Venous thromboembolic prophylaxis after a hepatic resection: patterns of care among liver surgeons

Abstract

Introduction: No consensus exists for post-hepatectomy venous thromboembolic (VTE) prophylaxis. Factors impacting VTE prophylaxis patterns among hepato-pancreato-biliary (HPB) surgeons were defined.

Method: Surgeons were invited to complete a web-based survey on VTE prophylaxis. The impact of physician and clinical factors was analysed.

Results: Two hundred responses were received. Most respondents were male (91%) and practiced at academic centres (88%) in the United States (80%). Surgical training varied: HPB (24%), transplantation (24%), surgical oncology (34%), HPB/transplantation (13%), or no specialty (5%). Respondents estimated VTE risk was higher after major (6%) versus minor (3%) resections. Although 98% use VTE prophylaxis, there was considerable variability: sequential compression devices (SCD) (91%), unfractionated heparin Q12h (31%) and Q8h (32%), and low-molecular weight heparin (39%). While 88% noted VTE prophylaxis was not impacted by operative indication, 16% stated major resections reduced their VTE prophylaxis. Factors associated with the decreased use of pharmacologic prophylaxis included: elevated international normalized ratio (INR) (74%), thrombocytopaenia (63%), liver insufficiency (58%), large EBL (46%) and complications (8%). Forty-seven per cent of respondents wait until ≥post-operative day 1 (POD1) and 35% hold pharmacologic VTE prophylaxis until no signs of coagulopathy. A minority (14%) discharge patients on pharmacologic prophylaxis. While 81% have institutional VTE guidelines, 79% believe hepatectomy-specific guidelines would be helpful.

Conclusion: There is considerable variation regarding VTE prophylaxis among liver surgeons. While most HPB surgeons employ VTE prophylaxis, the methods, timing and purported contraindications differ significantly.

Figure 1

Proportion of respondents identifying factor as increasing likelihood of administering pharmacological deep vein thrombosis (DVT)/pulmonary embolism (PE) prophylaxis

Figure 2

Proportion of respondents identifying factor as decreasing likelihood of administering pharmacological deep vein thrombosis (DVT)/pulmonary embolism (PE) prophylaxis