VTE Prophylaxis in Gynecologic Surgery: Quo Vadis?

Abstract & Commentary

By Robert L. Coleman, MD, Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.

Dr. Coleman reports no financial relationships relevant to this field of study.

Synopsis: Venous thromboembolism (VTE) prophylaxis interventions in gynecologic surgery are meritorious, supported by Level 1 evidence and the subject of multiple guidelines, including those published by the American College of Obstetricians and Gynecologists. However, new evidence suggests nearly one-third of women undergoing hysterectomy in this country still receive no VTE prophylaxis, placing thousands of women at unnecessary risk for preventable morbidity.

Source: Wright JD, et al. Quality of perioperative venous thromboembolism prophylaxis in gynecologic surgery. Obstet Gynecol 2011;118:978-986.

The objective of this study was to estimate the use of vte prophylaxis in women undergoing major gynecologic surgery and to estimate the patient, physician, and hospital characteristics associated with their use. To examine these factors, a validated and regularly audited national commercial database (Perspective®) of inpatient hospital admissions was interrogated for VTE prophylaxis use over an 11-year period (2000 to 2010). VTE prophylaxis was classified as none, mechanical, pharmacologic, or a combination. A total of 738,150 women who underwent major gynecologic surgery were identified. In this study, only abdominal or vaginal hysterectomy with or without salpingo-oophorectomy for benign disease were included. In addition, laparoscopic/robotic procedures were excluded. No prophylaxis was given to 292,034 (40%) women, whereas 344,068 (47%) received mechanical prophylaxis, 40,268 (6%) pharmacologic prophylaxis, and 61,780 (8%) combination prophylaxis. VTE prophylaxis use increased from 54% to 68% over the observation period and was more commonly used in older women, those with Medicare and more comorbidities, Caucasian women, patients treated at rural hospitals, patients treated at teaching facilities, and patients treated by high-volume surgeons and at high-volume centers. Factors associated with use of pharmacologic prophylaxis included advanced age, white race, noncommercial insurance, later year of diagnosis, greater comorbidity, treatment at large hospitals and urban facilities, and treatment by a high-volume surgeon. The survey data highlight that VTE prophylaxis use is substantially underutilized in women undergoing major gynecological surgery, despite clear recommendations from evidence-based guidelines. Hospital, physician, and patient factors influence use.

Commentary

There are many things in surgery we can't control: age, preexisting anatomy, preexisting comorbidities, characteristics of disease, and patient compliance, just to name a few. However, there are those factors under our control that should be as automatic as getting informed consent. VTE prophylaxis is one of them! For more than 35 years, Level 1 evidence from randomized clinical trials has clearly demonstrated, in nearly every surgical discipline (including 15 randomized trials in gynecology/gynecologic oncology), that fatal VTE can be prevented by intervention.1 Initially, unfractionated heparin given before and after surgery was advocated, but concerns for intraoperative and postoperative bleeding ushered in evaluation of alternative pharmacological agents and mechanical devices, such as graded compression stockings and intermittent pneumatic compression devices.2,3 In addition, risk stratification of patients and procedures (types and lengths) where VTE prophylaxis might be optimized led to well-publicized guidelines in gynecologic surgery by American College of Obstetricians and Gynecologists and the American College of Chest Physicians.4 With this proviso, it is hard to imagine that in 2010, nearly a third of patients undergoing major gynecologic surgery still were not given any form of VTE prophylaxis.

A second paper in this issue of Obstetrics & Gynecology suggests the quality of data among benign gynecology cohorts in their meta-analysis is not as strong as in others (e.g., oncology patients) and opines that the guidelines are viewed with tepid regard.5 Nevertheless, it is estimated that VTE occurs in up to 3% of patients following benign gynecologic procedures, which translates into hundreds of preventable cases every year. In the current study, it was reassuring that the proportion has significantly increased in the last decade, and that it is practiced more often in urban training centers with high-volume surgeons and hospitals, as this holds promise that the practice will continue to increase as more residents and operating room staff trainees are exposed to Best Practices and Quality Improvement projects around this topic. Data like these are hard to come by, and as with any voluntary national registry, true compliance with guidelines (dose, duration, and timing of pharmacological prophylaxis and patient compliance with compression devices) is difficult to adjudicate. However, this should serve as a wake-up call to review the guidelines and our compliance in order to provide the best care to our patients.

References

  1. No authors listed. Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet1975;2:45-51.
  2. Clarke-Pearson DL, et al. Perioperative external pneumatic calf compression as thromboembolism prophylaxis in gynecologic oncology: Report of a randomized controlled trial. Gynecol Oncol 1984;18:226-232.
  3. Clarke-Pearson DL, et al. Venous thromboembolism prophylaxis in gynecologic oncology: A prospective, controlled trial of low-dose heparin. Am J Obstet Gynecol 1983;145:606-613.
  4. ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet Gynecol2007;110:429-440.
  5. Rahn DD, et al. Venous thromboembolism prophylaxis in gynecologic surgery: A systematic review. Obstet Gynecol 2011;118:1111-1125.