Predicting venous thromboembolism and determining appropriate prophylaxis in elderly patients undergoing colorectal cancer surgery with Enhanced Recovery After Surgery (ERAS) using the adjusted Caprini score

Young Sun Choi; Hyung Jin Cho; Chul Seung Lee; Dong Geun Lee; Choon Sik Chung; Gwan Cheol Lee; Dong Woo Kang; Jeong Sub Kim; Tae Gyu Kim

doi:10.3393/ac.2024.00857.0122

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Original Article ERAS Predicting venous thromboembolism and determining appropriate prophylaxis in elderly patients undergoing colorectal cancer surgery with Enhanced Recovery After Surgery (ERAS) using the adjusted Caprini score: Young Sun Choi¹, Hyung Jin Cho², Chul Seung Lee¹, Dong Geun Lee¹, Choon Sik Chung¹, Gwan Cheol Lee¹, Dong Woo Kang¹, Jeong Sub Kim¹, Tae Gyu Kim¹; Annals of Coloproctology 2025;41(4):279-286.
DOI: https://doi.org/10.3393/ac.2024.00857.0122
Published online: August 26, 2025

¹Department of Colorectal Surgery, Hansol Hospital, Seoul, Korea

²Division of Vascular and Transplant Surgery, Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: Tae Gyu Kim, MD Department of Colorectal Surgery, Hansol Hospital, 445 Songpa-daero, Songpa-gu, Seoul 05616, Korea Email: piaka488@gmail.com

• Received: November 23, 2024 • Revised: April 15, 2025 • Accepted: April 28, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
SUPPLEMENTARY MATERIALS
REFERENCES

Video abstract

Abstract

Purpose
Age and postoperative complications are known risk factors for venous thromboembolism (VTE). Minimally invasive surgery and Enhanced Recovery After Surgery (ERAS) protocol has been implemented to reduce these risks. The purpose of this study was to assess the short- and long-term effects of a VTE prophylaxis program using the Caprini score in elderly patients undergoing minimally invasive colorectal cancer surgery with the ERAS protocol.
Methods
This retrospective cross-sectional study included 1,043 colorectal cancer patients requiring surgery from January 2017 to December 2019, divided into a control group (≤75 years) and an elderly group (>75 years), with 827 and 216 patients, respectively. The primary outcome was the incidence of VTE; secondary outcome was the incidence of postoperative complications, particularly bleeding.
Results
The incidence of VTE was 1.5% in the control group and 3.7% in the elderly group (P=0.061). Five patients (0.5%) experienced symptomatic VTE, and the Caprini score for all VTE patients was ≤8 points; thus, only mechanical prophylaxis was used. In the multivariable logistic regression, the Caprini score (P=0.024) and cancer stage (P=0.004) were selected. The odds ratios (95% confidence interval) of the Caprini score and TNM staging were 1.758 (1.078–2.867) and 6.152 (2.045–26.510), respectively.
Conclusion
When the ERAS protocol was used for patients with colorectal cancer as perioperative care, the VTE risk was lower than that estimated by the Caprini score. Given that age is a recognized risk factor for major bleeding, criteria for the use of anticoagulation to prevent VTE, particularly in elderly patients, should be carefully evaluated, considering both the bleeding risks and the potential benefits of pharmacologic prophylaxis.
Trial registration
Clinical Research Information Service (CRIS; cris.nih.go.kr) identifier: KCT0007804
Keywords: Aged; Enhanced Recovery After Surgery (ERAS); Venous thromboembolism

INTRODUCTION

Venous thromboembolism (VTE) can result in post-thrombotic syndrome, pulmonary thromboembolism, and even death. VTE is the second most common cause of death in patients with malignancies [1]. Among patients undergoing colorectal surgery in Western countries, the incidence of VTE with symptoms such as leg swelling or dyspnea ranges from 1.15% to 2.47%. [2]. Studies targeting the Asian population, including Koreans, indicates that the incidence of VTE is low, ranging from 0.3% to 0.85% [3, 4]. However, VTE is universally known to be associated with age, with its frequency increasing by approximately 1% annually in the elderly population [5].

The relatively high incidence of thrombotic complications in colorectal surgery appears to be due to the pelvic dissection, patient position during surgery, and additional risk factors common to this patient population (neoadjuvant or adjuvant chemotherapy or possibility of Inflammatory bowel disease comorbidity).

