Risk of postoperative venous thromboembolism after minimally invasive surgery for endometrial and cervical cancer is low: A multi-institutional study
Introduction
Endometrial and cervical cancers are diagnosed in 47,000 and 12,000 women respectively, in the United States every year [1]. For the vast majority of these women, surgery plays a major role in therapy. Of all the potentially life-threatening perioperative complications, venous thromboembolism (VTE) is potentially one of the most preventable [2]. In fact, perioperative VTE has been classified by the Centers for Medicare and Medicaid Services as a “never event” in certain surgeries [3].
Historically, VTE prophylaxis has been recommended for the duration of hospitalization starting shortly before surgery [4]. However, more than half of VTE events associated with gynecologic cancer surgery occur more than 7 days after surgical procedures [5], [6]. Naturally, these observations have shifted the focus of VTE prophylaxis from short-term (the duration of hospitalization) to long-term prophylaxis lasting for 4–6 weeks for patients undergoing high-risk surgical operations for cancer [7]. In fact, in the practice bulletin on the prevention of VTE, the ACOG urges for consideration of VTE prophylaxis for up to 28 days postoperatively [4] for high-risk cancer patients. The Society of Gynecologic Surgeons Systematic Review Group had a similar stance for high-risk patients undergoing gynecologic cancer surgery [8].
Recently, minimally invasive surgery (MIS) has demonstrated lower complication rates and shorter hospital stay for women with gynecologic cancers and is being adopted with increasing frequency in EC and CC. [9], [10], [11], [12]. In a variety of non-gynecological surgical procedures, MIS is associated with a much lower prevalence of VTE when compared to open surgery [13]. Despite the increased use of MIS for gynecologic malignancies, the evidence to guide thromboprophylaxis after MIS for EC and CC is insufficient. As such, the ACOG recommends, “Until more evidence is accumulated, patients undergoing laparoscopic surgery should be stratified by risk category (and provided prophylaxis) similar to patients undergoing laparotomy” [4]. This summary statement provides strong incentive to investigate the risk profile of MIS cases for EC and CC.
Several studies have reported a low prevalence of VTE after MIS as a part of reporting general complications but none provided details of the pharmacologic prophylaxis and risk factors specific to VTE [10], [14], [15], [16], [17], [18]. To date, there have been two dedicated investigations reporting on the prevalence of VTE after laparoscopic gynecologic surgery. The first report had the limitation of being comprised of more than half benign cases and only a small number (n = 109) of patients having complex, and potentially higher risk, cancer operations such as lymphadenectomy or radical hysterectomy [19]. Most recently, Sandadi et al. [20] reported on a large series of EC cases treated by MIS and found an overall incidence of VTE of 1.2%. Importantly, the authors noted that only 22% of patients received some type of postoperative heparin anticoagulation, and this allowed them to identify a specific high-risk group (obese women undergoing long surgeries) where the risk could be as high as 10%. The study was limited by relatively small number of high-risk patients (42 cases in the highest risk group). Needless to say, additional comprehensive investigations reporting on the prevalence of VTE after MIS for EC and CC are urgently needed.
Given the paucity of data on VTE after MIS for EC and CC, we undertook the present study. Our objectives were to determine the prevalence of VTE within 30 days of MIS for EC and CC and to investigate the relevance of current guidelines for extended prophylaxis in this cancer cohort treated with MIS.
Section snippets
Methods
This study was approved by the Institutional Review Boards of the Mayo Clinic Rochester, MN, and Wayne State University, Detroit, MI. The study included patients treated at both institutions between 2006 and 2011 with a new diagnosis of EC or CC, requiring at least a hysterectomy for their primary treatment.
The inclusion criteria were (a) diagnosis of EC/CC with the patient undergoing MIS for definitive primary treatment and (b) minimum of 30 days of postsurgical follow-up. The following
Results
A total of 611 patients were identified. Of these, 36 (6%) were excluded for being converted from minimally invasive to open during the course of the procedure and 14 (2%) were excluded as they had only vaginal hysterectomy as the definitive surgical procedure for endometrial cancer. Finally, 3 patients (< 1%) were excluded because the histology type of the tumor was of metastatic histology (one malignant melanoma, one gestational trophoblastic tumor, and one lobular breast cancer metastatic to
Discussion
In this retrospective multi-institutional study of patients undergoing MIS for EC and CC, we demonstrate that clinically evident VTE events are rare within 30 days of such surgery, with an extremely low prevalence of 0.5% (95% CI, 0.11%–1.6%). Given the low prevalence of VTE events, we do not believe the data justify giving such patients extended VTE prophylaxis without other accepted high-risk factors (i.e., previous history or recent VTE). In our study, VTE occurred long after patient
Conflicts of interest statement
All the authors declare that there are no conflicts of interests associated with this work.
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