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Ren X, Huang Y, Ying L, Wang J. Risk factors of venous thromboembolism for liver tumors: a systematic review and meta-analysis. HPB (Oxford) 2024; 26:1-7. [PMID: 37743139 DOI: 10.1016/j.hpb.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant complication in liver tumors patients, and understanding the associated risk factors is essential for effective risk assessment, prevention, and management strategies. This systematic review and meta-analysis aimed to identify key risk factors and their clinical implications for VTE in liver tumors patients. METHODS A comprehensive search of multiple databases was conducted to identify relevant studies. Eligible studies were selected, and odds ratios (ORs) and 95% confidence intervals (CIs) were extracted and synthesized for meta-analysis. RESULTS A total of 11 studies involving 73,652 liver tumors patients and 2049 VTE cases were included. The analysis identified several significant risk factors for VTE in liver tumors patients. Age (≥65 years), male gender, high BMI, diabetes, hepatitis B and C infections, elevated D-dimer and AST levels, reduced albumin levels, and MELD score were all associated with increased VTE risk. CONCLUSION This systematic review and meta-analysis revealed several key risk factors for VTE in liver tumors patients, these findings highlight the importance of risk assessment, prevention, and management strategies in this high-risk population. Further research with larger sample sizes and standardized methods is needed to strengthen the existing evidence and validate these findings.
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Affiliation(s)
- Xia Ren
- Affiliated People's Hospital of Ningbo University, Ningbo 315040, China.
| | - Yuan Huang
- Affiliated People's Hospital of Ningbo University, Ningbo 315040, China
| | - LiPing Ying
- Affiliated People's Hospital of Ningbo University, Ningbo 315040, China
| | - JinBo Wang
- Affiliated People's Hospital of Ningbo University, Ningbo 315040, China
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2
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Reddy MS, Kasahara M, Ikegami T, Lee KW. An international survey of venous thromboembolic events and current practices of peri-operative VTE prophylaxis after living donor hepatectomy. Clin Transplant 2024; 38:e15209. [PMID: 38064308 DOI: 10.1111/ctr.15209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/30/2023] [Accepted: 11/19/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Venous thromboembolic complications are an uncommon but significant cause of morbidity & mortality after live donor hepatectomy . The precise incidence of these events and the current practices of centers performing living donor liver transplantation worldwide are unknown. METHODS An online survey was shared amongst living donor liver transplantation centers containing questions regarding center activity, center protocols for donor screening, peri-operative thromboembolic prophylaxis and an audit of -perioperative venous thromboembolic events after live donor hepatectomy in the previous five years (2016-2020). RESULTS Fifty-one centers from twenty countries completed the survey. These centers had cumulatively performed 11500 living donor liver transplants between 2016-2020. All centers included pre-operative l assessment for thromboembolic risk amongst potential liver donors in their protocols. Testing for inherited prothrombotic conditions was performed by 58% of centers. Dual-mode prophylaxis was the most common practice (65%), while eight and four centers used single mode or no routine prophylaxis respectively. Twenty (39%) and 15 (29%) centers reported atleast one perioperative deep venous thrmobosis or pulmonary embolism event respectively. There was one donor mortality directly related to post-operative pulmonary embolism. Overall incidence of deep venous thrombosis and pulmonary embolism events was 3.65 and 1.74 per 1000 live donor hepatectomies respectively. Significant variations in center practices and incidence of thromboembolic events was identified in the survey primarily divided along world regions. 75% of participating centers agreed on the need for clear international guidelines. CONCLUSION Venous thromboembolic events after live donor hepatectomy are an uncommon but important cause of donor morbidity. There is significant variation in practice among centers. Evidence-based guidelines regarding risk assessment, and peri-operative prophylaxis are needed.
