Efficacy of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after gynecological cancer surgery: A systematic review and meta-analysis

Objective: To evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to enoxaparin, a low molecular weight heparin (LMWH). for postoperative thromboprophylaxis in patients undergoing gynecologic cancer surgery. Methods: This systematic review and meta-analysis followed Cochrane Handbook guidelines and PRISMA recommendations. We searched PubMed, Embase, Scopus, and CENTRAL for randomized controlled trials (RCTs) and observational studies comparing DOACs and LMWHs for postoperative VTE prophylaxis in gynecologic cancer surgeries. Outcomes included VTE incidence, major bleeding, clinically relevant non-major bleeding (CRNMB), hospital readmission, and drug adherence. The risk of bias was assessed using the Cochrane tools (RoB-2 and ROBINS-I), and statistical analyses were conducted using Review Manager 5. Results: Five studies (1436 patients) were included: two RCTs and three observational studies. There was no significant difference in 30-day VTE incidence between DOAC and LMWH groups (OR, 0.55; 95 % CI, 0.17 to 1.77; P = 0.31). Similarly, major bleeding rates showed no difference (OR, 1.13; 95 % CI, 0.29 to 4.42; P = 0.90). DOACs significantly reduced CRNMB events compared to LMWHs (OR, 0.44; 95 % CI, 0.23 to 0.82; P = 0.01). Hospital readmissions (OR, 0.68; 95 % CI, 0.33 to 1.41; P = 0.30) and drug adherence rates (OR, 0.95; 95 % CI, 0.36 to 2.52; P = 0.29) were comparable between the groups. Conclusions: DOACs provide a safe and effective alternative to LMWH for postoperative thromboprophylaxis in gynecologic cancer surgeries. The significant reduction in CRNMB events suggests a potential safety advantage of DOACs.