Extended Thromboprophylaxis following Major Open Abdominopelvic Surgery for Malignancy: A Review of Efficacy, Safety and Economic Impact

Abstract

The primary aim of this project was to perform a systematic review and meta-analysis of the currently available literature, comparing the effectiveness and safety of inpatient versus extended venous thromboembolism (VTE) prophylaxis with heparin following major open abdominal or pelvic surgery for malignancy. A secondary aim was to use the results of this review to evaluate the economic implications of providing extended pharmacological VTE prophylaxis in this population. A protocol for a systematic review of the literature was first developed, registered and published. Systematic literature review and meta-analysis were then performed in accordance with the protocol, and the results published. Finally, the results of the literature review were compared to literature estimates of the incidence and cost of VTE events in the absence of pharmacological prophylaxis, and current cost of Enoxaparin on the Pharmaceutical Benefits Scheme (PBS) in Australia, and a further manuscript produced which is currently submitted for consideration of publication. The result of the literature review was that no significant difference was found in either postoperative VTE rates or bleeding complications when comparing patients receiving extended duration versus inpatient only heparin VTE prophylaxis following major open abdominopelvic surgery for malignancy. However, the available contemporaneously published evidence was limited and of poor quality so this finding must be interpreted with caution. Regarding the secondary aim, cost analysis based on results of the literature review found the cost of providing extended duration heparin VTE prophylaxis to be less than that of treating predicted VTE events without prophylaxis, and therefore financially justifiable. However, if the initial finding of no significant difference in postoperative VTE events with extended compared to inpatient prophylaxis is assumed to be correct, on a purely financial basis inpatient only duration prophylaxis may be a more efficient use of resources.