The American Society of Colon and Rectal Surgeons Clinical Practice
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CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery Fergal Fleming, M.D. • Wolfgang Gaertner, M.D. • Charles A. Ternent M.D. Emily Finlayson, M.D., M.S. • Daniel Herzig, M.D. • Ian M. Paquette, M.D. Daniel L. Feingold, M.D. • Scott R. Steele, M.D. Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons ing the propriety of any specific procedure must be made is dedicated to ensuring high-quality patient care by the physician in light of all the circumstances presented Tby advancing the science, prevention, and manage- by the individual patient. ment of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is com- posed of society members who are chosen because they STATEMENT OF THE PROBLEM have demonstrated expertise in the specialty of colon and Venous thromboembolism (VTE), which includes deep rectal surgery. This committee was created to lead interna- venous thrombosis (DVT) and pulmonary embolism tional efforts in defining quality care for conditions related (PE), is a serious health problem in the United States, with to the colon, rectum, and anus. This is accompanied by de- an estimated 600,000 to 900,000 cases occurring annu- velopment of clinical practice guidelines based on the best ally.1,2 Venous thromboembolism is a common and often available evidence. These guidelines are inclusive but not morbid complication of any major surgery. Historical es- prescriptive. Their purpose is to provide information to timates from the control groups of randomized prophy- support decision making, rather than to dictate a specific laxis trials showed that over 30% of patients undergoing form of treatment. These guidelines are intended for the colorectal surgery developed DVT compared with 20% use of all practitioners, health care workers, and patients for all patients undergoing general surgery.3 Although who desire information about the management of the VTE may occur after any surgical procedure, patients conditions addressed by the topics covered in these guide- undergoing colorectal surgery are at significant risk for lines. It should be recognized that the guidelines should this perioperative complication with rates as high as 9% not be deemed inclusive of all proper methods of care nor even in patients receiving VTE chemoprophylaxis.3 This exclusive of methods of care reasonably directed toward elevated risk of a thrombotic complication is associated obtaining the same results. The ultimate judgment regard- with intraoperative patient positioning, pelvic dissection, and the presence of additional risk factors common in this Earn Continuing Education (CME) credit online at cme.lww.com. This patient cohort, including preexisting inflammation in the 4,5 activity has been approved for AMA PRA Category 1.5 Credit.TM form of malignancy or IBD. Although the focus of VTE prevention is often on those with malignancy, patients Supplemental digital content is available for this article. Direct URL ci- with IBD have a 2- to 3-fold increased risk of DVT and tations appear in the printed text, and links to the digital files are pro- PE compared with the general population.6 Results from vided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com). a multicenter randomized controlled trial in patients un- dergoing colorectal surgery comparing pharmacological Correspondence: Scott R. Steele, M.D., 9500 Euclid Ave/A30, Cleveland prophylaxis methods using ultrasound and venography Clinic, Cleveland OH, 44915. E-mail: [email protected] for diagnosis showed the rate of proximal DVT, defined 3 Dis Colon Rectum 2018; 61: 14–20 as popliteal or more proximal veins, to be 2.6% to 2.8%. DOI: 10.1097/DCR.0000000000000982 Population-based studies have also tried to estimate the © The ASCRS 2017 risk of DVT after colorectal surgery, although the lack of a 14 DISEASES OF THE COLON & RECTUM VOLUME 61: 1 (2018) Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. DISEASES OF THE COLON & RECTUM VOLUME 61: 1 (2018) 15 standardized definition and extended follow-up and diag- was examined, and a treatment guideline was formulated nostic testing limit the findings. by the subcommittee for this guideline. When agreement Deep venous thrombosis and PE have the potential to was incomplete regarding the evidence base or treatment result in short- and long-term morbidity. Pulmonary embo- guideline, consensus from the committee chair, vice chair, lism, although not common, remains the most likely cause and 2 assigned reviewers determined the outcome. The of potentially preventable death in surgical patients.7 