Prophylactic modalities against venous thromboembolism in complicated surgery for cancer patients

Introduction

Venous thromboembolism (VTE) is the most frequent complication following surgery in cancer patients. This complication becomes more serious in complicated surgery. The morbidity and mortality associated with VTE remains unacceptably high. The surgeon may not perceive VTE as a significant problem and would not be aware of the effects of prophylaxis. The aim of the work is to evaluate a different modality for prophylaxis against VTE among patients with complicated, major surgery, for cancer treatment.

Methods

One hundred and seventy-four patients admitted to the surgical ICU with complicated (unexpected long duration (more than 6 hours) or vascular injury) major surgery for cancer treatment, in the period from January 2006 to June 2007, were included. The patients were randomized to receive enoxaparin, 40 mg/12 hours (group (E)), intermittent pneumatic compression (group (PC)) or enoxaparin 40 mg/24 hours + intermittent pneumatic compressions (group (E + PC)). All patients underwent duplex venous ultrasonography examination on day 0; at discharge and at clinical suspicion of deep vein thrombosis (DVT) or pulmonary embolism (PE) (complaint of chest discomfort or shortness of breath, change on ECG), a same-day chest X-ray scan and ventilation-perfusion scan was obtained, to confirm PE. The incidence of DVT, PE and bleeding was recorded.

Results

Calf DVT was only recorded in one patient in group (E). The incidence of proximal DVT was significantly higher in group (E), 3.6%, compared with group (PC), 1.7%, and group (E + PC), 1.6%. No significant difference occurred in the incidence of clinical PE between the three groups, but the incidences of total and fatal PE were higher in group (PC), 3.4% and 1.7%, respectively. The bleeding complication was recorded in three patients in group (E), 5.5%, one patient in group (PC), 1.7%, and one patient in group (E + PC), 1.6%. The total incidence of mortality in the 174 patients admitted to the surgical ICU was 5.75%, 30% of deaths were ascribed to PE, 20% were sudden cardiac deaths (which undoubtedly included some undiagnosed PE). Fifty percent were due to surgical complication and cancer, of which 60% were considered due to respiratory failure, which may also have included some deaths due to PE.

Conclusion

In high-risk patients with complicated surgery the use of multimodality (intermittent pneumatic compression plus LMWH) provided excellent and safe prophylaxis against VTE.