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Dual mechanical and pharmacological thromboprophylaxis decreases risk of pulmonary embolus after laparotomy for gynecologic malignancies
  1. Julie My Van Nguyen1,
  2. Lilian T Gien2,
  3. Allan Covens2,
  4. Rachel Kupets2,
  5. Raymond J Osborne2,
  6. Mahsa Sadeghi3,
  7. Avery B Nathens4 and
  8. Danielle Vicus2
  1. 1Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
  2. 2Gynecologic Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
  3. 3Division of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  4. 4Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  1. Correspondence to Dr Danielle Vicus, Gynecologic Oncology, Odette Cancer Centre, Toronto, ON M5S 1A8, Canada; danielle.vicus{at}sunnybrook.ca

Abstract

Objectives Patients with gynecologic malignancies have high rates of post-operative venous thromboembolism. Currently, there is no consensus for peri-operative thromboprophylaxis specific to gynecologic oncology. We aimed to compare rates of symptomatic pulmonary embolus within 30 days post-operatively, and to identify risk factors for pulmonary embolus.

Methods The Division of Gynecologic Oncology at Sunnybrook Health Sciences Centre implemented dual thromboprophylaxis for laparotomies in December 2017. We conducted a prospective study of laparotomies for gynecologic malignancies from December 2017 to October 2018, with comparison to historical cohort from January 2016 to November 2017 using the institutional National Surgical Quality Improvement Program database (NSQIP). Pre-intervention, patients received low molecular weight heparin during admission and extended 28-day prophylaxis was continued at the surgeon’s discretion. Post-intervention, all patients received both mechanical thromboprophylaxis with sequential compression devices during admission and 28-day prophylaxis with low molecular weight heparin.

Results There were 371 and 163 laparotomies pre- and post-intervention, respectively. Patient characteristics (age, body mass index, diabetes, smoking, tumor stage), rate of malignant cases, operative blood loss and duration, and length of stay were similar between groups. After implementation, pulmonary emboli rates decreased from 5.1% to 0% (p=0.001). There were more cytoreductive procedures pre-intervention (p≤0.0001) but surgical complexity scores were similar (p=0.82). Univariate analysis revealed that surgery pre-intervention (OR 4.25, 95% CI 1.04 to 17.43, p=0.04), length of stay ≥5 days (OR 11.94, 95% CI 2.65 to 53.92, p=0.002), and operative blood loss ≥500 mL (OR 2.85, 95% CI 1.05 to 7.8, p=0.04) increased risk of pulmonary embolus. On multivariable analysis, surgery pre-intervention remained associated with more pulmonary emboli (OR 4.16, 95% CI 1.03 to 16.79, p=0.045), when adjusting for operative blood loss.

Conclusion Dual thromboprophylaxis after laparotomy significantly reduced rates of pulmonary embolus in this high-risk patient population.

  • venous thromboembolism
  • pulmonary embolism
  • postoperative care
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Footnotes

  • Contributors Study conception and design: JMVN, MS, ABN, DV. Design of deep vein thrombosis (DVT) prevention strategy: JMVN, MS, ABN, DV. Implementation of DVT prevention strategy: all authors contributed to implementation. Acquisition of data: JMVN, MS, DV. Analysis and interpretation of data: JMVN, DV. Drafting of manuscript: JMVN, DV. Critical revision: all authors contributed to critical revision. Study supervision: DV.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Not applicable.

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