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J Thorac Cardiovasc Surg 2008;135:705-706
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Department of Clinical Medicine, Insubria University, Varese, Italy
b Thrombosis/Haemostasis and Haematology Unit, University Hospital of Palermo, Palermo, Italy
c Center for Thoracic Surgery, University of Insubria, Varese, Italy
d Department of Surgery, Division of General and Thoracic Surgery, University of Palermo, Palermo, Italy
e Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Received for publication August 23, 2007; accepted for publication October 2, 2007. * Address for reprints: Francesco Dentali, MD, U.O. Medicina I, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy. (Email: fdentali{at}libero.it).
Limited information exists on the incidence of symptomatic venous thromboembolism (VTE) in patients undergoing chest surgery for lung cancer. Several factors increase the thromboembolic risk in patients undergoing surgery for lung cancer: the intrinsic procoagulant effect of cancer, extensive surgical intervention, dependent limb position in the operating room, and vessel injury consequent to the operation. Furthermore, these patients might be especially vulnerable to pulmonary embolism (PE) because of the loss of lung tissue and the presence of chronic obstructive pulmonary disease and cardiovascular diseases caused by smoking.1
Older studies found a very high incidence of thromboembolic events in these patients.2,3
However, the risk of thromboembolic complications in lung cancer surgery might have changed over the last years. Extensive use of antithrombotic prophylaxis, improvement in surgical techniques and perioperative care, and more prompt mobilization might have reduced the risk of VTE.
Therefore, the aim of our study was to provide up-to-date reliable data on the incidence of venous thromboembolic complication in a large cohort of patients undergoing chest surgery for malignant lung disease. Furthermore, the raw mortality rate and the mortality rate related to PE were evaluated.
We performed a chart review of all patients undergoing chest surgery for malignant lung disease who were operated on between January 1, 2002, and December 1, 2004, at St Joseph's Hospital, Hamilton, Ontario, Canada, and between January 1, 2005, and December 1, 2006, at 2 university hospitals in Italy (Varese and Palermo). The charts of eligible patients were reviewed for baseline clinical characteristics, including sex, age, prior history of cardiovascular disease, and use and type of antithrombotic prophylaxis. Perioperative mortality and all objectively confirmed venous thromboembolic events were noted. Notes of follow-up ambulatory surgical visits were also reviewed within 4 weeks of hospital discharge after surgical intervention to ensure that cases of VTE occurring after discharge were not missed. The study protocol was approved by the regional institutional review boards.
Baseline characteristics are summarized in
Table 1. Six hundred ninety-three patients were identified (mean age, 66.7 years; range, 23–90 years); 418 (60.6%) patients were male, and the median length of hospitalization was 7 days. One hundred fifty-five (22.5%) patients had a history of cardiovascular disease. Almost 90% of patients attended at least 1 follow-up ambulatory surgical visit after discharge. Postoperative antithrombotic prophylaxis with unfractionated heparin at a dose of 5000 U twice daily was used in 464 (67.2%) patients, and low-molecular-weight heparin was used in 153 (22.2%) patients. Only 16 (2.3%) patients did not receive antithrombotic prophylaxis. Five hundred seven (73.5%) patients had primary lung cancer, and 183 had secondary malignant lung cancer. Lung primary adenocarcinoma, epidermoid carcinoma, and anaplastic cancer were the most common cancer histologies. Ninety-three (13.5%) patients underwent pneumectomy, and 597 (86.5%) underwent lobectomy or wedge resection.
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In our chart review we collected data on almost 700 patients undergoing chest surgery for malignant lung disease, and almost 90% of these patients attended at least 1 follow-up visit. Venous thromboembolic events within 1 month after surgical intervention were uncommon in these patients. Incidence of VTE was lower than previously reported. In a previous study on 77 patients undergoing pulmonary resection,2 20 (26%) had a venous thromboembolic event (15 deep vein thromboses and 5 PEs) during hospitalization, and in a retrospective study on 1735 patients who underwent lung resection,3 PE was a common fatal postoperative complication, accounting for 15.2% of postresectional deaths. However, because these studies were carried out between 1975 and 1993, antithrombotic prophylaxis with heparin was rarely used in these patients.
Finally, in a small recent study carried out in 50 patients undergoing lung surgery for cancer,4 PE was detected by means of multislice computed tomographic analysis in 7 (14%) patients. However, only 2 of these patients were symptomatic, and the clinical relevance of this complication is undefined.
In conclusion, the results of our study suggest that symptomatic and fatal PEs are uncommon complications in these patients. Unfractionated heparin and low-molecular-weight heparin seem to be equally effective in reducing venous thromboembolic events also in patients with metastatic disease. Large prospective studies are warranted to confirm our results.
Footnotes
Mark Crowther reports consulting and lecture fees from Leo Pharma and grant support from Leo Laboratories. Leo Pharma produces heparin.
References
This article has been cited by other articles:
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  A. A. Khorana and G. C. Connolly Assessing Risk of Venous Thromboembolism in the Patient With Cancer J. Clin. Oncol., October 10, 2009; 27(29): 4839 - 4847. [Abstract] [Full Text] [PDF]
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 A. Patel, M. Anraku, G. E. Darling, F. A. Shepherd, A. F. Pierre, T. K. Waddell, S. Keshavjee, and M. de Perrot Venous thromboembolism in patients receiving multimodality therapy for thoracic malignancies J. Thorac. Cardiovasc. Surg., October 1, 2009; 138(4): 843 - 848. [Abstract] [Full Text] [PDF]
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