Advances and Challenges in the Application of Novel Oral Anticoagulants for Venous Thromboembolism Prevention Following Colorectal Cancer Surgery

Abstract

Background: Venous thromboembolism (VTE) is a common but severe complication following colorectal cancer (CRC) surgery. Traditional anticoagulants such as low molecular weight heparin (LMWH) and vitamin K antagonists face limitations in clinical due to requirements for frequent monitoring, subcutaneous administration, and poor patient adherence. Novel Oral Anticoagulants (NOACs), with advantages including oral administration, stable pharmacokinetics, and no requirement for routine monitoring, have emerged as potential alternatives for postoperative VTE prophylaxis.

Methods: This narrative review synthesized evidence from PubMed and Web of Science (up to October 2024). Initial plans for a systematic review were adjusted due to limited CRC-specific trials, focusing instead on bridging existing evidence to emerging clinical applications.

Results: Postoperative VTE incidence remains heterogeneous, influenced by symptom-driven versus systematic detection and temporal improvements in perioperative care. Extended LMWH reduces VTE risk, yet adherence remains low. The PROLAPS II trial demonstrated rivaroxaban's efficacy in reducing VTE after laparoscopic CRC surgery, with comparable major bleeding rates to placebo. Meta-analyses confirm NOACs' non-inferiority to LMWH for short-term prophylaxis, but CRC-specific extended regimens lack validation. Safety concerns include heightened gastrointestinal/genitourinary bleeding risks and potential drug interactions with anticancer therapies. Clinician familiarity gaps and patient resistance to injectable agents further impede guideline adherence. Conflicting guidelines underscore unresolved debates on ideal regimens.

Conclusion: NOACs offer practical advantages over LMWH for extended thromboprophylaxis in CRC surgery, particularly in enhancing adherence. However, bleeding risks and limited high-quality evidence necessitate cautious clinical integration. Future research must prioritize large-scale RCTs to validate LMWH-NOAC sequential regimens, optimize risk-stratified protocols, and address interactions within enhanced recovery pathways. Harmonized guidelines and provider education are critical to bridging implementation gaps.

Keywords: Colorectal cancer; Low molecular weight heparin; Novel oral anticoagulant; Surgery; Venous thromboembolism.