On av- final grade of recommendation was performed using the erage, postoperative patients with VTE stay in the hospital 1 Grade of Recommendation, Assessment, Development, week longer.8 The estimated health care costs for patients with and Evaluation (GRADE) system (Table 1).14 Members of a PE and for patients with both DVT and PE are $31,270 and the ASCRS practice guidelines committee worked in joint $38,296.9 Although the initial clinical presentation of DVT is production of these guidelines from inception to final pub- typically less severe than PE, nearly one-third of patients with lication. Recommendations formulated by the subcommit- DVT develop long-term complications. Postphlebitic syn- tee were reviewed by the entire Clinical Practice Guidelines drome, for example, can occur years after the initial throm- Committee. Final recommendations were approved by the botic event and is associated with limb swelling, leg pain, and ASCRS Clinical Guidelines Committee and ASCRS Execu- ulceration that can result in substantial disability.10,11 tive Committee. In general, each ASCRS Clinical Practice Postoperative VTE remains a significant health care Guideline is updated every 5 years. issue with both short- and long-term morbidity for the individual patient and significant costs for the health care system. The aim of this clinical practice guideline is to MANAGEMENT RECOMMENDATIONS present and grade the evidence base for preoperative risk 1. The use of a VTE risk assessment model is recom- assessment and thromboprophylaxis in patients undergo- mended to guide VTE prophylaxis in patients under- ing colorectal surgery. going colorectal surgery. Grade of Recommendation: Weak recommendation based on high-quality evi- METHODOLOGY dence, 2A. This clinical practice guideline expands on the previous Patient-specific risk factors for VTE, bleeding risks, and Practice Parameters for the Prevention of Venous Thrombo- the specific surgical procedure must all be considered sis published by the American Society of Colon and Rectal to balance the risks and benefits of specific methods of Surgeons (ASCRS) in 2006.12 A clinical practice guide- thromboprophylaxis. Risk factors for VTE are numerous, line addressing specific issues pertaining to ambulatory and unfortunately most hospitalized patients will have at colorectal surgery has been recently published that also least 1 risk factor for VTE, and as many as 40% will carry outlines evidence specifically pertaining to thrombopro- 3 or more risk factors.15 Therefore, determining the ap- phylaxis for ambulatory colorectal surgery.13 The majority propriate patients to receive extended thromboprophy- of articles used to construct the prior guideline were dated laxis based on risk factors alone often is problematic. In in 2002 and earlier; as such, an organized search of MED- addition, the specific quantifiable risk imparted by various LINE, PubMed, and the Cochrane Database of System- conditions alone or in conjunction may vary. Factors may atic Reviews was performed of articles from January 2003 be patient, disease, or surgery specific and may or may not through December 2016.12 See Appendix 1 (http://links. be modifiable or transient (Table 2). Various methodolo- lww.com/DCR/A488) for the research strategy used for gies attempt to quantify the risk of developing VTE. MEDLINE and PubMed; 1904 titles were screened, and 312 Recent Antithrombotic Therapy and Prevention of references were directly reviewed, ultimately yielding 79 Thrombosis, 9th edition guidelines7 for prevention of VTE references for consideration. A similar but colorectal and in nonorthopedic surgical patients describe stratification pelvic surgery-targeted search was performed, yielding an of VTE risk in patients undergoing general and abdomino- additional 19 unique references. In addition, the Cochrane pelvic surgery among others. Two risk assessment models Database of Systematic Reviews was searched for deep ve- are described yielding very-low-risk, low- to moderate-risk, nous thrombosis, resulting in 65 titles, which were again and high-risk groups (Table 3). First, the Rogers score is screened and yielded 5 references for inclusion. Prospec- based on a model from a study of over 183,000 patients and tive, randomized controlled trials and meta-analyses were it assigns points based on variables found to be indepen- given preference in developing these guidelines. Directed dent predictors of VTE risk, including type of operation, searches of the embedded references from the primary ar- work-relative value units, patient characteristics, and labo- ticles were also performed in certain circumstances.