VTE prophylaxis after gastrectomy may boost bleeding in Asian patients

Last Updated: 2018-07-25

By David Douglas

NEW YORK (Reuters Health) - In Asian patients, symptomatic venous thromboembolism (VTE) after gastrectomy is extremely rare, and pharmacological prophylactic measures may prompt bleeding complications, Korean researchers say.

While U.S. guidelines recommend prophylaxis in this setting, VTE rates appear to be much lower in Asian patients and "many surgeons in Asian countries do not use VTE prophylaxis," Dr. Kyo Young Song of The Catholic University of Korea in Seoul and colleagues note in a July 18 online paper in JAMA Surgery.

To further investigate, the researchers randomly assigned 666 patients who underwent gastrectomy for gastric adenocarcinoma to prophylaxis with intermittent pneumatic compression (IPC) alone or to IPC plus low-molecular-weight heparin sodium.

The overall incidence of VTE was 2.1% and was significantly higher with IPC alone (3.6%) than with IPC and heparin group (0.6%). Both per-protocol and intention-to-treat analysis gave similar results. There were no reported cases of VTE mortality.

However, 13 of the 14 VTE patients were asymptomatic and received a diagnosis of deep vein thrombosis (DVT) after routine postoperative duplex ultrasonography (DUS). Thus, say the investigators, "the incidence of symptomatic VTE was only 0.2% . . . which means that DVT might not have been diagnosed unless DUS had been performed."

The incidence of bleeding complications was 5.1% and was significantly higher in the heparin group (9.1% versus 1.2%). Both major and minor bleeding events were more frequent with heparin.

Thus, the investigators conclude, "Given the extremely low incidence of symptomatic VTE and the relatively higher incidence of bleeding complications among these patients, routine administration of IPC plus low-molecular-weight heparin for VTE prophylaxis is not recommended."

Commenting by email, Dr. Elliott R. Haut, co-author of an accompanying editorial, told Reuters Health, "The critically important aspect of this paper is the very large difference between VTE in this population of Korean patients versus those undergoing the same surgery in the United States."

Dr. Haut of The Johns Hopkins University School of Medicine, Baltimore, Maryland, added, "There is still debate about whether blood clot risk varies by ethnicity - a classic question of nature versus nurture. Is their rate lower due to their genes? Or something else that makes these patients systemically different?" Among such possibilities are diet, surgical approach, and screening practices.

Dr. Haut and his co-authors conclude their editorial by pointing out that the findings "offer compelling data on the need for future research to define optimal VTE prevention in selected populations."

Dr. Song did not respond to requests for comments.

SOURCE: http://bit.ly/2v4jkSq and http://bit.ly/2uZpdjE

JAMA Surg 2018.