Skip to main content
SpringerLink
Log in

Venous thromboembolism in patients with cancer undergoing surgical exploration

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

Malignancy and surgery are both independent risk factors for venous thromboembolism (VTE) events. The current NCCN guidelines recommend VTE prophylaxis for up to 28 days after major abdominal or pelvic surgery for malignancy. We set out to evaluate the rate and timing of VTEs among patients with gastric, pancreatic, colorectal, and gynecologic malignancies who underwent surgery. We performed a retrospective review of the NSQIP database (2005–2013) focusing on patients with gastric, colorectal, pancreatic, and gynecologic malignancies. Our primary endpoint was a diagnosis of VTE within 30 days of surgery. We analyzed 128,864 patients in this study. On multivariable analysis, patients with pre-operative sepsis (OR 2.36, CI 2.04–2.76, p < 0.001), disseminated cancer (OR 1.73, CI 1.55–1.92, p < 0.001), congestive heart failure (OR 1.69, CI 1.25–2.28, p = 0.001), gastric cancer (OR 1.3, CI 1.09–1.56, p = 0.004), and pancreatic cancer (OR 1.2, CI 1.03–1.30, p = 0.021) were more likely to have a VTE. Of patients who had a VTE event, 34% occurred after discharge from surgery (gastric: 25%, colorectal 34%, pancreatic 31%, gynecologic malignancy 42%). Our study demonstrates that patients who undergo an operation for malignancy with pre-operative sepsis, disseminated cancer, congestive heart failure, gastric cancer, or pancreatic cancer are more likely to develop a VTE within 30 days of their operation. Of those patients who developed a VTE, approximately one-third occurred after discharge during a 30 day post-operative period. This data supports that further studies are needed to determine the appropriate length of post-operative VTE chemoprophylaxis in patients with cancer.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Heit JA (2015) Epidemiology of venous thromboembolism. Nat Rev: Cardiol 12:464–474

    Google Scholar 

  2. Khorana AA, Francis CW, Culakova E et al (2007) Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients. Cancer 110:2339–2346

    Article  PubMed  Google Scholar 

  3. Khorana AA (2009) Cancer and thrombosis: implications of published guidelines for clinical practice. Ann Oncol 20:1619–1630

    Article  PubMed  CAS  Google Scholar 

  4. Dobesh PP (2009) Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy 29:943–953

    Article  PubMed  Google Scholar 

  5. Tesselaar ME, Romijn FP, Van Der Linden IK et al (2007) Microparticle-associated tissue factor activity: a link between cancer and thrombosis? J Thromb Haemost 5:520–527

    Article  PubMed  CAS  Google Scholar 

  6. Khorana AA (2010) Venous thromboembolism and prognosis of cancer. Thromb Res 125(6):490–493

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Mandala M, Reni M, Cascinu S et al (2007) Venous thromboembolism predicts poor prognosis in irresectable pancreatic cancer patients. Ann Oncol 18:1660–1665

    Article  PubMed  CAS  Google Scholar 

  8. Galster H, Kolb G, Kohsytorz A et al (2000) The pre-, peri-, and postsurgical activation of coagulation and the thromboembolic risk for different risk groups. Thromb Res 100:381–388

    Article  PubMed  CAS  Google Scholar 

  9. Gallus AS (1997) Prevention of post operative deep leg vein thrombosis in patients with cancer. Thromb Haemost 78:126–132

    Article  PubMed  CAS  Google Scholar 

  10. Lyman GH, Khorana AA, Falanga A et al (2007) American society of clinical oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490–5505

    Article  PubMed  CAS  Google Scholar 

  11. Mandala M, Falanga A, Roila F (2008) Management of venous thromboembolism in cancer patients: ESMO clinical recommendations. Ann Oncol 19:ii126–i7

    Article  PubMed  Google Scholar 

  12. Geerts WH, Bergqvist D, Pineo GF et al (2008) Prevention of venous thromboembolism: American College of Chest Physicians evidence based clinical practice guidelines (8th edn). Chest 133:381S–453S

    Article  PubMed  CAS  Google Scholar 

  13. National Comprehensive Cancer Network. Cancer-Associated Venous Thromboembolic Disease (Version I.2017). https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf. Accessed 25 Feb 2018

  14. Khalil J, Bensaid B, Elkacemi H et al (2015) Venous thromboembolism in cancer patients: an underestimated major health problem. World J Surg Oncol 13:204

    Article  PubMed  PubMed Central  Google Scholar 

  15. Khorana AA, Dalal M, Lin J et al (2013) Incidence and predictors of venous thromboembolism (VTE) among ambulatory high risk cancer patients undergoing chemotherapy in the United States. Cancer 119:648–655

    Article  PubMed  CAS  Google Scholar 

  16. “BMI Classification.” WHO: Global Database on Body Mass Index, World Health Organization, 28 Feb. 2018, https://apps.who.int/bmi/index.jsp?introPage=intro_3.html

  17. Ansari D, Ansari D, Andersson R et al (2015) Pancreatic cancer and thromboembolic disease, 150 years after Trousseau. Hepatobiliary Surg Nutr 4:325–335

