Practice patterns of VTE chemoprophylaxis after discharge following hepatic and pancreatic resections for cancer: A survey of hepatopancreatobiliary surgeons

  • Samantha M. Ruff
  • Reed I. Ayabe
  • Michael M. Wach
  • Laurence P. Diggs
  • Sean P. Martin
  • Jeremy L. Davis
  • Jonathan M. HernandezEmail author


Patients with hepatopancreatobiliary (HPB) malignancies undergoing resection are prone to venous thromboembolism (VTE), and current guidelines recommend up to 28 days of chemoprophylaxis after major surgery. We sought to determine the practice patterns among HPB surgeons for use of chemoprophylaxis after discharge. A survey on VTE chemoprophylaxis after oncologic HPB operations was distributed to attending surgeons at the 18 HPB fellowship training programs in the United States and Canada. Of the HPB surgeons surveyed, 44 (44%) responded. VTE prophylaxis is used by 93% of respondants in the inpatient postoperative setting. Chemoprophylaxis after discharge for pancreaticoduodenenctomy and distal pancreatectomy is utilized by 45% and 39% of respondants, respectively. Of those who prescribe chemoprophylaxis after discharge, 79% and 88% prescribe it for the recommended 28 days after pancreaticoduodenectomy and distal pancreatectomy, respectively. Chemoprophylaxis after discharge for major and minor hepatectomy is utilized by 39% and 26% of respondents, respectively. Of those who prescribe chemoprophylaxis after discharge, 67% and 55% provide it for the recommended 28 days after major and minor hepatectomy, respectively. Despite documented prolonged postoperative thrombogenic risk, the use of chemoprophylaxis following discharge after pancreatic and liver resections for cancer was moderate among surveyed HPB surgeons.


Venous thromboembolism Surgery Survey Chemoprophylaxis Cancer 



This project was in part funded by the intramural research program at the NIH, where the authors are employed.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflicts of interest.

Ethical approval

There were no animals used in this study. Survey results were collected from human (respondents) anonymously. This survey was approved by the Office of Human Subjects Research Protections and was determined not to need an IRB. A consent statement was included in the email that went to every respondent stating that by participating in the survey they consented to have their results included in this study.


