Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

doi:10.1097/SLA.0000000000006059

Meta-Analysis

. 2024 Feb 1;279(2):213-225.

doi: 10.1097/SLA.0000000000006059. Epub 2023 Aug 8.

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

Lauri I Lavikainen¹, Gordon H Guyatt^{2

3}, Ville J Sallinen^{4

5}, Paul J Karanicolas^{6

7}, Rachel J Couban⁸, Tino Singh⁹, Yung Lee¹⁰, Jaana Elberkennou¹¹, Riikka Aaltonen¹², Kaisa Ahopelto⁴, Ines Beilmann-Lehtonen⁴, Marco H Blanker¹³, Jovita L Cárdenas¹⁴, Rufus Cartwright¹⁵, Samantha Craigie², P J Devereaux^{2

3

16

17}, Herney A Garcia-Perdomo¹⁸, Fang Zhou Ge¹⁹, Huda A Gomaa^{20

21}, Alex L E Halme¹, Jari Haukka^{22

23}, Päivi K Karjalainen²⁴, Tuomas P Kilpeläinen²⁵, Antti J Kivelä⁵, Hanna Lampela⁵, Anne K Mattila²⁶, Borna Tadayon Najafabadi², Taina P Nykänen²⁷, Sanjay Pandanaboyana^{28

29}, Negar Pourjamal¹, Chathura B B Ratnayake^{30

31}, Aleksi Raudasoja¹, Robin W M Vernooij^{32

33}, Philippe D Violette^{2

34}, Yuting Wang², Yingqi Xiao^{2

35}, Liang Yao², Kari A O Tikkinen^{1

25

36}; ROTBIGGS Investigators

Collaborators, Affiliations

Collaborators

ROTBIGGS Investigators:
Yoshitaka Aoki, Karoliina M Aro, Päivi J Galambosi, Peter Gross, Sakineh Hajebrahimi, Linglong Huang, Matthew L Izett-Kay, Kirsi M Joronen, Ilkka E J Kalliala, Nadina Khamani, Tapio Korhonen, Anna L Luomaranta, Carolina Nystén, Sanna M Oksjoki, Riikka M Tähtinen

Affiliations

¹ Faculty of Medicine, University of Helsinki, Helsinki, Finland.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁴ Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
⁵ Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
⁶ Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁷ Department of Surgery, University of Toronto, Toronto, ON, Canada.
⁸ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
⁹ Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
¹⁰ Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada.
¹¹ Department of Surgery, Vaasa Central Hospital, Vaasa, Finland.
¹² Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland.
¹³ Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
¹⁴ Direction of Health Technologies Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico.
¹⁵ Departments of Gynecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK.
¹⁶ Anesthesiology, Perioperative Medicine, and Surgical Research Group, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
¹⁷ Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, USA.
¹⁸ Department of Surgery, Division of Urology, School of Medicine, Universidad del Valle, Cali, Colombia.
¹⁹ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
²⁰ Department of Biostatistics, High Institute of Public Health, Alexandria University, Egypt.
²¹ Department of Medical Pharmacology, Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt.
²² Health Sciences, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
²³ Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland.
²⁴ Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland.
²⁵ Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
²⁶ Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland.
²⁷ Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland.
²⁸ Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
²⁹ Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK.
³⁰ Department of Surgery, The University of Auckland, Auckland, New Zealand.
³¹ Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
³² Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
³³ Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
³⁴ Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada.
³⁵ Department of Nursing and West China School of Nursing, West China Hospital and Sichuan University, Chengdu, China.
³⁶ Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.

PMID: 37551583
PMCID: PMC10782937
DOI: 10.1097/SLA.0000000000006059

Meta-Analysis

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

Lauri I Lavikainen et al. Ann Surg. 2024.

. 2024 Feb 1;279(2):213-225.

doi: 10.1097/SLA.0000000000006059. Epub 2023 Aug 8.