Using VTE risk assessment models, like the widely used Caprini scoring system, VTE can be effectively prevented [6]. The Caprini score is a system for assessing the risk of VTE. A high score indicates a higher risk of VTE, which helps in deciding on preventive measures such as anticoagulation therapy (details on each item of the Caprini score are shown in Supplementary Fig. 1). However, several factors should be considered in the application of the model to elderly colorectal cancer patients under recent surgical circumstances. First, minimally invasive surgery and postoperative care, such as the Enhanced Recovery After Surgery (ERAS) protocol, have become more common, reducing postoperative complications and shortening hospital stays [7–9]. Complications during surgery and prolonged hospitalization are risk factors for VTE, and considering that a decrease in these factors also leads to a decrease in the incidence of VTE, it can be inferred that early ambulation may reduce the occurrence of VTE [2]. Second, because age is an independent predictor of anticoagulation-related major bleeding, elderly patients require careful evaluation of their risk of bleeding [10].

Considering the VTE incidence that decreases with the development of technology and the risk of side effects related to bleeding due to old age, it is difficult to apply the conventional Caprini score in this patient group. The purpose of this study was to assess the short- and long-term effects of a VTE prophylaxis program using the Caprini score in patients undergoing minimally invasive colorectal cancer surgery with the ERAS protocol.

METHODS

Ethics statement

This study is a parallel study to “Application of venous thromboembolism prophylaxis program in patients with colorectal cancer using the Enhanced Recovery After Surgery protocol” by Cho et al. [11]. It shows similarities in protocol, patient group selection method, and statistical method. The study protocol was reviewed and approved by the Institutional Review Board of College of Medicine, The Catholic University of Korea, with a waiver of informed consent (No. KC21RISI0303). The study was also registered at the Clinical Research Information Service (CRIS; cris.nih.go.kr identifier: KCT0007804) and has been reported in line with the STROCSS (Strengthening the Reporting of Cohort Studies in Surgery) guidelines [12].

Patients and data selection

We included 1,043 patients diagnosed with colorectal cancer who needed surgery at a single facility between January 2017 and December 2019. The patients were divided into 2 groups: the control group (≤75 years) and the elderly group (>75 years), with 827 and 216 patients, respectively. To ascertain the association between VTE and TNM staging, only patients diagnosed with adenocarcinoma or neuroendocrine tumors were included. All types of elective and palliative colorectal cancer surgery were included. Among them, surgeries for diagnostic purposes like simple biopsy were excluded, and less invasive surgeries, such as transanal local excision and transanal endoscopic microsurgery, were excluded because the postoperative care itself is different. The basic demographic about each patient (age, sex, and body mass index), the location and stage of the cancer, operation time, length of postoperative hospital stay, postoperative complications, and components required for Caprini scoring for VTE risk assessment were all included in the data selection.

In this study, the primary outcome is defined as the incidence and risk stratification of VTE in elderly colorectal cancer patients undergoing surgery with the ERAS protocol. This includes assessing the effectiveness of the Caprini score in predicting and preventing VTE events. Additionally, secondary outcomes focus on the incidence of postoperative complications, including bleeding complications associated with different prophylaxis strategies.

Overall protocol

The patients enrolled in this study followed the ERAS protocol [8, 13]. The Caprini score was applied to all patients, and they were divided into 3 groups based on their Caprini scores. Additionally, insertion of a central line catheter uses a micropuncture approach. For the moderate-to-high group (score ≥3) according to the Caprini scoring system, pharmacological prophylaxis is often recommended [14, 15]. However, prophylaxis was only administered to the highest-risk group (score ≥9) in this study, according to the VTE protocol of our institution (Table 1).

According to the American College of Clinical Pharmacy (ACCP) guidelines, the incidence of VTE is essentially the criterion for dividing the level of risk associated with VTE. That is, the VTE incidence criterion was 1% in the low-to-moderate-risk group and 1.9% in the highest-risk group [15]. Based on this fact, according to a study conducted on patients at our institution, the incidence rate of patients with a Caprini score of 10 was 1.12% [16], and as a result, the standard for highest-risk group at our institution was set at 9 points. According to the recommendations of the ACCP, low-molecular-weight heparin (1 mg/kg, once daily) was used for prophylactic anticoagulation treatment [15].

