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Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Venous thromboembolism (VTE) occurs in 3–11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy.

Methods

Esophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher’s Exact test, Kruskal–Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant.

Results

Four hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis.

Conclusion

 In this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.

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Data Availability

The data utilized for this study is not publicly available due as the data contains protected health information.

References

  1. Henke, P.K., et al., Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation, 2020. 141(24): p. e914-e931.

    Article  PubMed  Google Scholar 

  2. Mukherjee, D., et al., Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Operations. Journal of Gastrointestinal Surgery, 2008. 12(11): p. 2015.

    Article  PubMed  Google Scholar 

  3. Martin, J.T., et al., Identifying Esophagectomy Patients at Risk for Predischarge Versus Post-discharge Venous Thromboembolism. The Annals of Thoracic Surgery, 2015. 100(3): p. 932-938.

    Article  PubMed  Google Scholar 

  4. De Martino, R.R., et al., Variation in thromboembolic complications among patients undergoing commonly performed cancer operations. Journal of Vascular Surgery, 2012. 55(4): p. 1035-1040.e4.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Mantziari, S., et al., Incidence and Risk Factors Related to Symptomatic Venous Thromboembolic Events After Esophagectomy for Cancer. The Annals of Thoracic Surgery, 2016. 102(3): p. 979-984.

    Article  PubMed  Google Scholar 

  6. Byrne, M., et al., Long-term activation of the pro-coagulant response after neoadjuvant chemoradiation and major cancer surgery. British Journal of Cancer, 2010. 102(1): p. 73-79.

    Article  CAS  PubMed  Google Scholar 

  7. Tsutsumi, K., et al., Pulmonary thromboembolism after surgery for esophageal cancer: Its features and prophylaxis. Surgery Today, 2000. 30(5): p. 416-420.

    Article  CAS  PubMed  Google Scholar 

  8. Chen, S.Y., et al., Post-discharge complications after esophagectomy account for high readmission rates. World J Gastroenterol, 2016. 22(22): p. 5246-53.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rogers, S.O., Jr., et al., Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg, 2007. 204(6): p. 1211-21.

    Article  PubMed  Google Scholar 

  10. Pannucci, C.J., et al., A validated risk model to predict 90-day VTE events in postsurgical patients. Chest, 2014. 145(3): p. 567-573.

    Article  PubMed  Google Scholar 

  11. Pannucci, C.J., et al., Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery. Ann Surg, 2012. 255(6): p. 1093-9.

    Article  PubMed  Google Scholar 

  12. Bahl, V., et al., A Validation Study of a Retrospective Venous Thromboembolism Risk Scoring Method. Annals of Surgery, 2010. 251(2): p. 344-350.

    Article  PubMed  Google Scholar 

  13. Shuman, A.G., et al., Stratifying the risk of venous thromboembolism in otolaryngology. Otolaryngol Head Neck Surg, 2012. 146(5): p. 719-24.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zhou, H.X., et al., Validation of the Caprini risk assessment model in Chinese hospitalized patients with venous thromboembolism. Thromb Res, 2012. 130(5): p. 735–40.

    Article  CAS  PubMed  Google Scholar 

  15. Obi, A.T., et al., Validation of the Caprini Venous Thromboembolism Risk Assessment Model in Critically Ill Surgical Patients. JAMA Surg, 2015. 150(10): p. 941–8.

    Article  PubMed  Google Scholar 

  16. Hewes, P.D., et al., Evaluation of the Caprini Model for Venothromboembolism in Esophagectomy Patients. Ann Thorac Surg, 2015. 100(6): p. 2072–8.

    Article  PubMed  Google Scholar 

  17. Sterbling, H.M., et al., Caprini Risk Model Decreases Venous Thromboembolism Rates in Thoracic Surgery Cancer Patients. Ann Thorac Surg, 2018. 105(3): p. 879–885.

