Outcomes following pancreatic surgery using three different thromboprophylaxis regimens. Issue 6 (18th February 2019)

• Record Type: Journal Article
• Authors: Hanna-Sawires, R G; Groen, J V; Klok, F A; Tollenaar, R A E M; Mesker, W E; Swijnenburg, R J; Vahrmeijer, A L; Bonsing, B A; Mieog, J S D
• Is Part Of: British journal of surgery. Volume 106:Issue 6(2019)
• Page Start: 765
• Page End: 773
• Publication Date: 2019-02-18
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1002/bjs.11103
• Languages: English
• ISSNs: 0007-1323

Abstract

Abstract: Background: Postpancreatectomy haemorrhage (PPH) and venous thromboembolism (VTE) are serious complications following pancreatic surgery. The aim was to assess the timing, occurrence and predictors of PPH and VTE. Methods: Elective pancreatic resections undertaken in a single university hospital between November 2013 and September 2017 were assessed. Three intervals were reviewed, each with a different routine regimen of nadroparin: 2850 units once daily (single dose) administered in hospital only, or 5700 units once daily (double dose) or 2850 units twice daily (split dose) administered in hospital and continued for 6 weeks after surgery. Clinically relevant PPH (CR-PPH) was classified according to International Study Group of Pancreatic Surgery criteria. VTE was defined according to a number of key diagnostic criteria within 6 weeks of surgery. Cox regression analyses were performed to test the hypotheses that the double-dose group would experience more PPH than the other two groups, the single-dose group would experience more VTE than the other two groups, and the split-dose group would experience the fewest adverse events (PPH or VTE). Results: In total, 240 patients were included, 80 per group. The double-dose group experienced significantly more CR-PPH (hazard ratio (HR) 2·14, 95 per cent c.i. 1·16 to 3·94; P = 0·015). More relaparotomies due to CR-PPH were performed in the double-dose group (16 versus 3·8 per cent; P = 0·002). The single-dose group did not experience more VTE (HR 1·41, 0·43 to 4·62; P = 0·570). The split dose was not associated with fewer adverse events (HR 0·77, 0·41 to 1·46; P = 0·422). Double-dose low molecular weight heparin (LMWH), high BMI and pancreatic fistula were independent predictors of CR-PPH. Conclusion: A double dose of LMWH prophylaxis continued for 6 weeks after pancreatic resection was associated with a twofold higher rate of CR-PPH, resulting in four times more relaparotomies. Patients receiving a single daily dose of LMWH in hospital only did not experience a higher rate of VTE. Graphical Abstract: Three different low molecular weight heparin in-hospital regimens were reviewed retrospectively: once-daily 2850 units (single dose), once-daily 5700 units (double dose) or twice-daily 2850 units (split dose) of nadroparin. A double dose was independently associated with a twofold higher rate of clinically relevant postpancreatectomy haemorrhage, necessitating a fourfold higher relaparotomy rate. A single dose did not appear to increase the venous thromboembolism rate. Once daily single dose of low molecular weight heparin prophylaxis in hospital best