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Affiliation(s)
- Mettu Srinivas Reddy
- Department of Liver Transplantation & Hepatobiliary Surgery, Gleneagles Global Hospital, Chennai, India
| | - Mureo Kasahara
- Center for Organ Transplantation, National Center for Child Health & Development, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery & Science, Kyushu University, Fukuoka, Japan
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
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3
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Edwards MA, Hussain MWA, Spaulding AC, Brennan E, Colibaseanu D, Stauffer J. Venous thromboembolism and bleeding after hepatectomy: role and impact of risk adjusted prophylaxis. J Thromb Thrombolysis 2023; 56:375-387. [PMID: 37351821 DOI: 10.1007/s11239-023-02847-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/24/2023]
Abstract
Venous thromboembolism (VTE) occurs in 2-6% of post-hepatectomy patients and is associated with increased mortality and morbidity. The use of VTE risk assessment models in hepatectomy cases remains unclear. Our study aimed to determine the use and impact of Caprini guideline indicated VTE prophylaxis following hepatectomy. Hepatectomy cases performed during 2016-2021 were included. Caprini score and VTE prophylaxis were determined retroactively, and VTE prophylaxis was categorized as appropriate or inappropriate. The primary outcome was the receipt of appropriate prophylaxis, and secondary outcomes were postoperative VTE and bleeding. Statistical analyses included Fisher Exact test, Kruskal-Wallis, Pearson Chi-Square test, and multivariate regression models. R Statistical software was used for analysis. A p-value < 0.05 or 95% Confidence Interval (CI) excluding 1 was considered significant. A total of 1955 hepatectomy cases were analyzed. Patient demographics were similar between study cohorts. Inpatient, 30- and 90-day VTE rates were 1.28%, 0.56%, and 1.24%, respectively. By Caprini guidelines, 59% and 4.3% received appropriate in-hospital and discharged VTE prophylaxis, respectively. Inpatient VTE (4.5-fold) and mortality (9.5-fold) were lower in patients receiving appropriate prophylaxis. All discharged VTE and mortality occurred in patients not receiving appropriate prophylaxis. Inpatient, 30- and 90-day bleeding rates were 8.4%, 0.62%, and 0.68%, respectively. Appropriate prophylaxis did not increase postoperative bleeding. Increasing Caprini score inversely correlated with receiving appropriate prophylaxis (OR 0.38, CI 0.31-0.46) at discharge, and appropriate prophylaxis did not correlate with bleeding risk (OR 0.79, CI 0.57-1.12). Caprini guideline indicated prophylaxis resulted in reduced VTE complications without increasing bleeding risk.
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Affiliation(s)
- Michael A Edwards
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA.
- Department Surgery, Mayo Clinic Alix School of Medicine, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Md Walid Akram Hussain
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Emily Brennan
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Dorin Colibaseanu
- Division of Colorectal Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - John Stauffer
- Division of Surgical Oncology, Mayo Clinic, Jacksonville, FL, 32224, USA
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Mavros MN, Johnson LA, Schootman M, Orcutt ST, Peng C, Martin BC. Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery. Ann Surg Oncol 2023; 30:5522-5531. [PMID: 37338748 PMCID: PMC10409669 DOI: 10.1245/s10434-023-13677-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/08/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined. METHODS This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding. RESULTS The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61). CONCLUSIONS The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.
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Affiliation(s)
- Michail N Mavros
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Lauren A Johnson
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mario Schootman
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sonia T Orcutt
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cheng Peng
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Jackson WE, Kaplan A, Saben JL, Kriss MS, Cisek J, Samstein B, Liapakis A, Pillai AA, Brown RS, Pomfret EA. Practice patterns of the medical evaluation of living liver donors in the United States. Liver Transpl 2023; 29:164-171. [PMID: 37160068 DOI: 10.1002/lt.26571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 01/27/2023]
Abstract
Living donor liver transplantation (LDLT) can help address the growing organ shortage in the United States, yet little is known about the current practice patterns in the medical evaluation of living liver donors. We conducted a 131-question survey of all 53 active LDLT transplant programs in the United States to assess current LDLT practices. The response rate was 100%. Donor acceptance rate was 0.33 with an interquartile range of 0.33-0.54 across all centers. Areas of high intercenter agreement included minimum age cutoff of 18 years (73.6%) and the exclusion of those with greater than Class 1 obesity (body mass index, 30.0-34.9 m/kg 2 ) (88.4%). Diabetes mellitus was not an absolute exclusion at most centers (61.5%). Selective liver biopsies were performed for steatosis or iron overload on imaging (67.9% and 62.3%, respectively) or for elevated liver enzymes (60.4%). Steatohepatitis is considered an exclusion at most centers (84.9%). The most common hypercoagulable tests performed were factor V Leiden (FVL) (88.5%), protein C (73.1%), protein S (71.2%), antithrombin III (71.2%) and prothrombin gene mutation (65.4%). At 41.5% of centers, donors were allowed to proceed with donation with FVL heterozygote status. Most programs discontinue oral contraceptive pills at least 28 days prior to surgery. At most centers, the need for cardiovascular ischemic risk testing is based on age (73.6%) and the presence of one or more cardiac risk factors (68.0%). Defining areas of practice consensus and variation underscores the need for data generation to develop evidence-based guidance for the evaluation and risk assessment of living liver donors.
