A 58-year-old woman is admitted for elective open abdominal hysterectomy-adjacent surgery — a sigmoid colectomy for cancer. She has a BMI of 33 kg/m², is otherwise well, and mobilises normally. The admitting doctor completes her venous thromboembolism (VTE) risk assessment. Which prophylaxis strategy is most appropriate?
- ANo prophylaxis, as she is mobile
- BAspirin alone
- CTherapeutic-dose anticoagulation for one week after surgery
- DMechanical prophylaxis alone with stockings and intermittent pneumatic compression until fully mobile
- ELow-molecular-weight heparin plus mechanical prophylaxis, continued as extended prophylaxis for around 28 days because this is abdominal cancer surgery
Show answer and explanation
Correct answer: E
Her risk assessment stacks major thrombotic factors — active cancer, major abdominal/pelvic surgery, anaesthesia over 90 minutes, obesity — against no significant bleeding contraindication, mandating combined prophylaxis: pharmacological (low-molecular-weight heparin at prophylactic dose, timed against neuraxial anaesthesia per policy) plus mechanical (correctly fitted anti-embolism stockings or intermittent pneumatic compression intraoperatively and until mobile). The cancer-surgery-specific point is extended-duration prophylaxis: thrombotic risk after major abdominal or pelvic cancer surgery persists for weeks beyond discharge, and trials show 28 days of LMWH roughly halves late VTE compared with one week — so she goes home with a month's course and teaching for self-injection. VTE remains a leading cause of preventable hospital death, which is why assessment on admission (and reassessment at 24 hours and on change of condition) is a national mandate.
Why the others are wrong: A — mobility does not neutralise cancer plus major surgery; 'she walks' is the classic under-assessment. B — aspirin is not adequate prophylaxis for high-risk abdominal cancer surgery in UK practice. C — therapeutic dosing treats established thrombosis; for prophylaxis it adds bleeding without benefit. D — mechanical measures alone are for patients whose bleeding risk precludes heparin, reviewed daily as that risk recedes.
Key point: Major abdominal cancer surgery gets combined LMWH plus mechanical prophylaxis, extended to around 28 days post-operatively — risk-assess every admission, reserve mechanical-only for genuine bleeding contraindications, and never let mobility talk you out of prophylaxis in cancer surgery.
Guidelines: NICE VTE prevention guidance (NG89): major abdominal cancer surgery warrants combined LMWH and mechanical prophylaxis, with extended pharmacological prophylaxis to 28 days after abdominal or pelvic cancer resection.