Deep vein thrombosis diagnostic process

Six months after surgery, deep vein thrombosis (DVT) was diagnosed in a group of symptomatic VTE patients complaining of limb swelling, pain, and dyspnea. In this group, VTE was confirmed by duplex ultrasonography and chest computed tomography (CT). The group of people with asymptomatic VTE was also included. They were identified through routine CT imaging done during cancer follow-up.

Statistical analysis

Statistical analyses were performed using the R ver. 4.0.3 (R Foundation for Statistical Computing). Data was expressed as the median, frequency, percentage, and mean±standard deviation. The chi-square test, Fisher exact test, and Student t-test were used to compare the continuous and categorical variables. A multivariable analysis of VTE occurrence was performed using a multiple logistic regression model. The parameters were included in the multivariable analysis according to a backward elimination technique. The statistical significance was set at P<0.05.

RESULTS

The clinical characteristics of the control group and the elderly group are shown in Table 2. The 2 groups showed no significant differences in sex and body mass index. However, in relation to age, the American Society of Anesthesiologists (ASA) physical status was naturally higher in the elderly group, the hospital stay was longer, and the Caprini score was also higher. In addition, there were more past histories of diabetes and chronic obstructive pulmonary disease. Smoking was more common in the control group, and the cancer stage tended to be slightly higher in the elderly group, but the difference was not statistically significant. Cancer was located as follows: 178 cases (17.1%) in the ascending colon, 51 cases (4.9%) in the transverse colon, 43 cases (4.1%) in the descending colon, 282 cases (27.0%) in the sigmoid colon, 105 cases (10.1%) in the rectosigmoid junction, 300 cases (28.8%) of rectal cancer, 41 cases (3.9%) of cecal cancer, 9 cases (0.9%) of appendiceal cancer, and 4 cases (0.4%) of anal cancer. The remaining 30 cases (2.9%) included patients with simultaneous cancers in 2 locations or patients with neuroendocrine tumors. Additionally, 39 patients with rectal cancer and 2 patients with anal cancer received neoadjuvant concurrent chemoradiotherapy. Patients with a Caprini score of 9 or above included 2 individuals (0.2%) in the control group, while none were found in the elderly group. According to the protocol, these 2 patients received mechanical prophylaxis (intermittent pneumatic compression or elastic stockings) plus pharmacological prophylaxis, and there were no additional VTE events thereafter.

The 2 groups were compared in terms of surgery-related factors, as shown in Table 2. There was no difference between the 2 groups in terms of operation time (P=0.939) and surgical complications include cases classified as Clavien-Dindo grades III to V, such as bleeding, anastomosis leakage, and other organ injuries (P=0.742). Additionally, neoadjuvant chemotherapy was significantly higher in the control group compared to the elderly group (P=0.017).

In addition, the incidence of VTE was 1.5% in the control group and 3.7% in the elderly group, but the difference was not statistically significant (P=0.061). Patients with VTE had Caprini score in the high-risk category, which ranged from 5 to 8. Our institution recommends only mechanical prophylaxis in Caprini score of 8 or less. Pharmacological prophylaxis was used in cases with a Caprini score of 9 or higher, corresponding to the highest-risk group as a general classification. Because all patients in the VTE group were included in the high-risk group, only mechanical prevention was performed (Table 3). There was a total of 20 patients with VTE, but only 5 of them (25%) complained of symptoms, while the others were found accidentally via imaging tests conducted during the follow-up period.

Results of univariable and multivariable analyses of VTE incidence are presented in Table 4. Univariate logistic regression analysis showed that cancer stage was associated with VTE. In the multivariable logistic regression, we used a backward elimination technique to select variables. The Caprini score (P=0.024) and cancer stage (P=0.004) were selected. The odds ratios for the Caprini score and TNM staging, as derived from multivariable analysis, were 1.758 (95% confidence interval [CI], 1.078–2.867) and 6.152 (95% CI, 2.045–26.510), respectively. Additionally, the multivariable analysis shows that the incidence of VTE is relatively higher in the cancer stage IV (odds ratio, 14.454; 95% CI, 1.768–118.205; P=0.013).