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Affiliation(s)
- Whitney E Jackson
- Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA.,Colorado Center for Transplantation Care , Research and Education , Aurora , Colorado , USA
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Jessica L Saben
- Colorado Center for Transplantation Care , Research and Education , Aurora , Colorado , USA.,Department of Surgery , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA
| | - Michael S Kriss
- Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA.,Colorado Center for Transplantation Care , Research and Education , Aurora , Colorado , USA
| | - Jaime Cisek
- Colorado Center for Transplantation Care , Research and Education , Aurora , Colorado , USA.,Department of Surgery , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA
| | - Benjamin Samstein
- Department of Surgery , Weill Cornell Medicine , New York , New York , USA
| | - AnnMarie Liapakis
- Yale University Division of Gastroenterology and Hepatology , Yale New Haven Transplantation Center , New Haven , Connecticut , USA
| | - Anjana A Pillai
- Division of Gastroenterology and Hepatology , University of Chicago Medicine , Chicago , Illinois , USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology , Weill Cornell Medicine , New York , New York , USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care , Research and Education , Aurora , Colorado , USA.,Department of Surgery , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA
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Welsh FKS, Walsh CM, Chandrakumaran K, Rathnaweera WS, Roy A, Needham J, Cresswell AB, McVey JH, Rees M. Peri-operative thrombophilia in patients undergoing liver resection for colorectal metastases. HPB (Oxford) 2023; 25:63-72. [PMID: 36253269 DOI: 10.1016/j.hpb.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/09/2022] [Accepted: 09/28/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Routine chemical venous thromboembolism (VTE) prophylaxis for liver surgery remains controversial, and often delayed post-operatively due to perceived bleeding risk. This study asked whether patients undergoing hepatectomy for colorectal metastases (CRM) were at risk from VTE pre-operatively, and the impact of hepatectomy on that risk. METHODS Single-centre prospective observational cohort study of patients undergoing open hepatectomy for CRM, comparing pre-, peri- and post-operative haemostatic variables. RESULTS Of 336 hepatectomies performed October 2017-December 2019, 60 resections in 57 patients were recruited. There were 28 (46.7%) major resections, with median (interquartile range [IQR]) blood loss 150.0 (76.3-263.7) mls, no blood transfusions, post-operative VTE events or deaths. Patients were prothrombotic pre-operatively (high median factor VIIIC and increased thrombin generation velocity index), an effect exacerbated post-hepatectomy. Major hepatectomies had a significantly greater median drop in Protein C, rise in Factor VIIIC and von Willebrand Factor, versus minor resections (p = 0.001, 0.005, 0.001 respectively). Patients with parenchymal transection times greater than median (40 min), had significantly increased median (IQR) PMBC-TFmRNA expression [1.65(0.93-2.70)2ddCt], versus quicker transections [0.99(0.69-1.28)2ddCt, p = 0.020]. CONCLUSIONS Patients with CRM are prothrombotic pre-operatively, an effect exacerbated by hepatectomy, particularly longer, complex resections, suggesting chemical thromboprophylaxis be considered early in the patient pathway.
