Kun Yang, Song Zhao
Department of General Surgery, The Thirteenth People's Hospital of Chongqing (Chongqing Geriatrics Hospital), No.16, Tieluxincun, Huangjueping, Jiulongpo District, Chongqing, 400053, China.
J Gastrointest Cancer. 2025 Apr 22;56(1):104. doi: 10.1007/s12029-025-01232-w.
Venous thromboembolism (VTE) is a common but severe complication following colorectal cancer (CRC) surgery. Traditional anticoagulants such as low molecular weight heparin (LMWH) and vitamin K antagonists face limitations in clinical due to requirements for frequent monitoring, subcutaneous administration, and poor patient adherence. Novel Oral Anticoagulants (NOACs), with advantages including oral administration, stable pharmacokinetics, and no requirement for routine monitoring, have emerged as potential alternatives for postoperative VTE prophylaxis.
This narrative review synthesized evidence from PubMed and Web of Science (up to October 2024). Initial plans for a systematic review were adjusted due to limited CRC-specific trials, focusing instead on bridging existing evidence to emerging clinical applications.
Postoperative VTE incidence remains heterogeneous, influenced by symptom-driven versus systematic detection and temporal improvements in perioperative care. Extended LMWH reduces VTE risk, yet adherence remains low. The PROLAPS II trial demonstrated rivaroxaban's efficacy in reducing VTE after laparoscopic CRC surgery, with comparable major bleeding rates to placebo. Meta-analyses confirm NOACs' non-inferiority to LMWH for short-term prophylaxis, but CRC-specific extended regimens lack validation. Safety concerns include heightened gastrointestinal/genitourinary bleeding risks and potential drug interactions with anticancer therapies. Clinician familiarity gaps and patient resistance to injectable agents further impede guideline adherence. Conflicting guidelines underscore unresolved debates on ideal regimens.
NOACs offer practical advantages over LMWH for extended thromboprophylaxis in CRC surgery, particularly in enhancing adherence. However, bleeding risks and limited high-quality evidence necessitate cautious clinical integration. Future research must prioritize large-scale RCTs to validate LMWH-NOAC sequential regimens, optimize risk-stratified protocols, and address interactions within enhanced recovery pathways. Harmonized guidelines and provider education are critical to bridging implementation gaps.
静脉血栓栓塞症（VTE）是结直肠癌（CRC）手术后常见但严重的并发症。传统抗凝剂如低分子肝素（LMWH）和维生素K拮抗剂，由于需要频繁监测、皮下给药以及患者依从性差等原因，在临床上面临局限性。新型口服抗凝剂（NOACs）具有口服给药、药代动力学稳定且无需常规监测等优点，已成为术后VTE预防的潜在替代方案。
本叙述性综述综合了来自PubMed和Web of Science（截至2024年10月）的证据。由于特定于CRC的试验有限，最初的系统综述计划进行了调整，转而侧重于将现有证据与新兴临床应用相衔接。
术后VTE发生率仍然存在异质性，受症状驱动检测与系统检测以及围手术期护理的时间性改善影响。延长LMWH治疗可降低VTE风险，但依从性仍然较低。PROLAPS II试验证明利伐沙班在降低腹腔镜CRC手术后VTE方面的疗效，主要出血率与安慰剂相当。荟萃分析证实，在短期预防方面，NOACs不劣于LMWH，但特定于CRC的延长治疗方案缺乏验证。安全问题包括胃肠道/泌尿生殖系统出血风险增加以及与抗癌治疗的潜在药物相互作用。临床医生的认知差距以及患者对注射剂的抵触进一步阻碍了指南的依从性。相互矛盾的指南凸显了关于理想治疗方案的未解决争论。
在CRC手术的延长血栓预防方面，NOACs相对于LMWH具有实际优势，尤其是在提高依从性方面。然而，出血风险和有限的高质量证据需要谨慎地进行临床整合。未来的研究必须优先开展大规模随机对照试验，以验证LMWH - NOAC序贯治疗方案，优化风险分层方案，并解决强化康复路径中的相互作用问题。统一的指南和提供者教育对于弥合实施差距至关重要。
