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Timing of Chemical Thromboprophylaxis and Deep Vein Thrombosis in Major Colorectal Surgery - A Randomized Clinical Trial
Karen Zaghiyan*, Harry Sax*, Emily Miraflor*, David Cossman*, Willis Wagner*, Bruce Gewertz, Phillip Fleshner*
Cedars Sinai Medical Center, Los Angeles, CA

OBJECTIVE(S):
There is limited Level 1 data regarding the optimal timing of chemical thromboprophylaxis (CTP) for colorectal surgery. The incidence of occult preoperative deep vein thrombosis (DVT) also remains unclear. Both issues influence the occurrence of venous thromboembolism (VTE) and may jeopardize Medicare reimbursement due to penalties for hospital acquired conditions.
METHODS:
Patients undergoing major colorectal surgery underwent lower extremity venous duplex immediately prior to surgery. Those without occult preoperative DVT were randomized to preoperative or postoperative CTP (5000 units subcutaneous heparin). Patients underwent venous duplex immediately postoperatively and on day 2. Subsequent duplex scans and other studies were dictated by clinical need. The primary outcome was VTE defined as pulmonary embolism (PE) or DVT within 48 hours of surgery. Secondary outcomes included VTE at 30-days and bleeding complications. Fisher’s exact test was used to compared categorical variables with p <0.05 considered statistically significant.
RESULTS:
Eighteen patients (4.2%) had occult preoperative DVT and were excluded. The randomized group included 376 patients (51.6% female) with mean age of 52.7±17.6 years. No PE were noted. There was no significant difference between preoperative and postoperative CTP patient groups in early postoperative DVT (3/184, 1.6% vs 5/192, 2.6%), DVT at 30 days (1.6% vs 3.6%) or bleeding complications requiring reoperation (0.5% vs 1.6%).
CONCLUSIONS:
Preoperative and postoperative CTP are equally safe and effective. Since occult preoperative DVT is twice as common as postoperative DVT, lower extremity duplex scans should be performed prior to colorectal surgery and anticoagulation tailored to the result.


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