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Affiliation(s)
- Fenella K S Welsh
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.
| | - Caoimhe M Walsh
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - Kandiah Chandrakumaran
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - Wasula S Rathnaweera
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - Ashok Roy
- Haemophilia, Haemostasis & Thrombosis Centre, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - Jane Needham
- Haemophilia, Haemostasis & Thrombosis Centre, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - Adrian B Cresswell
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
| | - John H McVey
- Department of Biochemical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Myrddin Rees
- Hepatobiliary Unit, Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK
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Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis. Langenbecks Arch Surg 2022; 407:3221-3233. [PMID: 35881311 DOI: 10.1007/s00423-022-02610-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/12/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Patients undergoing hepatectomy are at moderate-to-high risk of venous thromboembolism (VTE). This study critically examines the efficacy of combining pharmacological (PTP) and mechanical thromboprophylaxis (MTP) versus only MTP in reducing VTE events against the risk of hemorrhagic complications. METHODS A systematic review of major reference databases was undertaken, and a meta-analysis was performed using common-effects model. Risk of bias assessment was performed using Newcastle-Ottawa scale. Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 8 studies (n = 4238 patients) meeting inclusion criteria were included in the analysis. Use of PTP + MTP was found to be associated with significantly lower VTE rates compared to only MTP (2.5% vs 5.3%; pooled RR 0.50, p = 0.03, I2 = 46%) with minimal type I error. PTP + MTP was not associated with an increased risk of hemorrhagic complications (3.04% vs 1.9%; pooled RR 1.54, p = 0.11, I2 = 0%) and had no significant impact on post-operative length of stay (12.1 vs 10.8 days; pooled MD - 0.66, p = 0.98, I2 = 0%) and mortality (2.9% vs 3.7%; pooled RR 0.73, p = 0.33, I2 = 0%). CONCLUSION Despite differences in the baseline patient characteristics, extent of hepatectomy, PTP regimens, and heterogeneity in the pooled analysis, the current study supports the use of PTP in post-hepatectomy patients (grade of recommendation: strong) as the combination of PTP + MTP is associated with a significantly lower incidence of VTE (level of evidence, moderate), without an increased risk of post-hepatectomy hemorrhage (level of evidence, low).
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8
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Hue JJ, Katayama E, Markt SC, Rothermel LD, Hardacre JM, Ammori JB, Winter JM, Ocuin LM. Association Between Operative Approach and Venous Thromboembolism Rate Following Hepatectomy: a Propensity-Matched Analysis. J Gastrointest Surg 2021; 25:2778-2787. [PMID: 33236321 DOI: 10.1007/s11605-020-04887-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of minimally invasive approaches to hepatectomy has increased in recent years, but the risk of postoperative venous thromboembolism (VTE) is undefined. We aimed to compare VTE rates after open hepatectomy and minimally invasive hepatectomy using an administrative dataset. STUDY DESIGN Patients with primary or metastatic liver tumors were identified in the National Surgical Quality Improvement Program-targeted hepatectomy database (2016-2018). VTE was compared between patients who underwent open or minimally invasive hepatectomy after a propensity score matching of 1:1 for demographics, comorbidities, and operative factors. RESULTS A total of 6935 patients underwent open hepatectomy and 2237 underwent minimally invasive hepatectomy. After matching, there were 1968 patients per group without differences in demographics, comorbidities, or operative variables. Prior to matching, the VTE rate was higher among patients who underwent open hepatectomy (2.8% vs. 1.1%, p < 0.001), and open hepatectomy was independently associated with VTE (OR = 1.90, p = 0.006). The VTE rate remained higher among open hepatectomy compared to minimally invasive hepatectomy after matching (2.4% vs. 1.1%, p = 0.003). Open hepatectomy was associated with a higher VTE rate in patients undergoing minor (1.9 vs. 1.0%, p = 0.028) and major hepatectomy (5.0 vs. 1.9%, p = 0.045). CONCLUSION Patients who undergo an open hepatectomy for malignancy have a higher incidence of postoperative VTE compared to minimally invasive hepatectomy for both minor and major hepatectomy.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Sarah C Markt
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Atrium Health Cabarrus, 200 Medical Park Drive, Suite 430, Concord, NC, 28025, USA.
