SB resections for distal ileal strictures mimicking what appeared to be macroscopic Crohns disease. The entero-biliary fistula was undisturbed. Pathological analysis revealed the dual pathologies of gallstone ileus and metastatic carcinoma from a breast primary causing luminal SB obstruction. Improvements in staging and treatment modalities have contributed to the increased overall long-term survival for breast cancer, compelling clinicians to consider metastatic breast cancer as a differential diagnosis in women presenting with new onset of gastrointestinal symptoms in order that appropriate treatment be administered in a timely fashion.