DISCUSSION

This study found a 1.9% incidence of VTE in colorectal cancer patients, which is comparable to the incidence of VTE reported in other studies involving Asian population, including Koreans (1.6%–3.0%) [3, 4, 17]. According to Chan et al. [18], the ratio of asymptomatic DVT to symptomatic VTE rates in general surgery patients is approximately 15.81. Considering that, it is judged that the actual asymptomatic DVT patients number would have been higher. However, it should be taken into account that this study had a relatively long follow-up period of 21 months. Even when incidental VTE was considered, the incidence rate remained relatively low at 0.6% if the incidence period was less than 6 months. Given that this study had a relatively long follow-up period of 21 months, even considering incidental VTE, the incidence rate remained relatively low at 0.6% for periods of less than 6 months. Therefore, it is reasonable to conclude that preventive pharmacological treatment may not have been necessary.

In general, it is known that age, perioperative complications, and the number of days of hospitalization after surgery are related to the incidence of VTE [19, 20], but in this study, only the Caprini score and the TNM stage were related. Since there were no significant differences in the frequency of major complications classified as Clavien-Dindo grade III to IV or in the range of surgical operation time between the 2 groups, it is possible that these factors contributed to the observed results.

As an aging society gradually progresses, the proportion of the elderly among colorectal cancer patients is increasing [21]. It tends to have complications and frailty problems in the elderly and is associated with increased postoperative complications in patients with gastrointestinal cancer [9, 22]. It seems to be effective in improving physical strength, improving quality of life, relieving psychological anxiety and depression, and reducing fatigue during cancer treatment through exercise or physical therapy [9].

Although the findings suggest a higher incidence of VTE in the elderly group, this difference is not statistically significant. The incidence rates of symptomatic DVT were 0.2% in the control group and 1.4% in the elderly group. Consideration of asymptomatic DVT indicates that, while there may be a tendency for increased incidence in the elderly, the evidence does not reach statistical significance to draw definitive conclusions about the differences in VTE incidence between the 2 groups (P=0.061). Additionally, it is necessary to interpret these results from different perspectives. There was no significant difference in the incidence of DVT although ASA physical status was higher, and hospital stay was much longer in the elderly group. Although it was not included in this study, we conducted a separate analysis of the VTE incidence rates by type of surgery (open, laparoscopic, robotic), and the differences in VTE incidence rates among the groups were not statistically significant. Additionally, there is no significant difference in the incidence of VTE as the cancer stage increases. However, while the exact mechanism is not clear, the incidence of VTE was observed to be significantly higher in stage IV according to the multivariable analysis (P=0.013), indicating that attention should be paid to the occurrence of VTE after surgery. This might be because various factors in the ERAS protocol, such as early ambulation, mechanical prophylaxis, and regional anesthesia [23, 24], offset the impact of the aforementioned variables on the mechanism of VTE occurrence. However, there are few studies on the incidence of VTE in the ERAS population, particularly in cancer patients and nonorthopedic patients. Thus, further research is needed to elucidate how ERAS affects VTE development.

In this study, 20 patients with VTE occurred within 6 months after surgery, accounting for approximately 0.6%, and the Caprini score was ≤8 points (including low-to-moderate-, high-, and highest-risk groups). They only received mechanical prophylaxis according to our hospital’s protocol; nevertheless, the incidence of VTE was lower than the 0.7% incidence rate threshold set for the low-risk group in the ACCP guidelines and also lower than the incidence rate of 1.67% observed in Korean colorectal cancer surgeries [17]. In fact, if a cancer patient is undergoing cancer surgery and even if their age is over 75 years, they will already be in the high-risk group with a total of 7 points, even if there is no other risk factor. Therefore, if anticoagulation is applied according to the Caprini score, unnecessary measures are taken in a group with a lower incidence than expected, as various studies often recommend a flexible attitude when using the Caprini score [16, 23, 25]. The use of anticoagulation in this manner can lead to cost issues and potential bleeding [26]. In particular, the use of anticoagulants, such as VTE, active cancer, and old age, were independent risk factors for major bleeding [27]. Although age is recognized as a risk factor for bleeding, our study did not provide specific data on bleeding complications associated with anticoagulation use in elderly patients. Even though the safety of anticoagulation has been proven due to the development of oral anticoagulation [28, 29], there are many opinions that caution should be paid to its use in old age [30, 31].

