RecommendationExtend pharmacological prophylaxis to 28 days postoperatively for patients who have had major cancer surgery in the abdomen or pelvis.
Relative values of different outcomesThe outcomes included in the economic model were thromboembolic events (asymptomatic and symptomatic DVT, symptomatic pulmonary embolism and fatal pulmonary embolism), bleeding events (major bleeding, fatal bleeding and stroke) and other long term events occurring as a result of VTE (chronic thromboembolic pulmonary hypertension and post thrombotic syndrome). Each of these events had a cost and loss of quality adjusted life year associated with it, the details of which are provided in the methods of cost effectiveness chapter.
Trade off between clinical benefit and harmsThe benefit of reducing the risk of venous thromboembolism and long term events occurring as a result of thromboembolism were considered against the risk of major bleeding. Our decision model indicated that the QALYs lost due to major bleeding were outweighed by the QALYs gained from drug prophylaxis.
Economic considerationsIn our economic analysis, post-discharge prophylaxis with LMWH was cost-effective for cancer surgery patients at £4,400 per QALY gained.
Quality of evidenceThere are 3 RCTs covering this group of patients. All included RCTs were either individually critically appraised to be of a high quality (level 1+ or level 1++) or came from systematic reviews of RCTs which had been critically appraised to be of a high quality (level 1+ or level 1++).
1 of the RCTs investigated cancer surgery patients, the other 2 were a mixture of cancer surgery patients. Overall, the majority of patients had cancer.
There was little direct evidence for pulmonary embolism as most the trials screened for DVT and may have reduced the risk of pulmonary embolism from developing.
Other considerationsOnly trials for LMWH for extended duration prophylaxis in this population had been conducted. In these trial, the average duration of VTE prophylaxis was 28 days.
However, some patients may be contraindicated to LMWH and/or offered one of the other agents. The GDG still considered it important to extend pharmacological prophylaxis for 28 days postoperatively in these cases.

From: 9, Gastrointestinal, gynaecological, laparoscopic, thoracic and urological surgery

Cover of Venous Thromboembolism
Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital.
NICE Clinical Guidelines, No. 92.
National Clinical Guideline Centre – Acute and Chronic Conditions (UK).
Copyright © 2010, National Clinical Guideline Centre - Acute and Chronic Conditions.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre - Acute and Chronic Conditions to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.