Outcomes| Volume 172, ISSUE 1, P234-240, July 2022

Prophylaxis extension for venous thromboembolism after major abdominal and pelvic surgery for cancer (prevent): Quality improvement transitioned into a cohort study

Published:February 10, 2022DOI:



      Extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery has not been widely adopted. We compared outcomes of patients pre- and postimplementation of extended venous thromboembolism prophylaxis with low molecular weight heparin.


      Prospectively collected data from a quality initiative project aimed at prescribing extended venous thromboembolism prophylaxis after abdominopelvic cancer surgery was compared with previously published data from a prospective cohort without extended venous thromboembolism prophylaxis. The primary outcome was 6-month postoperative symptomatic venous thromboembolism incidence. Secondary outcomes: differences in 1- and 3-month venous thromboembolism incidence and factors associated with venous thromboembolism using Cox-proportional hazard models. Cumulative incidence of venous thromboembolism was estimated using Kaplan-Meier methods and expressed as proportions with 95% confidence interval.


      There were 241 patients in the venous thromboembolism-prophylaxis cohort and 284 patients in the no venous thromboembolism prophylaxis cohort. Patients in the venous thromboembolism-prophylaxis cohort were more likely to be female (69% vs 60%, P = .018), have metastatic disease (49% vs 29%, P < .001), have longer operative times (236 min vs 197 min, P < .001), and to receive neoadjuvant chemotherapy (27% vs 23%, P = .006). Respectively, the 1- (0.5% [95% confidence interval, 0.1–2.5] vs 0.4% [95% confidence interval, 0.1–2.5]), 3- (2.6% [95% confidence interval, 1.2–5.6] vs 2.5% [95% confidence interval, 1.2–5.2]), and 6-month (7.5% [95% confidence interval, 4.8–11.5] vs 7.2% [95% confidence interval, 4.7–11.0]) venous thromboembolism incidence were similar. By multivariable analysis, history of venous thromboembolism (hazard ratio 3.52; 95% confidence interval, 1.03–12.05; P = .045) and longer duration of hospital stay (hazard ratio 1.07; 95% confidence interval, 1.01–1.12; P = .016) demonstrated increased risk of venous thromboembolism.


      This study failed to demonstrate a decreased 1-, 3-, and 6-month postoperative venous thromboembolism incidence after the implementation of extended venous thromboembolism prophylaxis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lyman G.H.
        Venous thromboembolism in the patient with cancer.
        Cancer. 2011; 117: 1334-1349
        • Gould M.K.
        • Garcia D.A.
        • Wren S.M.
        • et al.
        Prevention of VTE in nonorthopedic surgical patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2012; 141: e227S-e277S
        • Trinh V.Q.
        • Karakiewicz P.I.
        • Sammon J.
        • et al.
        Venous thromboembolism after major cancer surgery: Temporal trends and patterns of care.
        JAMA Surgery. 2014; 149: 43-49
        • Agnelli G.
        • Bolis G.
        • Capussotti L.
        • et al.
        A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: The @RISTOS Project.
        Ann Surg. 2006; 243: 89-95
        • Geerts W.H.
        • Pineo G.F.
        • Heit J.A.
        • et al.
        Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
        Chest. 2004; 126: 338S-400S
        • Lyman G.H.
        • Khorana A.A.
        • Kuderer N.M.
        • et al.
        Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.
        J Clin Oncol. 2013; 31: 2189-2204
        • Rasmussen M.S.
        • Jorgensen L.N.
        • Wille-Jorgensen P.
        • et al.
        Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: A multicenter randomized open-label study.
        J Thromb Haemost. 2006; 4: 2384-2390
        • Avid D.
        • Ergqvist B.
        • Gnelli I.A.
        • et al.
        Prophylaxis with enoxaparin after surgery for cancer: Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer.
        N Engl J Med. 2002; 346: 975-980
        • Kakkar V.
        • Balibrea J.
        • Martinez-Gonzalez J.
        • Prandoni P.
        Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: The CANBESURE randomized study.
        J Thromb Haemost. 2010; 8: 1223-1229
        • Serrano P.E.
        • Parpia S.
        • Valencia M.
        • Simunovic M.
        • Bhandari M.
        • Levine M.
        Incidence of delayed venous thromboembolic events in patients undergoing abdominal and pelvic surgery for cancer: A systematic review and meta-analysis.
        ANZ J Surg. 2019; 89: 1217-1223
        • Serrano P.E.
        • Parpia S.
        • Linkins L.A.
        • et al.
        Venous thromboembolic events following major pelvic and abdominal surgeries for cancer: A prospective cohort study.
        Ann Surg Oncol. 2018; 25: 3214-3221
        • Griffiths C.D.
        • Simunovic M.
        • Gafni A.
        • Parpia S.
        • Linkins L.A.
        • Serrano P.E.
        Posthospital discharge venous thromboembolism prophylaxis among colorectal and hepatobiliary surgeons: A practice survey.
        Surgery. 2021; 170: 173-179
        • Elm E von
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        Strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies.
        BMJ. 2007; 335: 806-808
        • Schünemann H.J.
        • Cushman M.
        • Burnett A.E.
        • et al.
        American Society of Hematology 2018 guidelines for management of venous thromboembolism: Prophylaxis for hospitalized and nonhospitalized medical patients.
        Blood Advances. 2018; 2: 3198-3225
        • Schulman S.
        • Anger S.U.
        • Bergqvist D.
        • Eriksson B.
        • Lassen M.R.
        • Fisher W.
        Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients.
        J Thromb Haemost. 2010; 8: 202-204
        • Cronin M.A.
        • Dengler N.
        • Krauss E.S.
        • et al.
        Completion of the Updated Caprini Risk Assessment Model (2013 Version).
        Clin Appl Thromb Hemost. 2019; 25
        • Fagarasanu A.
        • Alotaibi G.S.
        • Hrimiuc R.
        • Lee A.Y.Y.
        • Wu C.
        Role of extended thromboprophylaxis after abdominal and pelvic surgery in cancer patients: A systematic review and meta-analysis.
        Ann Surg Oncol. 2016; 23: 1422-1430
        • Bottaro F.J.
        • Elizondo M.C.
        • Doti C.
        • et al.
        Efficacy of extended thrombo-prophylaxis in major abdominal surgery: What does the evidence show? A meta-analysis.
        Thromb Haemost. 2008; 99: 1104-1111
        • Khorana A.A.
        • Francis C.W.
        • Culakova E.
        • Kuderer N.M.
        • Lyman G.H.
        Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients.
        Cancer. 2007; 110: 2339-2346