Therefore, in accordance with previous studies, if the ERAS protocol is followed in patients with colon cancer, mechanical prophylaxis is recommended for patients with Caprini scores ≤8. However, given the slightly higher incidence of VTE and the associated bleeding risks in elderly patients, it is essential to continuously monitor these patients, and the potential benefits of pharmacologic prophylaxis for those with Caprini scores >9 (corresponding to the highest-risk group) should be evaluated [11]. Existing literature highlights the increased risk of bleeding in older populations, particularly when anticoagulants are used. This approach ensures that we balance the need for effective VTE prevention while considering the risk of bleeding complications.

This retrospective study has several limitations. First, various pieces of information were omitted when collecting the initial data because of the retrospective nature of the study. Second, as mentioned earlier, there will be many asymptomatic VTE patients who are missing because VTE screening (including duplex sonography or DVT CT) was not performed on all patients. Third, VTE events did not occur in the highest-risk group. Given that pharmacological prophylaxis was used only in this group, further research is needed to determine whether the frequency of VTE could have been reduced if pharmacological prophylaxis had been applied more broadly across high-risk groups. Fourth, there was a significant difference in the implementation rate of neoadjuvant chemotherapy between the 2 groups (P=0.017). While the univariate analysis did not show significant results (P=0.514), there may be bias related to VTE occurrence as a result. Therefore, in future follow-ups, we could further reduce this bias through propensity score matching. Fifth, this study involves patients treated with the ERAS protocol, but there is no comparator group of patients who did not receive ERAS. This highlights the need for additional research to validate the efficacy of ERAS on its own. Lastly, since this study targeted only Koreans, it may also be difficult to apply it directly to all ethnicities.

On the other hand, to the best of our knowledge, this is the first study to have evaluated the effects of age on the incidence of VTE in the colon cancer patient group with ERAS. Therefore, as life expectancy gradually increases, there will be more elderly patients, and accordingly, follow-up studies in these fields will be needed. Given that the Caprini score gradually rises as the patient population ages, and medical technology evolves, prevention measures need to be validated.

In conclusion, when the ERAS protocol was applied as perioperative care for patients with colorectal cancer, the VTE risk was lower than the incidence estimated by the Caprini score. Therefore, in this case, the criteria for the use of anticoagulants should be more stringent. In particular, the VTE incidence was slightly higher in the elderly group, but the difference was not statistically significant (P=0.061). Given that age is a recognized risk factor for major bleeding, criteria for the use of anticoagulation to prevent VTE, particularly in elderly patients, should be carefully evaluated, considering both the bleeding risks and the potential benefits of pharmacologic prophylaxis. Furthermore, future studies are essential to assess the economic implications and the safety profiles of anticoagulant use in this population.

ARTICLE INFORMATION

Conflict of interest

Chul Seung Lee is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.

Funding

This work was supported by a grant from the National Research Foundation of Korea (NRF), funded by the Korean government (No. NRF-2021M3A9I2080494).

Acknowledgments

The authors thank the patients, nurses, and physicians at Seoul St. Mary’s Hospital (Seoul, Korea).

Author contributions

Conceptualization: YSC, TGK; Data curation: HJC, CSL; Formal analysis: YSC, HJC; Funding acquisition: CSL, TGK; Investigation: YSC, CSL; Methodology: YSC, TGK; Project administration: TGK; Resources: DGL, CSC, GCL, DWK, JSK; Software: HJC; Supervision: TGK; Validation: HJC, CSL; Visualization: YSC, CSL; Writing–original draft: YSC; Writing–review & editing: all authors. All authors read and approved the final manuscript.

SUPPLEMENTARY MATERIALS

Supplementary Fig. 1.

Caprini risk assessment model for venous thromboembolism.

ac-2024-00857-0122-Supplementary-Fig-1.pdf

Supplementary materials are available from https://doi.org/10.3393/ac.2024.00857.0122.

Table 1.

Venous thromboembolism risk classification

Risk group	Caprini score	Treatment
Low to moderate risk	0–4	No prophylaxis
High risk	5–8	Mechanical prophylaxis (IPC or ES)
Highest risk	≥9	Mechanical prophylaxis (IPC or ES)+pharmacological prophylaxis (low-dose heparin)

IPC, intermittent pneumatic compression; ES, elastic stockings.