    PubMed  PubMed Central  Google Scholar 

  18. Kessler CM (2009) The link between cancer and venous thromboembolism: a review. Am J Clin Oncol 32(4):S3–S7

    Article  PubMed  Google Scholar 

  19. Khorana AA, Dalal M, Tangirala K et al (2011) Higher incidence of venous thromboembolism in outpatient versus the inpatient setting among US cancer patients. Blood 118:674

    Google Scholar 

  20. Agnelli G, Bolis G, Capussotti L et al (2006) A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project. Ann Surg 243:89–95

    Article  PubMed  PubMed Central  Google Scholar 

  21. Utne KK, Tavoly M, Wik HS et al (2016) Health-related quality of life after deep vein thrombosis. SpringerPlus 5:1278

    Article  PubMed  PubMed Central  Google Scholar 

  22. Qureshi W, Ali Z, Amjad W et al (2016) Venous thromboembolism in cancer: an update of treatment and prevention in the era of newer anticoagulants. Front Cardiovasc Med 3:24

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. Cain K, Schmeler K, Langley G et al (2012) Patient cost associated with filling a prescription for extended duration venous thromboembolism (VTE) prophylaxis following surgery for gynecologic cancer. Gynecol Oncol 127(1):18–21

    Article  PubMed  Google Scholar 

  24. Merkow RP, Bilimoria KY, McCarter MD et al (2011) Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg 254:131–137

    Article  PubMed  Google Scholar 

  25. Iversen LH, Thorlacius-Ussing O (2002) Relations of coagulation test abnormalities to tumour burden and postoperative DVT in resected colorectal cancer. Thromb Haemost 87:402–408

    Article  PubMed  CAS  Google Scholar 

  26. Rickles FR (2006) Mechanisms of cancer induced thrombosis. J Pathophysiol Haemost Thromb 35:103–110

    Article  Google Scholar 

  27. Abdol Razak NB, Jones G, Bhandari M et al (2018) Cancer associated thrombosis: an overview of mechanisms, risk factors, and treatment. Cancers 10(10):380

    Article  PubMed Central  Google Scholar 

  28. Lee AY, Levine MN (2003) Venous thromboembolism and cancer: risks and outcomes. Circulation 107:117–121

    Google Scholar 

  29. Neoptolemos JP, Palmer DH, Ghaneh P et al (2017) Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicenter, open-label, randomized phase 3 trial. Lancet 389:1011–1024

    Article  PubMed  CAS  Google Scholar 

  30. Martino MA, Borges E, Wiliammson E et al (2006) Pulmonary embolism after major abdominal surgery in gynecologic oncology. Obstet Gynecol 107:666–671

    Article  PubMed  Google Scholar 

  31. Bergqvist D, Agnelli G, Cohen AT et al (2002) Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 346:975–980

    Article  PubMed  CAS  Google Scholar 

  32. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P et al (2006) Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open-label study. J Thromb Haemost 4:2384–2390

    Article  PubMed  CAS  Google Scholar 

  33. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P (2009) Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD004318.pub2

    Article  PubMed  Google Scholar 

  34. Petch S, Norris L, O’Toole S et al (2016) Peri operative venous thromboembolism prophylaxis in gynaecological cancer patients. A survey of current practice. Thromb Res 145:126–128

    Article  PubMed  CAS  Google Scholar 

  35. Kakkar VV, Balibrea JL, Martinez-Gonzalez J et al (2010) Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: the CANBESURE randomized study. J Thromb Haemost 8(6):1223–1229

    Article  PubMed  CAS  Google Scholar 

  36. Kaplan D, Casper TC, Elliott CG (2015) VTE incidence and risk factors in patients with severe sepsis and septic shock. Chest 148:1224–1230

    Article  PubMed  PubMed Central  Google Scholar 

  37. Donze JD, Ridker PM, Finlayson SRG et al (2014) Impact of sepsis on risk of postoperative arterial and venous thromboses: large prospective cohort study. BMJ 349:5334

    Article  CAS  Google Scholar 

  38. Schmeler KM, Langley G, Cain K et al (2013) Venous thromboembolism (VTE) rates following the implementation of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies. Gynecol Oncol 128:204–208

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Surgery, Long Island Jewish Hospital, Northwell Health, 270-05 76th Ave, Queens, NY, 11040, USA

    Samantha M. Ruff, Kathryn T. Weber & Adam Khader

  2. Division of Surgical Oncology, Northwell Health, 450 Lakeville Rd, Lake Success, NY, 11042, USA

    Charles Conte, Alan Kadison, James Sullivan, John Wang, Raza Zaidi & Gary B. Deutsch

Authors
  1. Samantha M. Ruff
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kathryn T. Weber
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Adam Khader
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Charles Conte
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alan Kadison
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. James Sullivan
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. John Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Raza Zaidi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Gary B. Deutsch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Samantha M. Ruff.

Ethics declarations

Conflict of interest

None of the authors have any potential conflicts of interest or financial disclosures.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ruff, S.M., Weber, K.T., Khader, A. et al. Venous thromboembolism in patients with cancer undergoing surgical exploration. J Thromb Thrombolysis 47, 316–323 (2019). https://doi.org/10.1007/s11239-018-1774-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-018-1774-3

Keywords

Search

Navigation