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Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis
  1. Steven Bisch1,
  2. Rachelle Findley1,
  3. Christina Ince1,
  4. Maria Nardell2 and
  5. Gregg Nelson1
  1. 1Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
  2. 2Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Rachelle Findley, Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; rachelle.findley{at}albertahealthservices.ca

Abstract

Introduction Venous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic thromboprophylaxis pre-operatively. The aim of this meta-analysis was to assess the role of pre-operative pharmacologic thromboprophylaxis in preventing post-operative venous thromboembolism.

Methods PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials were searched to find randomized controlled, cohort, and case–control trials comparing pre-operative pharmacologic thromboprophylaxis to no prophylaxis, mechanical prophylaxis, or only post-operative pharmacologic thromboprophylaxis for open and minimally invasive major gynecologic surgery (benign and malignant conditions). Two authors independently assessed abstracts, full-text articles, and methodological quality. Data were extracted and pooled using ORs for random effects meta-analysis. Heterogeneity was explored using forest plots, Q-statistic, and I2 statistics. Planned subgroup analysis of use of sequential compression devices, equivalent versus non-equivalent post-operative prophylaxis, cancer diagnosis, and methodological quality were performed.

Results Some 503 unique studies were found, and 16 studies (28 806 patients) were included in the systematic review. Twelve studies (14 273 patients) were included in the meta-analysis. The OR for incidence of post-operative venous thromboembolism was 0.59 (95% CI 0.39, 0.89), favoring pre-operative pharmacologic thromboembolism prophylaxis compared with no pre-operative pharmacologic prophylaxis (Q=13.80, I2=20.30). In studies where post-operative care was equivalent between groups, the OR for venous thromboembolism was 0.56 (95% CI 0.22, 1.40). Pre-operative pharmacologic prophylaxis demonstrated greatest benefit when utilized with both intra-operative and post-operative sequential compression devices (OR 0.43, 95% CI 0.30, 0.64) compared with when no sequential compression devices were utilized (OR 1.27, 95% CI 0.63, 2.56). When looking at only studies determined to be of high quality, the results no longer reached significance (OR 0.73, 95% CI 0.36, 1.46).

Conclusions Pre-operative pharmacologic thromboprophylaxis decreases the odds of venous thromboembolism in the peri-operative period for major gynecologic oncology surgery by approximately 40%. It remains unclear whether this benefit is present in benign and minor procedures. Adequately powered studies are needed.

  • venous thromboembolism
  • surgery
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Footnotes

  • SB and RF are joint first authors.

  • Contributors All authors reviewed the article for its content and editing. SB and MN formulated the idea for the systematic review and meta-analysis and contributed to the literature review, data collection, preparation, and editing of the article. RF and CI contributed to the literature review, data collection, preparation, and editing of the article. GN contributed to the review and editing of the article.

  • Funding This article has arisen, in whole or in part, from direct costs funded by the National Institutes of Health (“NIH”), and is subject to the National Institutes of Health’s Revised Policy on Enhancing Public Access to Archived Publications Resulting from National Institutes of Health-Funded Research, NOT-OD-08-033 (the “Policy”). As a result, the author retains the rights necessary to comply with the Policy, including the right to submit, or have submitted to the National Library of Medicine’s PubMed Central, an electronic version of the final, peer-reviewed manuscript no later than 12 months after the official date of publication. If this not acceptable, we request that the Journal notify the author. This publication was made possible by Grant Number T32 AI007433 from the National Institute of Allergy and Infectious Diseases and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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