Preoperative management of patients with gynecologic malignancy complicated by existing venous thromboembolism

In treating gynecologic malignancies, we sometimes encounter patients in whom venous thromboembolism (VTE) has developed before surgery. Few reports exist on preoperative management of VTE. We conducted a study to determine the optimum preoperative management strategy for patients with gynecologic malignancy and existing VTE.

We reviewed the clinical records of patients treated between April 2004 and March 2010 in the Department of Obstetrics and Gynecology at Mie University Hospital. During this period, 654 exploratory or therapeutic laparotomies were performed for gynecologic malignancy. All patients were assessed by ultrasound for VTE before and after surgery. Twenty-five of the 654 patients (3.8%) had preoperative VTE. We reviewed the 25 cases and evaluated the management method and outcomes in terms of VTE.

Most preoperative VTEs were located in a crural vein (23 cases; 92%); only 2 (8%) were in a pelvic vein. Three patients were excluded from the study because they had only a small organized thrombus and were treated with VTE prophylaxis according to American College of Chest Physicians (ACCP) guidelines. The other 22 patients were given graduated compression stockings and began anticoagulation therapy with heparin (unfractionated heparin or heparin calcium) immediately after the VTE diagnosis. Anticoagulation therapy was continued until a mean 8.5h before surgery and then restarted 10h (mean) after surgery. Sixteen of the 22 patients were treated by intermittent pneumatic compression during and after surgery. This management strategy resulted in six cases (27%) of diminished VTE, 10 cases (46%) without remarkable change, and six cases (27%) of deterioration. Clinical deterioration occurred in two of the 22 cases (9%), i.e., PE or pelvic VTE developed.

Our preoperative management of existing VTE appears to be insufficient. Shorter or no interruption of antithrombotic therapy and/or another intervention such as inferior vena cava filter placement may be necessary in patients with preoperative VTE.