Table 2.

Clinical characteristics of the control and elderly groups (n=1,043)

Characteristic	Control group (n=827)	Elderly group (n=216)	P-value
Age (yr)	59.7±10.1	80.6±4.0	<0.001^*
Sex			0.146
Male	473 (57.2)	111 (51.4)
Female	354 (42.8)	105 (48.6)
Body mass index (kg/m²)	23.8±3.4	23.2±3.5	0.024^*
<25	562 (68.0)	154 (71.3)	0.242
≥25	265 (32.0)	62 (28.7)
ASA physical status			<0.001^*
I	158 (19.1)	6 (2.8)
II	647 (78.2)	179 (82.9)
III	18 (2.2)	29 (13.4)
IV	4 (0.5)	2 (0.9)
Smoking status			0.004^*
No	605 (73.2)	179 (81.9)
Yes	222 (26.8)	37 (17.1)
Postoperative day	6.4±6.8	8.6±14.5	0.030^*
Past history
Diabetes			0.003^*
No	684 (82.7)	159 (73.6)
Yes	143 (17.3)	57 (26.4)
COPD			0.005^*
No	816 (98.7)	206 (95.4)
Yes	11 (1.3)	10 (4.6)
DVT/PTE			0.863
No	824 (99.6)	216 (100)
Yes	3 (0.4)	0 (0)
Caprini score	5.6±0.7	7.1±0.2	<0.001^*
Low to moderate (<5)	28 (3.4)^a	0 (0)	0.010^*
High (5–8)	797 (96.4)^b	216 (100)
Highest (≥9)	2 (0.2)^c	0 (0)
Venous thromboembolism			0.061^*
No	815 (98.5)	208 (96.3)
Yes	12 (1.5)	8 (3.7)
AJCC TNM staging			<0.001^*
Stage 0	30 (3.6)	3 (1.4)
Stage I	234 (28.3)	34 (15.7)
Stage II	174 (21.0)	69 (31.9)
Stage III	273 (33.0)	85 (39.4)
Stage IV	116 (14.0)	25 (11.6)
Operation time (min)	214.9±91.5	215.6±129.5	0.939
Complication (Clavien-Dindo grades III–V)			0.742
No	766 (92.6)	198 (91.7)
Yes	61 (7.4)	18 (8.3)
Neoadjuvant chemotherapy			0.017^*
No	766 (92.6)	210 (97.2)
Yes	61 (7.4)	6 (2.8)

ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; PTE, pulmonary thromboembolism;　AJCC, American Joint Committee on Cancer.

^aAverage±standard deviation, 4.0±0.0. ^bAverage±standard deviation, 5.9±0.9. ^cAverage±standard deviation, 10.0±0.0.

^*P<0.05.

Table 3.

Clinical characteristics of patients with VTE (n=20)

Variable	No. of patients (%)
Variable	Control group (n=12)	Elderly group (n=8)
VTE prophylaxis (mechanical only)	12 (100)	8 (100)
AJCC TNM staging
Stage I	0 (0)	1 (12.5)
Stage II	1 (8.3)	1 (12.5)
Stage III	5 (41.7)	5 (62.5)
Stage IV	6 (50.0)	1 (12.5)
Symptomatic VTE	2 (16.7)	3 (37.5)
Time from VTE diagnosis to operation (mo)
<1	1 (8.3)	2 (25.0)
1–6	3 (25.0)	3 (37.5)
>6	8 (66.7)	3 (37.5)
Caprini score
Low to moderate (<5)	0 (0)	0 (0)
High (5–8)	12 (100)	8 (100)
Highest (≥9)	0 (0)	0 (0)
PTE/DVT
PTE only	10 (83.3)	4 (50.0)
DVT only	1 (8.3)	2 (25.0)
PTE with DVT	1 (8.3)	2 (25.0)

Percentages may not total 100 due to rounding.

VTE, venous thromboembolism; AJCC, American Joint Committee on Cancer; PTE, pulmonary thromboembolism; DVT, deep vein thrombosis.

Table 4.

