HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Head Neck. 2017; 39(6):1249-1258.

CLINICAL REVIEW

Systematic review and meta-analysis of venous thromboembolism in otolaryngology–head and neck surgery

Sami P. Moubayed, MD, 1 * Antoine Eskander, MD, ScM, 2 Moustafa W. Mourad, MD, 3 Sam P. Most, MD 1

1 Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, 2 Department of Otolaryngology – Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada, 3 Department of Otolaryngology – Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Accepted 2 February 2017 Published online 29 March 2017 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24758

ABSTRACT: Background. The purpose of this study was to present our systematic review and meta-analysis of the data on venous thromboem- bolism (VTE; deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in otolaryngology–head and neck surgery (OHNS). Methods. PubMed and Scopus databases were searched for studies reporting VTE in OHNS. Incidence of VTE and bleeding is reported and meta-analyzed overall and for chemoprophylaxis and squamous cell carcinoma (SCC)/free flap subgroups. Results. A total of 23 studies were included with a total of 618,264 patients. Incidence of VTE was 0.4%. The incidence of bleeding complications was INTRODUCTION The importance of venous thromboembolism (VTE), defined by deep venous thrombosis (DVT) with or with- out pulmonary embolism (PE), cannot be underempha- sized. It is a common cause of preventable death in the United States, affecting up to 200,000 Americans every year. 1 Moreover, one third of these deaths occur after sur- gery. 1 In 2012, the American College of Chest Physicians released a set of guidelines (CHEST guidelines) for the prevention of VTE in nonsurgical, 2 orthopedic, 3 and non- orthopedic surgery 1 patients. Unfortunately, the otolaryn- gology–head and neck surgery (OHNS) population is not specifically addressed in these guidelines. There is a paucity of high-quality literature pertaining to VTE incidence and prophylaxis in OHNS. 4 OHNS is the oldest medical specialty in the United States and treats high volumes of patients both in the inpatient and outpatient set- tings using both medical and surgical therapies. 5 Unfortu- nately, there are no specific recommendations pertaining to this population based on the available evidence. This study had 3 main objectives. First, we performed a systematic review of studies that report the incidence of VTE and bleeding complications in all OHNS patients. Second,

0.9%. The addition of chemoprophylaxis did not result in a decreased VTE incidence (odds ratio [OR], 0.86), but produced an increased risk of bleeding (OR, 3.78). The overall OR for VTE in SCC/free flap cases was 6.28. Conclusion. Chemoprophylaxis may not be necessary in the OHNS non-SCC or free flap patient population and must be balanced against an increased risk of bleeding. V C 2017 Wiley Periodicals, Inc. Head Neck 39: 1249–1258, 2017 KEY WORDS: thrombosis, thromboembolic, thromboembolism, thromboprophylaxis, otolaryngology having reviewed this literature, we assessed whether VTE chemoprophylaxis has an impact on the incidence of VTE and bleeding complications. Last, we would performed a subgroup analysis by OHNS subspecialty to assess whether chemoprophylaxis may have a differing impact on out- comes depending on the patient population within OHNS on which it is being used. We hypothesized that the inci- dence of VTE in the general OHNS population is so low, that thromboprophylaxis may not be beneficial, except for in the highest risk patients, such as those being treated for head and neck cancer with or without free flap reconstruction. METHODS Search strategy A systematic review was conducted using the PubMed and Scopus databases (from 1947 to the present). The 2 databases were searched for English-language studies between the data- base start date and December 2015 using the key words (“thrombosis” OR “thromboembolic” OR “thromboembolism” OR “thromboprophylaxis”) AND (“otolaryngology” OR “otorhinolaryngology”). Key terms were explored and explod- ed in each database separately, and non-medical subject head- ing words were included when they were not included in the databases. The date of the last search was December 31, 2015. Before reviewing any articles, a number of techniques were used to ensure that all the relevant references were included in our search algorithm and results. Citations were cross-checked (snowballing) from key publications. 6–9 Citations from existing

* Corresponding author: S. P. Moubayed, 1 Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305. E-mail: moubayed@stanford.edu

HEAD & NECK—DOI 10.1002/HED JUNE 2017

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