Authors

Collaborators

ROTBIGGS Investigators:
Yoshitaka Aoki, Karoliina M Aro, Päivi J Galambosi, Peter Gross, Sakineh Hajebrahimi, Linglong Huang, Matthew L Izett-Kay, Kirsi M Joronen, Ilkka E J Kalliala, Nadina Khamani, Tapio Korhonen, Anna L Luomaranta, Carolina Nystén, Sanna M Oksjoki, Riikka M Tähtinen

Affiliations

¹ Faculty of Medicine, University of Helsinki, Helsinki, Finland.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
³ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁴ Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
⁵ Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
⁶ Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁷ Department of Surgery, University of Toronto, Toronto, ON, Canada.
⁸ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
⁹ Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
¹⁰ Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada.
¹¹ Department of Surgery, Vaasa Central Hospital, Vaasa, Finland.
¹² Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland.
¹³ Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
¹⁴ Direction of Health Technologies Assessment, National Center for Health Technology Excellence (CENETEC), Mexico City, Mexico.
¹⁵ Departments of Gynecology and Gender Affirmation Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK.
¹⁶ Anesthesiology, Perioperative Medicine, and Surgical Research Group, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
¹⁷ Department of Outcomes Research, Outcomes Research Consortium, Cleveland, OH, USA.
¹⁸ Department of Surgery, Division of Urology, School of Medicine, Universidad del Valle, Cali, Colombia.
¹⁹ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
²⁰ Department of Biostatistics, High Institute of Public Health, Alexandria University, Egypt.
²¹ Department of Medical Pharmacology, Tanta Chest Hospital, Ministry of Health and Population, Tanta, Egypt.
²² Health Sciences, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
²³ Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland.
²⁴ Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland.
²⁵ Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
²⁶ Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland.
²⁷ Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland.
²⁸ Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
²⁹ Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK.
³⁰ Department of Surgery, The University of Auckland, Auckland, New Zealand.
³¹ Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
³² Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
³³ Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
³⁴ Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada.
³⁵ Department of Nursing and West China School of Nursing, West China Hospital and Sichuan University, Chengdu, China.
³⁶ Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland.

PMID: 37551583
PMCID: PMC10782937
DOI: 10.1097/SLA.0000000000006059

Abstract

Objective: To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery.

Background: The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain.

Methods: We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty.

Results: After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer.

Conclusions: VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

PubMed Disclaimer

Conflict of interest statement

P.J.K. received a research grant from the Focused Ultrasound Foundation (all unrelated to this manuscript). P.J.D. received research grants from Abbott Laboratories, CloudDX, Philips Healthcare, Roche Diagnostics, and Siemens (all unrelated to this manuscript). R.C., P.D.V., and K.A.O.T. are panel members of the European Society of Anesthesiology and Intensive Care (ESAIC) Task Force for the European Guidelines on Venous Thromboembolism (VTE). The remaining authors report no conflicts of interest.

Figures

**FIGURE 1**
Infographic providing procedure-specific risk estimates of symptomatic VTE and bleeding requiring reintervention after general abdominal surgery procedures.

**FIGURE 2**
Infographic providing procedure-specific risk estimates of symptomatic VTE and bleeding requiring reintervention after colorectal surgery procedures.

**FIGURE 3**
Infographic providing procedure-specific risk estimates of symptomatic VTE and bleeding requiring reintervention after upper gastrointestinal and hepatopancreatobiliary surgery procedures.

See this image and copyright information in PMC

Comment in

"To bleed or to clot, that is the question"-the benefit of a procedure-specific risk tool to guide perioperative anticoagulation.
Ivankovic V, Delisle M, Noureldin A, Carrier M, Auer RC. Ivankovic V, et al. Hepatobiliary Surg Nutr. 2024 Dec 1;13(6):1058-1061. doi: 10.21037/hbsn-24-608. Epub 2024 Nov 20. Hepatobiliary Surg Nutr. 2024. PMID: 39669071 Free PMC article. No abstract available.
Balancing the risks of venous thromboembolism and bleeding in abdominal surgery: factors to consider in personalising thromboprophylaxis.
Asgill T, Allaway MGR, Liu DS. Asgill T, et al. Hepatobiliary Surg Nutr. 2024 Dec 1;13(6):1051-1053. doi: 10.21037/hbsn-24-602. Epub 2024 Nov 15. Hepatobiliary Surg Nutr. 2024. PMID: 39669089 Free PMC article. No abstract available.