Analysis of factors related to the venous thromboembolism incidence

Variable	Univariable analysis		Multivariable analysis
Variable	OR (95% CI)	P-value	OR (95% CI)	P-value
Age (yr)	1.039 (0.999–1.080)	0.053	-	-
>75	2.612 (1.052–6.482)	0.038^*
Body mass index (kg/m²)	0.984 (0.860–1.127)	0.813	-	-
>25	0.725 (0.262–2.007)	0.537
ASA physical status	1.270 (0.492–3.132)	0.621	-	-
I	1.000 (Reference)
II–IV	1.693 (0.393–7.283)	0.482
Smoking	0.753 (0.214–2.075)	0.615	-	-
Postoperative day	0.996 (0.904–1.027)	0.905	-	-
Diabetes	2.316 (0.860–5.732)	0.078	-	-
COPD	2.639 (0.143–13.740)	0.356	-	-
Caprini score	1.835 (1.113–3.023)	0.018^*	1.758 (1.078–2.867)	0.024^*
AJCC TNM staging	6.360 (2.121–27.362)	0.003^*	6.152 (2.045–26.510)	0.004^*
Stage 0–I	1.000 (Reference)		-	-
Stage II	2.490 (0.259–23.903)	0.458	2.059 (0.207–20.463)	0.558
Stage III	8.624 (1.098–67.749)	0.041^*	7.616 (0.953–60.838)	0.054
Stage IV	15.660 (1.911–128.264)	0.010^*	14.454 (1.768–118.205)	0.013^*
Operation time (min)	0.999 (0.995–1.004)	0.600	-	-
Complication (Claven-Dindo grades III–V)	0.638 (0.035–3.136)	0.663	-	-
Complication (Claven-Dindo grades III–V)	0.638 (0.035–3.136)
Neoadjuvant chemotherapy	1.637 (0.379–7.074)	0.514	-	-

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; AJCC, American Joint Committee on Cancer.

^*P<0.05.

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Predicting venous thromboembolism and determining appropriate prophylaxis in elderly patients undergoing colorectal cancer surgery with Enhanced Recovery After Surgery (ERAS) using the adjusted Caprini score

Ann Coloproctol. 2025;41(4):279-286. Published online August 26, 2025

DOI: https://doi.org/10.3393/ac.2024.00857.0122

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Risk group	Caprini score	Treatment
Low to moderate risk	0–4	No prophylaxis
High risk	5–8	Mechanical prophylaxis (IPC or ES)
Highest risk	≥9	Mechanical prophylaxis (IPC or ES)+pharmacological prophylaxis (low-dose heparin)

Characteristic	Control group (n=827)	Elderly group (n=216)	P-value
Age (yr)	59.7±10.1	80.6±4.0	<0.001^*
Sex			0.146
Male	473 (57.2)	111 (51.4)
Female	354 (42.8)	105 (48.6)
Body mass index (kg/m²)	23.8±3.4	23.2±3.5	0.024^*
<25	562 (68.0)	154 (71.3)	0.242
≥25	265 (32.0)	62 (28.7)
ASA physical status			<0.001^*
I	158 (19.1)	6 (2.8)
II	647 (78.2)	179 (82.9)
III	18 (2.2)	29 (13.4)
IV	4 (0.5)	2 (0.9)
Smoking status			0.004^*
No	605 (73.2)	179 (81.9)
Yes	222 (26.8)	37 (17.1)
Postoperative day	6.4±6.8	8.6±14.5	0.030^*
Past history
Diabetes			0.003^*
No	684 (82.7)	159 (73.6)
Yes	143 (17.3)	57 (26.4)
COPD			0.005^*
No	816 (98.7)	206 (95.4)
Yes	11 (1.3)	10 (4.6)
DVT/PTE			0.863
No	824 (99.6)	216 (100)
Yes	3 (0.4)	0 (0)
Caprini score	5.6±0.7	7.1±0.2	<0.001^*
Low to moderate (<5)	28 (3.4)^a	0 (0)	0.010^*
High (5–8)	797 (96.4)^b	216 (100)
Highest (≥9)	2 (0.2)^c	0 (0)
Venous thromboembolism			0.061^*
No	815 (98.5)	208 (96.3)
Yes	12 (1.5)	8 (3.7)
AJCC TNM staging			<0.001^*
Stage 0	30 (3.6)	3 (1.4)
Stage I	234 (28.3)	34 (15.7)
Stage II	174 (21.0)	69 (31.9)
Stage III	273 (33.0)	85 (39.4)
Stage IV	116 (14.0)	25 (11.6)
Operation time (min)	214.9±91.5	215.6±129.5	0.939
Complication (Clavien-Dindo grades III–V)			0.742
No	766 (92.6)	198 (91.7)
Yes	61 (7.4)	18 (8.3)
Neoadjuvant chemotherapy			0.017^*
No	766 (92.6)	210 (97.2)
Yes	61 (7.4)	6 (2.8)

