Preoperative Heparin 'Severely' Underused in Cancer Surgery

Miriam E. Tucker

October 27, 2016

Washington, DC — Despite guidelines, preoperative administration of subcutaneous heparin for venous thromboembolism (VTE) prophylaxis before oncologic surgery is "severely underutilized," new research suggests.

Results of the study, a 5-year data analysis for three university-affiliated hospitals, were presented here at the American College of Surgeons Clinical Congress 2016 by Seyed A. Razavi, MD, a surgical resident at Emory University in Atlanta, Georgia.

Guidelines from the American College of Chest Physicians and the Surgical Care Improvement Project advise that chemical thromboprophylaxis be started before complex oncologic abdominal surgeries. Yet, "even though we talk about this constantly and weekly at our [morbidity and mortality] sessions, obstacles to implementation still remain regarding [concern about] increased risk of intraoperative bleeding, particularly in high-risk cases and those receiving epidurals for pain control," Dr Razavi noted during his presentation.

Indeed, session co-moderator Karyn B. Stitzenberg, MD, a surgical oncologist at the University of North Carolina, Chapel Hill, told Medscape Medical News, "We all know what the best practices should be and there are guidelines, but what's actually done in reality is quite different."

For one thing, she said, "There are logistic barriers to getting it done, and also ingrained beliefs in people about the risks of bleeding."

Another reason is that the guidelines are vague, session co-moderator David J. Bentrem, MD, a surgical oncologist at Northwestern University Feinberg School of Medicine, Chicago, told Medscape Medical News. "They say 'consider,' so it's an option and people use it selectively," he said, adding "the data just aren't very good. We need better, more [procedure-] specific data."

Heparin Underused, but No Difference in VTE

Dr Razavi and colleagues used data from the National Surgical Quality Improvement Program on 2710 consecutive adult patients undergoing elective inpatient surgery for hepatobiliary, colorectal, endocrine, breast, and soft tissue malignancies between January 1, 2010, and February 29, 2015. Patients having outpatient procedures and those receiving epidurals for pain control were excluded.

The patients had a mean age 59 years and were 47% male. Surgery types included 45% hepatobiliary, 38% colorectal, 10% endocrine, 6% soft tissue, and 1% breast.

In all, only 2.1% of patients (n = 57) received preoperative subcutaneous heparin within 4 hours before surgery, all but 1 of whom had undergone colorectal procedures (the other case was hepatobiliary), totalling just 0.1% of hepatobiliary and 5% of all colorectal procedures. Most of those occurred in 2014–2015 after implementation of a quality improvement project that added 5000 units of preoperative subcutaneous heparin to the order set for all colorectal surgery patients, Dr Razavi noted.

Postoperative VTE occurred in 1.8% (n = 49) of patients overall, with 1.9% of the hepatobiliary, 1.7% of the colorectal, and 1.9% of the endocrine surgery cases. There was no significant difference among the surgical groups (P = .4).

Although none of the patients who developed VTE had received preoperative heparin, there was no significant difference between heparin use and the occurrence of postoperative VTE (P = .3).

However, Dr Razavi pointed out that the primary aim of the study was to assess compliance with the guidelines and that it wasn't adequately powered to detect an association between use of heparin — or lack thereof — and subsequent VTE.

Dr Razavi, Dr Stitzenberg, and Dr Bentrem have disclosed no relevant financial relationships.

American College of Surgeons (ACS) Clinical Congress 2016. Presented October 17, 2016.

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