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McAlpine K, Breau RH, Werlang P, Carrier M, Le Gal G, Fergusson DA, Shorr R, Cagiannos I, Morash C, Lavallée LT. Timing of Perioperative Pharmacologic Thromboprophylaxis Initiation and its Effect on Venous Thromboembolism and Bleeding Outcomes: A Systematic Review and Meta-Analysis. J Am Coll Surg 2021; 233:619-631.e14. [PMID: 34438079 DOI: 10.1016/j.jamcollsurg.2021.07.687] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Perioperative thromboprophylaxis guidelines offer conflicting recommendations on when to start thromboprophylaxis. As a result, there is considerable variation in clinical practice, which can lead to worse patient outcomes. The objective of this study was to evaluate the association between the start time of perioperative thromboprophylaxis with venous thromboembolism (VTE) and bleeding outcomes. STUDY DESIGN Embase, Medline, and CENTRAL (Cochrane Central Register of Controlled Trials) databases were searched on October 23, 2020. Randomized controlled trials that evaluated VTE and/or bleeding among groups receiving the initial dose of pharmacologic thromboprophylaxis at different times preoperatively, intraoperatively, or postoperatively were included. Only trials that randomized patients to the same medication among groups were eligible. Studies on any type of operation were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The Cochrane Collaboration risk of bias tool was used. The review was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42019142079). The outcomes of interest were VTE and bleeding. Prespecified subgroup analyses of studies including orthopaedic and nonorthopaedic operations were performed. RESULTS A total of 22 trials (n = 17,124 patients) met eligibility criteria. Pooled results showed a nonstatistically significant decrease in the rate of VTE with preoperative initiation of thromboprophylaxis compared with postoperative initiation (risk ratio 0.77; 95% CI, 0.55 to 1.08; I2 = 0%, n = 1,933). There was also a nonstatistically significant increase in the rate of bleeding with preoperative compared with postoperative initiation (risk ratio 1.17; 95% CI, 0.94 to 1.46; I2 = 35%, n = 2,752). Risk of bias was moderate. Heterogeneity between studies was low (I2 = 0% to 35%). CONCLUSIONS This meta-analysis found a nonstatistically significant decrease in the rate of VTE and an increase in the rate of bleeding when thromboprophylaxis was initiated preoperatively compared with postoperatively.
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Affiliation(s)
- Kristen McAlpine
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; Division of Urology, University of Toronto, Toronto, ON, Canada
| | - Rodney H Breau
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Paulo Werlang
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Marc Carrier
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Medicine, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital, Ottawa, University of Ottawa, Ottawa, ON, Canada
| | - Gregoire Le Gal
- The Ottawa Hospital, Ottawa, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, University of Ottawa, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Morash
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Luke T Lavallée
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
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10
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Pre- vs. postoperative initiation of thromboprophylaxis in liver surgery. HPB (Oxford) 2021; 23:1016-1024. [PMID: 33223433 DOI: 10.1016/j.hpb.2020.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/05/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Thromboprophylaxis protocols in liver surgery vary greatly worldwide. Due to limited research, there is no consensus whether the administration of thromboprophylaxis should be initiated pre- or postoperatively. METHODS Patients undergoing liver resection in Helsinki University Hospital between 2014 and 2017 were reviewed retrospectively. Initiation of thromboprophylaxis was changed in the institution in the beginning of 2016 from postoperative to preoperative. Patients were classified into two groups for analyses: thromboprophylaxis initiated preoperatively (Preop-group) or postoperatively (Postop-group). The incidences of VTE and haemorrhage within 30 days of surgery were compared between these groups. Patients with permanent anticoagulation were excluded. RESULTS A total of 512 patients were included to the study (Preop, n = 253, Postop, n = 259). The incidence of VTE was significantly lower in the Preop-group compared to the Postop-group (3 (1.2%) vs. 25 (9.7%), P = <.0001), mainly due to a lower incidence of pulmonary embolisms in the Preop-group (3 (1.2%) vs. 24 (9.3%), P < .0001). The rates of posthepatectomy haemorrhage within 30 days of surgery were similar (Preop 38 (15.0%) vs. Postop 36 (13.9%), p = .719). CONCLUSION Initiating thromboprophylaxis preoperatively may reduce the incidence of postoperative VTE without affecting the incidence of posthepatectomy haemorrhage in patients undergoing liver resection.
