Role of extended venous thromboembolism prophylaxis in patients with colorectal neoplasia who underwent minimally invasive colorectal surgery within an enhanced recovery after surgery protocol.

Abstract

Background: Patients with colorectal cancer are at increased risk of venous thromboembolism (VTE) due to malignancy-associated hypercoagulability and the physiologic stress of surgery. Current guidelines recommend extended-duration thromboprophylaxis for up to 28 days following major abdominal or pelvic cancer surgery. However, its effectiveness in patients managed by Enhanced Recovery After Surgery (ERAS) pathways is uncertain. This study evaluated the effectiveness of extended thromboprophylaxis after minimally invasive colorectal resection managed within a mature ERAS program in reducing clinically significant VTE.

Methods: A retrospective cohort study was conducted including all adult patients undergoing elective minimally invasive colorectal resection for neoplasia at a high-volume Canadian academic centre between 01/2016 and 12/2024. Patients undergoing open surgery, emergency procedures, or receiving therapeutic anticoagulation were excluded. All patients received standard in-hospital thromboprophylaxis. Extended thromboprophylaxis with dalteparin 5000 U for 28 days post-discharge was provided at the physician's discretion before 03/2018 and was subsequently included in the ERAS protocol. The primary outcome was symptomatic post-discharge VTE within 30 days of surgery. Secondary outcomes included bleeding complications, length of stay, emergency department visits, and readmissions.

Results: A total of 1043 included in the primary analysis after excluding inpatient VTE events (n=351 patients did not receive extended prophylaxis, n=692 received extended prophylaxis). The incidence of post-discharge VTE was 0.5% (6/1043). There was a higher incidence of VTEs in the -eDVTp group compared to the +eDVTp group [5/351(1.4%) vs. 1/692 (0.1%), p=0.010]. Post-discharge VTE was significantly higher in patients who did not receive extended prophylaxis compared with those who did (1.4% vs. 0.1%, p = 0.010). There were no significant differences in overall or clinically significant bleeding between groups.

Conclusions: In patients undergoing minimally invasive colorectal resection within a mature ERAS pathway, the incidence of symptomatic post-discharge VTE is very low. Although extended thromboprophylaxis was associated with a statistically significant reduction in VTE events, the absolute risk reduction was small.