  1. 1.
    Lyman GH, Khorana AA, Falanga A, Clarke-Pearson D, Flowers C, Jahanzeb M, Kakkar A, Kuderer NM, Levine MN, Liebman H, Mendelson D, Raskob G, Somerfield MR, Thodiyil P, Trent D, Francis CW (2007) American Society of Clinical Oncology. American society of clinical oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25(34):5490–5505CrossRefPubMedGoogle Scholar
  2. 2.
    Khorana AA (2010) Venous thromboembolism and prognosis of cancer. Thromb Res 125(6):490–493CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Heit JA (2015) Epidemiology of venous thromboembolism. Nat Rev 12(8):464–474Google Scholar
  4. 4.
    Khorana AA, Francis CW, Culakova E, Kuderer NM, Lyman GH (2007) Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients. Cancer 110(10):2339–2346CrossRefPubMedGoogle Scholar
  5. 5.
    Rasmussen MS, Jorgensen LN, Wille-Jorgensen P (2009) Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 1:CD004318Google Scholar
  6. 6.
    Martino MA, Borges E, Williamson E, Siegfried S, Cantor AB, Lancaster J, Roberts WS, Hoffman MS (2006) Pulmonary embolism after major abdominal surgery in gynecologic oncology. Obstet Gynecol 107(3):666–671CrossRefPubMedGoogle Scholar
  7. 7.
    Agnelli G, Bolis G, Capussotti L, Scarpa RM, Tonelli F, Bonizzoni E, Moia M, Parazzini F, Rossi R, Sonaglia F, Valarani B, Bianchini C, Gussoni G (2006) A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project. Ann Surg 243(1):89–95CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Khorana AA, Dalal M, Tangirala K, Miao R (2011) Higher incidence of venous thromboembolism in outpatient versus the inpatient setting among US cancer patients. Blood 118:674Google Scholar
  9. 9.
    Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, Dietrich-Neto F (2002) Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 346:975–980CrossRefPubMedGoogle Scholar
  10. 10.
    Rasmussen MS, Jorgensen LN, Wille-Jorgensen P, Nielsen JD, Horn A, Mohn AC, Somod L, Olsen B, FAME Investigators (2006 Nov) 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(11):2384–2390CrossRefPubMedGoogle Scholar
  11. 11.
    National Comprehensive Cancer Network. Cancer-Associated Venous Thromboembolic Disease (Version 1.2017) Accessed 2 May 2018
  12. 12.
    Merkow RP, Bilimoria KY, McCarter MD, Cohen ME, Barnett CC, Raval MV, Cparini JA, Gordon HS, Ko CY, Bentrem DJ (2011) Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg 254(1):131–137CrossRefPubMedGoogle Scholar
  13. 13.
    Weiss MJ, Kim Y, Ejaz A, Spolverato G, Haut ER, Hirose K, Wolfgang CL, Choti MA, Pawlik TM (2014) Venous thromboembolic prophylaxis after a hepatic resection: patterns of care among liver surgeons. HPB 16:892–898CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Iversen LH, Thorlacius-Ussing O (2002) Relationship of coagulation test abnormalities to tumour burden and postoperative DVT in resected colorectal cancer. Thrombosis Haemostasis 87:402–408CrossRefPubMedGoogle Scholar
  15. 15.
    Ansari D, Ansari D, Andersson R, Andren-Sandberg A (2015) Pancreatic cancer and thromboembolic disease, 150 years after Trousseau. Hepatobiliary Surg Nutr 4(5):325–335PubMedPubMedCentralGoogle Scholar
  16. 16.
    Kessler CM (2009) The link between cancer and venous thromboembolism: a review. Am J Clin Oncol 32(4):S3–S7CrossRefPubMedGoogle Scholar
  17. 17.
    Cancer Statistics. National Cancer Institute, Accessed 18 May 2018
  18. 18.
    Rickles FR (2006) Mechanisms of Cancer Induced Thrombosis. Pathophysiol Haemost Thromb 35(1–2):103–110CrossRefPubMedGoogle Scholar
  19. 19.
    Utne KK, Tavoly M, Wik HS, Jelsness-Jorgensen LP, Holst R, Sandset PM, Ghanima W (2016) Health-related quality of life after deep vein thrombosis. SpringerPlus 5(1):1278CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Qureshi W, Ali Z, Amjad W, Alirhayim Z, Farooq H, Qadir S, Khalid F, Al-Mallah MH (2016) Venous thromboembolism in cancer: an update of treatment and prevention in the era of newer anticoagulants. Front Cardiovasc Med 3:24CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Cain K, Schmeler K, Langley G, Max O, Ramirez PT, Levenback CF (2012) Patient cost associated with filling a prescription for extended duration venous thromboembolism (VTE) prophylaxis following surgery for gynecologic cancer. Gynecol Oncol 127(1):18–21CrossRefPubMedGoogle Scholar
  22. 22.
    National Comprehensive Cancer Network. Cancer-Associated Venous Thromboembolic Disease (Version 1.2007)Google Scholar
  23. 23.
    National Comprehensive Cancer Network. Venous Thromboembolic Disease (Version 2.2006)Google Scholar
  24. 24.
    Manoucheri R, Fallahi MJ (2015) Adherence to venous thromboprophylaxis guidelines for medical and surgical inpatients of teaching hospitals. Shiraz-Iran Tanaffos 14(1):17–26PubMedGoogle Scholar
  25. 25.
    Yong YP, Karangizi A, Banerjea A (2014) A persuasive intervention: improving the compliance of extended venous thromboembolism prophylaxis following cancer resections in a tertiary colorectal and hepatobiliary unit. BMJ Qual Improv Rep 3(1):u202594.w2216CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Yekebas EF, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR (2007) Postpancreatectomy hemorrhage: diagnosis and treatment. Ann Surg 246(2):269–280CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Ansari D, Tingstedt B, Lindell G, Keussen I, Ansari D, Andersson R (2017) Hemorrhage after major pancreatic resection: incidence, risk factors, management, and outcome. Scand J Surg 106(1):47–53CrossRefPubMedGoogle Scholar
  28. 28.
    Ho CK, Kleef J, Friess H, Buchler MW (2005) Complications of pancreatic surgery. HPB 7(2):99–108CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Kazanjian KK, Hines OJ, Eibl G, Reber HA (2005) Management of pancreatic fistulas after pancreaticoduodenectomy. JAMA Surg 140(9):849–855Google Scholar
  30. 30.
    Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M (2013) Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. Case Rep Gastroenterol 7(2):332–339CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Shoeb M, Fang MC (2013) Assessing bleeding risk in patients taking anticoagulants. J Thromb Thrombolysis 35(3):312–319CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Mallett SV, Sugavanam A, Krzanicki DA, Patel S, Broomhead RH, Davidson BR, Riddell A, Gatt A, Chowdary P (2016) Alterations in coagulation following major liver resection. Anaesthesia 71:657–668CrossRefPubMedGoogle Scholar
  33. 33.
    Turley RS, Reddy SK, Shortell CK, Clary BM, Scarborough JE (2012) Venous thromboembolism after hepatic resection: analysis of 5,706 patients. J Gastrointest Surg 16:1705–1714CrossRefPubMedGoogle Scholar
  34. 34.
    Ejaz A, Spolverato G, Kim Y, Lucas DL, Lau B, Weiss M, Johnston FM, Kheng M, Hirose K, Wolfgang CL, Haut E, Pawlik TM (2014) Defining incidence and risk factors of venous thromboembolism after hepatectomy. J Gastrointest Surg 18(6):1116–1124CrossRefPubMedGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  • Samantha M. Ruff
    • 1
  • Reed I. Ayabe
    • 1
  • Michael M. Wach
    • 1
  • Laurence P. Diggs
    • 1
  • Sean P. Martin
    • 1
  • Jeremy L. Davis
    • 1
  • Jonathan M. Hernandez
    • 1
    Email author
  1. 1.National Institutes of HealthBethesdaUSA

Personalised recommendations