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Risk of venous thromboembolism in patients with elevated INR undergoing hepatectomy: an analysis of the American college of surgeons national surgical quality improvement program registry. HPB (Oxford) 2021; 23:1008-1015. [PMID: 33177005 DOI: 10.1016/j.hpb.2020.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/18/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients undergoing hepatectomy can have elevated INR and may have venous thromboembolism (VTE) prophylaxis withheld as a result. We sought to examine the association between preoperative INR elevation and VTE following hepatectomy. METHODS Hepatectomies captured in the American College of Surgeons National Surgical Quality Improvement Program registry between 2007 and 2016 were analyzed. Univariable and multivariable models examined the effect of incremental increases in preoperative INR on 30-day VTE, perioperative transfusion, serious morbidity, and mortality, adjusting for potential confounders. RESULTS We included 25,220 elective hepatectomies (62.4% partial lobectomies, 10.1% left hepatectomies, 18.6% right hepatectomies, 9.2% trisegmentectomies). The median age of the patients was 60 years and 49% were male. INR was elevated in 3089 patients (12.2%): 1.1-1.2 in 8.1%, 1.2-1.4 in 3.3%, and 1.4-2.0 in 0.9%. Incremental elevations in INR were independently associated with increasing risk for postoperative VTE [odds ratio (OR) 1.15, 95% confidence intervals 1.01-1.31], perioperative transfusion [OR 1.35 (1.28-1.43)], serious morbidity [OR 1.35 (1.28-1.43)], and mortality [OR 1.76 (1.56-1.98)]. CONCLUSION Elevation in preoperative INR was counter-intuitively associated with increased risk of both VTE and perioperative transfusion following hepatectomy. The role of perioperative thromboprophylaxis warrants further investigation to determine optimal care in patients with elevated preoperative INR.
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12
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Schlick CJR, Ellis RJ, Merkow RP, Yang AD, Bentrem DJ. Development and validation of a risk calculator for post-discharge venous thromboembolism following hepatectomy for malignancy. HPB (Oxford) 2021; 23:723-732. [PMID: 32988755 PMCID: PMC7990740 DOI: 10.1016/j.hpb.2020.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk. METHODS Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated. RESULTS Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31-3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04-2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99-14.07]), transfusion (OR 1.77 [95%CI 1.12-2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81-4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21-4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity. CONCLUSIONS Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.
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Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan J. Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA
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13
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Posthospital discharge venous thromboembolism prophylaxis among colorectal and hepatobiliary surgeons: A practice survey. Surgery 2021; 170:173-179. [PMID: 33736865 DOI: 10.1016/j.surg.2021.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/26/2021] [Accepted: 02/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recent practice guidelines recommend venous thromboembolism prophylaxis for 28 days after cancer surgery. We sought to characterize and compare awareness, agreement, adoption, and adherence to these guidelines among surgeons. METHODS We electronically surveyed Canadian hepatobiliary surgeons registered with the Canadian Hepatopancreatobiliary Association, general and colorectal surgeons registered with the College of Physicians and Surgeons of Ontario and the Canadian Society of Colorectal Surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Attitudes to relevant guideline recommendations and perceived barriers to postdischarge venous thromboembolism prophylaxis were assessed on a 5-point Likert scale. RESULTS There were 128 responses (response rate 60%, 128 of 213), including 60 general/colorectal and 68 hepatobiliary surgeons. Most surgeons were aware (122 of 128, 95%), agreed (101 of 122, 83%), adopted (78 of 101, 77%), and adhered (74 of 78, 95%) with guidelines. Preexisting venous thromboembolism-prophylaxis hospital programs, hepatobiliary surgeons, and geographical region were associated with increased likelihood of adherence. Among respondents that did not agree, insufficient evidence (median Likert: 4, interquartile range 3-5) and low incidence of venous thromboembolism (median Likert: 4, interquartile range 3-4) were cited as the strongest barriers. Surgeons who agreed but did not adopt these programs reported that the most significant barriers were "drug cost" (median Likert: 4, interquartile range 3-4) and "subcutaneous injections" (median Likert: 4, interquartile range 3-4). Surgeons that adhered additionally reported "logistical challenges of prescribing" as the greatest implementation barrier. CONCLUSION Surgeons who remain apprehensive about postdischarge venous thromboembolism prophylaxis cite poor evidence and cost of the medication as the major barriers. Adherence was higher among hepatobiliary surgeons and at hospitals with existing venous thromboembolism-prophylaxis programs.
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14
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Cordova-Cassia C, Wong D, Cotter MB, Cataldo TE, Poylin VY. Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study. Surg Endosc 2021; 36:267-273. [PMID: 33495879 DOI: 10.1007/s00464-020-08271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe. METHODS This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30 days of enoxaparin. Safety of use and patient compliance were examined. RESULTS Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance. CONCLUSION Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.