Variable	No. of patients (%)
Variable	Control group (n=12)	Elderly group (n=8)
VTE prophylaxis (mechanical only)	12 (100)	8 (100)
AJCC TNM staging
Stage I	0 (0)	1 (12.5)
Stage II	1 (8.3)	1 (12.5)
Stage III	5 (41.7)	5 (62.5)
Stage IV	6 (50.0)	1 (12.5)
Symptomatic VTE	2 (16.7)	3 (37.5)
Time from VTE diagnosis to operation (mo)
<1	1 (8.3)	2 (25.0)
1–6	3 (25.0)	3 (37.5)
>6	8 (66.7)	3 (37.5)
Caprini score
Low to moderate (<5)	0 (0)	0 (0)
High (5–8)	12 (100)	8 (100)
Highest (≥9)	0 (0)	0 (0)
PTE/DVT
PTE only	10 (83.3)	4 (50.0)
DVT only	1 (8.3)	2 (25.0)
PTE with DVT	1 (8.3)	2 (25.0)

Variable	Univariable analysis		Multivariable analysis
Variable	OR (95% CI)	P-value	OR (95% CI)	P-value
Age (yr)	1.039 (0.999–1.080)	0.053	-	-
>75	2.612 (1.052–6.482)	0.038^*
Body mass index (kg/m²)	0.984 (0.860–1.127)	0.813	-	-
>25	0.725 (0.262–2.007)	0.537
ASA physical status	1.270 (0.492–3.132)	0.621	-	-
I	1.000 (Reference)
II–IV	1.693 (0.393–7.283)	0.482
Smoking	0.753 (0.214–2.075)	0.615	-	-
Postoperative day	0.996 (0.904–1.027)	0.905	-	-
Diabetes	2.316 (0.860–5.732)	0.078	-	-
COPD	2.639 (0.143–13.740)	0.356	-	-
Caprini score	1.835 (1.113–3.023)	0.018^*	1.758 (1.078–2.867)	0.024^*
AJCC TNM staging	6.360 (2.121–27.362)	0.003^*	6.152 (2.045–26.510)	0.004^*
Stage 0–I	1.000 (Reference)		-	-
Stage II	2.490 (0.259–23.903)	0.458	2.059 (0.207–20.463)	0.558
Stage III	8.624 (1.098–67.749)	0.041^*	7.616 (0.953–60.838)	0.054
Stage IV	15.660 (1.911–128.264)	0.010^*	14.454 (1.768–118.205)	0.013^*
Operation time (min)	0.999 (0.995–1.004)	0.600	-	-
Complication (Claven-Dindo grades III–V)	0.638 (0.035–3.136)	0.663	-	-
Complication (Claven-Dindo grades III–V)	0.638 (0.035–3.136)
Neoadjuvant chemotherapy	1.637 (0.379–7.074)	0.514	-	-

Table 1. Venous thromboembolism risk classification

IPC, intermittent pneumatic compression; ES, elastic stockings.

Table 2. Clinical characteristics of the control and elderly groups (n=1,043)

ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; PTE, pulmonary thromboembolism;　AJCC, American Joint Committee on Cancer.

^aAverage±standard deviation, 4.0±0.0. ^bAverage±standard deviation, 5.9±0.9. ^cAverage±standard deviation, 10.0±0.0.

P<0.05.

Table 3. Clinical characteristics of patients with VTE (n=20)

Percentages may not total 100 due to rounding.

VTE, venous thromboembolism; AJCC, American Joint Committee on Cancer; PTE, pulmonary thromboembolism; DVT, deep vein thrombosis.

Table 4. Analysis of factors related to the venous thromboembolism incidence

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease; AJCC, American Joint Committee on Cancer.