This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for the prevention of venous thromboembolism. The Standards Task Force of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Aug;43(8):1037-47.

Venous thrombosis

Prevention
Risk Assessment

Colon and Rectal Surgery
Preventive Medicine

Health Care Providers
Patients
Physicians

To provide practice parameters for the prevention of venous thrombosis

Patients undergoing surgery of the colon and rectum

1. Assessment of risk category (low, moderate, high, or highest)
2. Physical prophylactic measures including early ambulation, elastic stockings, and intermittent pneumatic compression (IPC) devices
3. Chemical prophylaxis including low-dose unfractionated heparin (LDUH) or low-molecular-weight heparin (LMWH)

• Efficacy of venous thromboembolism (VTE) prophylaxis
• Risk and rates of venous thromboembolism
• Adverse effects associated with chemical prophylaxis

Searches of Electronic Databases

Not stated

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1. Meta-analysis of multiple well-designed, controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
2. At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
3. Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series
4. Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
5. Case reports and clinical examples

Review of Published Meta-Analyses
Systematic Review

Not stated

Not stated

Grades of Recommendations

1. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
2. Evidence of Type II, III, or IV and generally consistent findings
3. Evidence of Type II, III, or IV but inconsistent findings
4. Little or no systematic empirical evidence

In numerous well-performed studies and several meta-analyses comparing the efficacy of venous thromboembolism (VTE) prophylaxis between low-molecular-weight-heparin (LMWH) and low-dose-unfractionated heparin (LDUH) for VTE prophylaxis, unfractionated heparin has been shown to be equally effective and more cost-effective.

Not stated

Not stated

The levels of evidence (I-V) and the grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Treatment Recommendations

1. Patients undergoing anorectal procedures who are younger than 40 years of age and have no additional risk factors (see Table 1 in the original guideline document for a list of risk factors) for venous thromboembolism (VTE) require no specific prophylaxis. Level of Evidence: V; Grade of Recommendation: D
2. Patients undergoing anorectal procedures who are older than 40 and/or have additional risk factors for VTE should be considered for prophylaxis on a case-by-case basis. Level of Evidence: V; Grade of Recommendation: D

   Patients in the moderate-risk to high-risk group (see original guideline document for a description of each of the four risk categories: low-risk, moderate-risk, high-risk, and highest risk) are appropriately considered for prophylaxis based on the number of risk factors, the length and magnitude of the planned surgery, and the risk of bleeding. The appropriate means of prophylaxis would be mechanical compression or heparin (low-dose unfractionated heparin [LDUH] or low-molecular-weight heparin [LMWH]). Because of the frequent outpatient nature of this type of surgery and the potential for bleeding in many anorectal procedures, mechanical prophylaxis may be preferable in most cases.

3. Patients in the moderate-risk to high-risk categories for VTE undergoing abdominal surgery should receive prophylaxis with LDUH or LMWH. Patients at risk for bleeding may receive mechanical prophylaxis instead. Level of Evidence: I; Grade of Recommendation: A

   Mechanical methods may be chosen in patients in whom the risk of bleeding is judged to outweigh the benefit of prophylactic heparin.

4. Patients in the highest-risk category for VTE should receive both mechanical and heparin prophylaxis. Level of Evidence: I; Grade of Recommendation: A

   In this high-risk group, mechanical prophylaxis adds further protection compared with heparin alone.

5. Patients undergoing laparoscopic colorectal procedures should receive VTE prophylaxis according to the same risk assessment that would be applicable for the same surgery performed as an open procedure. Level of Evidence: V; Grade of Recommendation: D
6. Patients who have undergone major cancer surgery may benefit from posthospital prophylaxis with LMWH. Level of Evidence: II; Grade of Recommendation: C

   The optimum duration of VTE prophylaxis is currently unknown. Although most deep vein thrombosis (DVT) occurs within the first week or two after surgery, VTE complications, including pulmonary embolism (PE), can occur beyond that time frame. These findings combined with shrinking hospital stays have generated an interest in the appropriate duration of VTE prophylaxis. There is evidence that in cancer-surgery patients, continued prophylaxis for two to three weeks after discharge reduces the incidence of asymptomatic DVT.

Definitions

Levels of Evidence

1. Meta-analysis of multiple well-designed, controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
2. At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
3. Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series
4. Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
5. Case reports and clinical examples

Grades of Recommendations

1. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
2. Evidence of Type II, III, or IV and generally consistent findings
3. Evidence of Type II, III, or IV but inconsistent findings
4. Little or no systematic empirical evidence

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Appropriate use of practice parameters for the prevention of venous thrombosis

• Low-dose unfractionated heparin (LDUH) is associated with only a modest increase in minor bleeding complications, such as wound hematoma
• A potential danger has been associated with the use of heparin prophylaxis in conjunction with spinal or epidural anesthesia. The most serious potential complication is the development of a perispinal hematoma, which can lead to spinal cord ischemia and paraplegia. This complication has been reported with both LDUH and LMWH, but more so with LMWH. Refer to the original guideline document for detailed instructions on the use of heparin prophylaxis in conjunction with spinal or epidural anesthesia.

These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

An implementation strategy was not provided.

Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2000 Aug (revised 2006 Oct)

American Society of Colon and Rectal Surgeons - Medical Specialty Society

American Society of Colon and Rectal Surgeons

Standards Practice Task Force of the American Society of Colon and Rectal Surgeons

Authors: Thomas J. Stahl, MD; Sharon G. Gregorcyk, MD; Neil H. Hyman, MD; W. Donald Buie, MD; and the Standards Practice Task Force of The American Society of Colon and Rectal Surgeons (ASCRS)

Contributing Members of the ASCRS Standards Committee: Amir L. Bastawrous, MD; Gary D. Dunn, MD; C. Neal Ellis, MD; Phillip R. Fleshner, MD; Clifford Y. Ko, MD; Nancy A. Morin, MD; Richard L. Nelson, MD; Graham L. Newstead, MD; Jason R. Penzer, MD; W. Brian Perry, MD; Janice F. Rafferty, MD; Paul C. Shellito, MD; Charles A. Ternent, MD; Joe J. Tjandra, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Practice parameters for the prevention of venous thromboembolism. The Standards Task Force of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000 Aug;43(8):1037-47.

None available

None available

This summary was completed by ECRI on February 13, 2001. The information was verified by the guideline developer on May 9, 2002. This NGC summary was updated by ECRI Institute on May 30, 2007. This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection. This summary was updated by ECRI Institute on December 26, 2008 following the FDA advisory on Innohep (tinzaparin).

American Society of Colon and Rectal Surgeons (ASCRS) parameters may be downloaded for personal use (one copy); copies for other purposes, please contact the ASCRS office at (847) 290-9184.