    Article  PubMed  Google Scholar 

  18. Sterbling, H.M., et al., Caprini Risk Model Decreases Venous Thromboembolism Rates in Thoracic Surgery Cancer Patients. The Annals of Thoracic Surgery, 2018. 105(3): p. 879–885.

    Article  PubMed  Google Scholar 

  19. Zwischenberger, B.A., et al., Venous Thromboembolism Prophylaxis For Esophagectomy: A Survey of Practice Patterns Among Thoracic Surgeons. The Annals of Thoracic Surgery, 2016. 101(2): p. 489-494.

    Article  PubMed  Google Scholar 

  20. Findlay, J.M., et al., Enhanced Recovery for Esophagectomy: A Systematic Review and Evidence-Based Guidelines. Annals of Surgery, 2014. 259(3): p. 413–431.

    Article  PubMed  Google Scholar 

  21. Gould, M.K., et al., Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012. 141(2, Supplement): p. e227S–e277S.

  22. Agzarian, J., et al., Practice patterns in venous thromboembolism (VTE) prophylaxis in thoracic surgery: a comprehensive Canadian Delphi survey. J Thorac Dis, 2017. 9(1): p. 80–87.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Moriarty, J.P., et al., Going Beyond Administrative Data: Retrospective Evaluation of an Algorithm Using the Electronic Health Record to Help Identify Bleeding Events Among Hospitalized Medical Patients on Warfarin. Am J Med Qual, 2017. 32(4): p. 391–396.

    Article  PubMed  Google Scholar 

  24. Yoshida, N., et al., Prophylaxis of Postoperative Venous Thromboembolism Using Enoxaparin After Esophagectomy: A Prospective Observational Study of Effectiveness and Safety. Ann Surg Oncol, 2018. 25(8): p. 2434–2440.

    Article  PubMed  Google Scholar 

  25. Akhtar-Danesh, G.-G., N. Akhtar-Danesh, and Y. Shargall, Venous Thromboembolism in Surgically Treated Esophageal Cancer Patients: A Provincial Population-Based Study. TH Open, 2022. 06(03): p. e168–e176.

    Article  Google Scholar 

  26. Bergqvist, D., et al., Duration of Prophylaxis against Venous Thromboembolism with Enoxaparin after Surgery for Cancer. New England Journal of Medicine, 2002. 346(13): p. 975–980.

    Article  CAS  PubMed  Google Scholar 

  27. Kakkar, V.V., et al., Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: the CANBESURE randomized study. Journal of Thrombosis and Haemostasis, 2010. 8(6): p. 1223–1229.

    Article  CAS  PubMed  Google Scholar 

  28. Rasmussen, M.S., et al., Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open‐label study. Journal of Thrombosis and Haemostasis, 2006. 4(11): p. 2384–2390.

    Article  CAS  PubMed  Google Scholar 

  29. Hanna, N.M., et al., Incidence, Timing, and Outcomes of Venous Thromboembolism in Patients Undergoing Surgery for Esophagogastric Cancer: A Population-Based Cohort Study. Annals of Surgical Oncology, 2022. 29(7): p. 4393–4404.

    Article  Google Scholar 

  30. Trinh, V.Q., et al., Venous Thromboembolism After Major Cancer Surgery: Temporal Trends and Patterns of Care. JAMA Surgery, 2014. 149(1): p. 43–49.

    Article  PubMed  Google Scholar 

  31. Merkow et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg, 2011. 254(1): p. 131–7.

    Article  PubMed  Google Scholar 

  32. Shah, S.P., et al., Why are patients being readmitted after surgery for esophageal cancer? The Journal of Thoracic and Cardiovascular Surgery, 2015. 149(5): p. 1384–1391.

    Article  PubMed  Google Scholar 

  33. Goel, N.J., et al., Nationwide Analysis of 30-Day Readmissions After Esophagectomy: Causes, Costs, and Risk Factors. The Annals of Thoracic Surgery, 2020. 109(1): p. 185–193.