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Surgical Outcome After Distal Pancreatectomy With and Without Portomesenteric Venous Resection in Patients with Pancreatic Adenocarcinoma: A Transatlantic Evaluation of Patients in North America, Germany, Sweden, and The Netherlands (GAPASURG).
Stoop TF, Augustinus S, Björnsson B, Tingstedt B, Andersson B, Wolfgang CL, Werner J, Johansen K, Stommel MWJ, Katz MHG, Ghadimi M, House MG, Ghorbani P, Molenaar IQ, de Wilde RF, Mieog JSD, Keck T, Wellner UF, Uhl W, Besselink MG, Pitt HA, Del Chiaro M; for the Global Audits on Pancreatic Surgery Group (GAPASURG). Stoop TF, et al. Ann Surg Oncol. 2024 Nov;31(12):8327-8339. doi: 10.1245/s10434-024-15932-3. Epub 2024 Aug 9. Ann Surg Oncol. 2024. PMID: 39120839 Free PMC article.
Integrating 7-day D-dimer exposure into deep vein thrombosis risk prediction after gastrointestinal surgery.
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The CLUE postsurgery VTE risk instrument for abdominal and pelvic surgery: validation of patient risk factor component.
Tikkinen KAO, Siegal DM, Devereaux PJ, Tornberg SV, Borges FK, Ofori S, Pinthus J, Shayegan B, Lavikainen LI; CLUE Post-Surgery VTE Risk Instrument Group; Guyatt GH, Roshanov PS. Tikkinen KAO, et al. Blood Adv. 2025 Aug 12;9(15):3837-3844. doi: 10.1182/bloodadvances.2024015515. Blood Adv. 2025. PMID: 40354313 Free PMC article.
Analysis of the efficacy of a prophylactic increasing blood pressure before the end of surgery to reduce postoperative bleeding after gastrectomy: a propensity score-matched analysis.
Zhu G, Zhou S, Sun Q, Lu X, Zhu Q, Yin X, Yu L, Qu J, Lang X. Zhu G, et al. BMC Surg. 2025 Mar 10;25(1):93. doi: 10.1186/s12893-025-02826-8. BMC Surg. 2025. PMID: 40065338 Free PMC article.
Balancing the risks of venous thromboembolism and bleeding in abdominal surgery: factors to consider in personalising thromboprophylaxis.
Asgill T, Allaway MGR, Liu DS. Asgill T, et al. Hepatobiliary Surg Nutr. 2024 Dec 1;13(6):1051-1053. doi: 10.21037/hbsn-24-602. Epub 2024 Nov 15. Hepatobiliary Surg Nutr. 2024. PMID: 39669089 Free PMC article. No abstract available.

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References

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[1] Research and Markets. General surgery trends and opportunities—procedure volumes analysis—Global 2018. Accessed April 10, 2023. https://www.researchandmarkets.com/reports/4658245/general-surgery-trend...

[2] Research and Markets. General surgery trends and opportunities—procedure volumes analysis—Global 2018. Accessed April 10, 2023. https://www.researchandmarkets.com/reports/4658245/general-surgery-trend...

[3] Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Study I, Spence J, LeManach Y, et al. . Association between complications and death within 30 days after noncardiac surgery. CMAJ. 2019;191:E830–E837. - PMC - PubMed

[4] Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Study I, Spence J, LeManach Y, et al. . Association between complications and death within 30 days after noncardiac surgery. CMAJ. 2019;191:E830–E837. - PMC - PubMed

[5] Pak H, Maghsoudi LH, Soltanian A, et al. . Surgical complications in colorectal cancer patients. Ann Med Surg (Lond). 2020;55:13–18. - PMC - PubMed

[6] Pak H, Maghsoudi LH, Soltanian A, et al. . Surgical complications in colorectal cancer patients. Ann Med Surg (Lond). 2020;55:13–18. - PMC - PubMed

[7] Tevis SE, Kennedy GD. Postoperative complications: looking forward to a safer future. Clin Colon Rectal Surg. 2016;29:246–252. - PMC - PubMed

[8] Tevis SE, Kennedy GD. Postoperative complications: looking forward to a safer future. Clin Colon Rectal Surg. 2016;29:246–252. - PMC - PubMed

[9] International Surgical Outcomes Study g. Global patient outcomes after elective surgery: prospective cohort study in 27 low, middle and high-income countries. Br J Anaesth. 2016;117:601–609. - PMC - PubMed

[10] International Surgical Outcomes Study g. Global patient outcomes after elective surgery: prospective cohort study in 27 low, middle and high-income countries. Br J Anaesth. 2016;117:601–609. - PMC - PubMed

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Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

Collaborators

Affiliations

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

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Abstract

Conflict of interest statement

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