Putsarat Insin1, Kasidin Vitoopinyoparb2, Kunlawat Thadanipon3, Chuenkamon Charakorn4, John Attia5, Gareth J McKay6, Ammarin Thakkinstian3. 1. Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI road, Thung Phaya Thai, Ratchathewi District, Bangkok 10400, Thailand; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Rajavithi Hospital, 2 Phayathai Road, Ratchathewi Districts, Bangkok 10400, Thailand. 2. Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI road, Thung Phaya Thai, Ratchathewi District, Bangkok 10400, Thailand; Department of Surgery, Rajavithi Hospital, 2 Phayathai Road, Ratchathewi Districts, Bangkok, 10400, Thailand. 3. Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI road, Thung Phaya Thai, Ratchathewi District, Bangkok 10400, Thailand. 4. Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI road, Thung Phaya Thai, Ratchathewi District, Bangkok 10400, Thailand; Department of Clinical Epidemiology and Biostatistics, and Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Khet Ratchathewi, Bangkok, 10400, Thailand. Electronic address: chuenkamon.cha@mahidol.ac.th. 5. Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, Newcastle, University Dr, Callaghan, NSW 2308, Australia. 6. Centre for Public Health, Queen's University Belfast, Institute of Clinical Science, Block A, Royal Victoria Hospital, Belfast BT12 6BA, United Kingdom.
Abstract
OBJECTIVE: Although thromboprophylaxis is recommended to reduce death and disability from venous thromboembolism (VTE), it remains underused due to a perceived risk of bleeding, especially in major abdominopelvic surgical patients. METHODS: We conducted a systematic literature review to identify all eligible randomized controlled trials (RCTs), searching MEDLINE and Scopus databases through November 25, 2020. RCTs published in any language were eligible if they studied in gynecological cancer patients undergoing major abdominopelvic surgery and assessed efficacy of mechanical and pharmacological interventions. Studies with insufficient data for pooling or those comparing different doses/schedules of interventions were excluded. Outcomes of interest were composite VTE (ie, deep vein thrombosis or pulmonary embolism) and major bleeding. Relevant data were extracted for direct and network meta-analyses. Risk ratios (RR) and 95% confidence interval (CI) were estimated and the best intervention probability calculated for each outcome. This study was registered with PROSPERO (CRD42019145508). RESULTS: We identified 1990 studies; 20 RCTs (4970 patients) were eligible. The overall risk of bias was of some concern. In direct meta-analyses, antithrombins were superior to unfractionated heparin in preventing composite VTE (RR 0.69; 95% CI 0.48-0.99), with no difference detected in the rate of major bleeding for any pairwise comparison. In network meta-analyses, graduated compression stockings plus low-molecular-weight heparin (LMWH) was top-ranked for prevention of composite VTE, whereas sequential compression devices (SCD) ranked second, after no treatment, for major bleeding. In a clustered ranking plot, SCD plus LMWH provided optimal balance between efficacy and safety. CONCLUSIONS: SCD plus LMWH might be safe and effective in VTE prevention following gynecological cancer surgery. However, the patient's bleeding risk should be considered to balance the risk and benefit of treatment.
OBJECTIVE: Although thromboprophylaxis is recommended to reduce death and disability from venous thromboembolism (VTE), it remains underused due to a perceived risk of bleeding, especially in major abdominopelvic surgical patients. METHODS: We conducted a systematic literature review to identify all eligible randomized controlled trials (RCTs), searching MEDLINE and Scopus databases through November 25, 2020. RCTs published in any language were eligible if they studied in gynecological cancerpatients undergoing major abdominopelvic surgery and assessed efficacy of mechanical and pharmacological interventions. Studies with insufficient data for pooling or those comparing different doses/schedules of interventions were excluded. Outcomes of interest were composite VTE (ie, deep vein thrombosis or pulmonary embolism) and major bleeding. Relevant data were extracted for direct and network meta-analyses. Risk ratios (RR) and 95% confidence interval (CI) were estimated and the best intervention probability calculated for each outcome. This study was registered with PROSPERO (CRD42019145508). RESULTS: We identified 1990 studies; 20 RCTs (4970 patients) were eligible. The overall risk of bias was of some concern. In direct meta-analyses, antithrombins were superior to unfractionated heparin in preventing composite VTE (RR 0.69; 95% CI 0.48-0.99), with no difference detected in the rate of major bleeding for any pairwise comparison. In network meta-analyses, graduated compression stockings plus low-molecular-weight heparin (LMWH) was top-ranked for prevention of composite VTE, whereas sequential compression devices (SCD) ranked second, after no treatment, for major bleeding. In a clustered ranking plot, SCD plus LMWH provided optimal balance between efficacy and safety. CONCLUSIONS:SCD plus LMWH might be safe and effective in VTE prevention following gynecological cancer surgery. However, the patient's bleeding risk should be considered to balance the risk and benefit of treatment.
Authors: Dominique Farge; Corinne Frere; Jean M Connors; Alok A Khorana; Ajay Kakkar; Cihan Ay; Andres Muñoz; Benjamin Brenner; Pedro H Prata; Dialina Brilhante; Darko Antic; Patricia Casais; María Cecilia Guillermo Esposito; Takayuki Ikezoe; Syed A Abutalib; Luis A Meillon-García; Henri Bounameaux; Ingrid Pabinger; James Douketis Journal: Lancet Oncol Date: 2022-07 Impact factor: 54.433