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  • 2022-RA-933-ESGO Risk of venous thromboembolism and major bleeding in gynaecological cancer surgery: series of systematic reviews and meta-analyses

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2022-RA-933-ESGO Risk of venous thromboembolism and major bleeding in gynaecological cancer surgery: series of systematic reviews and meta-analyses
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  1. Lauri I Lavikainen1,
  2. Gordon Guyatt2,3,
  3. Anna L Luomaranta4,
  4. Rufus Cartwrigth5,
  5. Ilkka EJ Kalliala4,6,
  6. Rachel J Couban7,
  7. Riikka L Aaltonen8,
  8. Karoliina M Aro4,
  9. Jovita L Cárdenas9,
  10. PJ Devereaux2,3,10,11,
  11. Päivi J Galambosi4,
  12. Fang Zhou Ge12,
  13. Alex LE Halme1,
  14. Jari Haukka13,14,
  15. Matthew L Izett-Kay15,
  16. Kirsi M Joronen8,
  17. Päivi K Karjalainen16,17,
  18. Nadina Khamani18,19,
  19. Carolina Nystén20,
  20. Sanna M Oksjoki21,
  21. Negar Pourjamal22,
  22. Tino Singh17,
  23. Riikka M Tähtinen23,
  24. Robin WM Vernooij24,25,
  25. Philippe D Violette2 and
  26. Kari AO Tikkinen19,26
  1. 1Faculty of Medicine, University of Helsinki, Helsinki, Finland
  2. 2Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
  3. 3Department of Medicine, McMaster University, Hamilton, ON, Canada
  4. 4Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
  5. 5LNWH NHS Trust, London, UK
  6. 6Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
  7. 7McMaster University, Hamilton, ON, Canada
  8. 8Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
  9. 9National Center for Health Technology Excellence (CENETEC) Direction of Health Technologies assessment, Mexico City, Mexico
  10. 10Population Health Research Institute, Hamilton, ON, Canada
  11. 11Outcomes Research Consortium, Cleveland, OH
  12. 12Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
  13. 13Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
  14. 14Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
  15. 15Urogynaecology Department, The John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
  16. 16Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyväskylä, Finland
  17. 17Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
  18. 18Department of Obstetrics and Gynecology, Institute of Childrens’ Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
  19. 19Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
  20. 20University of Helsinki, Helsinki, Finland
  21. 21Felicitas Mehiläinen Turku, Turku, Finland
  22. 22Laboratory of Molecular Oncology, Faculty of Medicine, University Helsinki, Helsinki, Finland
  23. 23Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
  24. 24Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
  25. 25Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
  26. 26Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland

Abstract

Introduction/Background Pharmacological thromboprophylaxis involves balancing lower risk of venous thromboembolism (VTE) against higher risk of bleeding, a trade-off that critically depends on VTE and bleeding risks in the absence of prophylaxis (baseline risk). Baseline risks likely vary between procedures, but their magnitude remains uncertain. At least in part due to uncertainty regarding baseline risks in gynaecological cancer surgery, thromboprophylaxis practices vary substantially within and between countries.

Methodology We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. We identified observational studies reporting symptomatic VTE or major bleeding (bleeding requiring reoperation, bleeding leading to transfusion, or Hb <70g/L) after gynaecological cancer surgery. Furthermore, we performed separate searches for randomised trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice. We adjusted the reported risk estimates for thromboprophylaxis and follow-up length to determine baseline cumulative incidence at 4 weeks post-surgery for each procedure. We stratified VTE risk by patient risk factors as low (no patient risk factors), medium (age >75, BMI >35, or VTE in a 1st degree relative), or high (any combination or personal VTE history). We used the GRADE approach to rate evidence certainty.

Results We identified 7,556 titles and abstracts, of which 188 proved eligible, reporting on 37 gynaecological cancer surgery procedures. The quality of evidence was generally very low or low. 4-week risks of major bleeding and especially of VTE varied widely between procedures, and between approaches within the same procedure (tables 1–2).

View this table:
Abstract 2022-RA-933-ESGO Table 1

4-week postoperative risk of symptomatic venous thromboembolism (VTE) and bleeding requiring reoperation (BRR) after certain gynaecological cancer procedures

View this table:
Abstract 2022-RA-933-ESGO Table 2

4-week postoperative risk of symptomatic venous thromboembolism (VTE) and bleeding requiring reoperation (BRR) after hysterectomy for malignant disease

Conclusion Our results suggest that extended thromboprophylaxis is warranted in many gynaecological cancer procedures, such as ovarian cancer surgery, total hysterectomy with lymphadenectomy and radical hysterectomy. In some procedures, such as laparoscopic total hysterectomy without lymphadenectomy, the risks of VTE and bleeding are closely balanced. In these cases, decisions depend on individual risk prediction and patient values and preferences.

https://doi.org/10.1136/ijgc-2022-ESGO.420

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