    Article  PubMed  Google Scholar 

  34. Tanaka, Y., et al., Efficacy and Safety of Enoxaparin for Prophylaxis of Postoperative Venous Thromboembolism After Esophagectomy: A Single-center Prospective Randomized Controlled Phase II Study. Anticancer Research, 2019. 39(5): p. 2615.

    Article  CAS  PubMed  Google Scholar 

  35. Krell, R.W., et al., Variation in Hospital Thromboprophylaxis Practices for Abdominal Cancer Surgery. Annals of Surgical Oncology, 2016. 23(5): p. 1431–1439.

    Article  PubMed  Google Scholar 

  36. Streiff, M.B., et al., Venous thromboembolic disease. Journal of the National Comprehensive Cancer Network, 2013. 11(11): p. 1402–1429.

    Article  CAS  PubMed  Google Scholar 

  37. Farge, D., et al., International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Journal of Thrombosis and Haemostasis, 2013. 11(1): p. 56–70.

    Article  CAS  PubMed  Google Scholar 

  38. Ruff, S.M., et al., Practice patterns of VTE chemoprophylaxis after discharge following hepatic and pancreatic resections for cancer: a survey of hepatopancreatobiliary surgeons. Journal of thrombosis and thrombolysis, 2019. 48: p. 119–124.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Merkow, R.P., et al., Adherence with post-discharge venous thromboembolism chemoprophylaxis recommendations after colorectal cancer surgery among elderly Medicare beneficiaries. Ann Surg, 2014. 260(1): p. 103–8.

    Article  PubMed  Google Scholar 

  40. 40 Lui D.S., Newbold R, Stevens S. et al. Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study. Journal of Gastrointestinal Surgery (2022) 26:1495–1502.

    Article  Google Scholar 

  41. Hachey, K.J., et al., Caprini venous thromboembolism risk assessment permits selection for post-discharge prophylactic anticoagulation in patients with resectable lung cancer. J Thorac Cardiovasc Surg, 2016. 151(1): p. 37-44.e1.

    Article  PubMed  Google Scholar 

  42. Kakkar, A.K., Prevention of venous thromboembolism in the cancer surgical patient. Journal of clinical oncology, 2009. 27(29): p. 4881–4884.

    Article  PubMed  Google Scholar 

  43. Song, J.-Q., et al., Low molecular weight heparin once versus twice for thromboprophylaxis following esophagectomy: a randomised, double-blind and placebo-controlled trial. Journal of Thoracic Disease, 2015. 7(7): p. 1158.

    PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA

    Michael A. Edwards, Steven P. Bowers & Enrique Fernando Elli

  2. Department Surgery, Mayo Clinic Alix School of Medicine, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA

    Michael A. Edwards

  3. Department of Surgery, UConn Health, Farmington, CT, 06030, USA

    Md Walid Akram Hussain

  4. Mayo Clinic, Division of Health Care Delivery Research, Jacksonville, FL, 32224, USA

    Aaron C. Spaulding

  5. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, 32224, USA

    Emily Brennan

  6. Department of Cardio/Thoracic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA

    Mathew Thomas

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  1. Michael A. Edwards
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Correspondence to Michael A. Edwards.

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Appendix

Appendix

Caprini guided VTE prophylaxis

Caprini Score

Recommended VTE Prophylaxis

1-2

Either compression device or anticoagulant prophylaxis preoperatively and postoperatively.

3-4

Compression device and anticoagulant prophylaxis, preoperatively and postoperatively. 

5-8

Compression device and anticoagulant prophylaxis preoperatively and postoperatively, and discharge anticoagulant prophylaxis x 7-10 days

>8

Compression device and anticoagulant prophylaxis preoperatively and postoperatively, and discharge anticoagulant prophylaxis x 30 days 

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Edwards, M.A., Hussain, M.W.A., Spaulding, A.C. et al. Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System. J Gastrointest Surg 27, 2045–2056 (2023). https://doi.org/10.1007/s11605-023-05815-5

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