Prospectively screening for venous thromboembolism in patients with esophagectomy for cancer improves survival: The complexity of simplicity.

BACKGROUND

We implemented a prospective screening program to detect deep venous thromboembolism and define its prevalence in patients with esophageal cancer undergoing esophagectomy. We sought to delineate contributions of the underlying cancer and the esophagectomy itself to the development of venous thromboembolism (VTE), as well as to determine the potential of screening to reduce VTE-related mortality.

METHODS

A total of 370 consecutive patients were offered enrollment in the double-screening program and followed for a median of 3.4 years. Of these, 309 patients (84%) received both screens. VTE development was classified into 3 periods: cancer diagnosis to perioperative Screen 1 (Period 1), after Screen 1 to predischarge Screen 2 (Period 2), and postdischarge (Period 3). Endpoints were VTE development and all-cause mortality. The negative predictive value of screening was assessed. Factors predictive of mortality were identified via parametric hazard modeling.

RESULTS

Sixty-seven patients had new VTE during their care; 42 occurred in Period 1 (63%), and 30 were screen-detected/asymptomatic. The negative predictive value of dual screening was 97% to 90 days. A history of VTE was most predictive of VTE in Period 1, while a history of chronic obstructive pulmonary disease was predictive in Period 2. Survival was independent of postoperative VTE development, suggesting effective mitigation when identified. Lack of complete screening correlated with worse survival.

CONCLUSIONS

Advanced esophageal cancer portends a risk of VTE, confounding the effect of surgery and highlighting the complexity of establishing cause-effect relationships. Nonetheless, early VTE identification with screening and associated aggressive VTE management appear to mitigate the expected deleterious effects of VTE on short- and long-term survival after esophagectomy.