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Affiliation(s)
- Carlos Cordova-Cassia
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Daniel Wong
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Mary B Cotter
- HMFP Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Thomas E Cataldo
- Colon and Rectal Surgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School Teaching Hospital, Boston, USA
| | - Vitaliy Y Poylin
- Gastrointestinal and Oncologic Surgery, Feinberg School of Medicine, Northwestern Medical Group, Arkes Family Pavilion, 676 North St Clair Street, Suite 650, Chicago, IL, 60611, USA.
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15
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Schlick CJR, Merkow RP, Yang AD, Bentrem DJ. Post-discharge venous thromboembolism after pancreatectomy for malignancy: Predicting risk based on preoperative, intraoperative, and postoperative factors. J Surg Oncol 2020; 122:675-683. [PMID: 32531819 PMCID: PMC7755307 DOI: 10.1002/jso.26046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended chemoprophylaxis is recommended for high-risk patients following pancreatectomy for malignancy. However, quantifying risk remains difficult. We sought to (a) identify factors associated with post-discharge venous thromboembolism (VTE) following pancreatectomy for malignancy and (b) develop a post-discharge VTE risk calculator to identify high-risk patients. METHODS Patients who underwent pancreatectomy for malignant histology from 2014 to 2018 were identified from the ACS NSQIP pancreatectomy procedure targeted dataset. Preoperative, intraoperative, and postoperative factors known at hospital discharge were evaluated for association with post-discharge VTE via multivariable logistic regression. A post-discharge VTE risk calculator was developed and validated. RESULTS Of 19 340 analyzed patients, 280 (1.5%) developed post-discharge VTE. Post-discharge VTE was associated with increasing body mass index (BMI; eg, morbidly obese BMI odds ratio [OR]: 1.99 [95% confidence interval {CI}: 1.30-3.02] vs normal BMI), procedure type (distal pancreatectomy OR: 1.47 [95% CI: 1.02-2.12] vs pancreaticoduodenectomy), pancreatic fistula (OR: 1.59 [95% CI: 1.19-2.13]) and delayed gastric emptying (OR: 1.81 [95% CI: 1.29-2.52]). Patients' predicted probability of post-discharge VTE ranged from 0.7% to 9.0%. Twenty iterations of 10-fold cross-validation demonstrated internal validity. CONCLUSIONS Preoperative, intraoperative, and postoperative factors were associated with post-discharge VTE following pancreatectomy for malignancy. This post-discharge VTE risk calculator allows for quantification of individual post-discharge VTE risk, which ranged from 0.7% to 9.0%.
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Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
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Adaramola O, Solomon N, Anyanwu F, Desrosier A, Smith M. Anticoagulation status post radiofrequency ablation in a patient with hepatocellular carcinoma and delayed bleeding event. Radiol Case Rep 2020; 15:1381-1385. [PMID: 32636978 PMCID: PMC7327773 DOI: 10.1016/j.radcr.2020.05.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 11/28/2022] Open
Abstract
Restarting anticoagulation is a tricky component of patient care. This is a case of a 65-year-old female presenting with hepatocellular carcinoma. A nonocclusive thrombus in the main portal vein was also identified. Six days postradiofrequency ablation (RFA), the patient's hemoglobin dropped to critical values and noncontrast computed tomography of the abdomen/pelvis revealed high density free fluid consistent with a bleed. The patient was medically managed and accepted for transfer to another hospital for IR-guided TIPS procedure. Patient recovered without any other complications. In conclusion, VTE prophylaxis be routinely initiated immediately following hepatectomy in hemodynamically stable patients without signs of active bleeding and should bleeding occur halt source then restart anticoagulation immediately.
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Affiliation(s)
- Oladapo Adaramola
- Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY, USA.,Queens Hospital Center, Jamaica, NY, USA
| | - Nadia Solomon
- Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, Department of Internal Medicine, New York, NY, USA
| | | | | | - Mathew Smith
- Queens Hospital Center, Jamaica, NY, USA.,Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, Department of Internal Medicine, New York, NY, USA.,Mount Sinai Ichan SOM, Mount Sinai, NY, USA
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17
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18
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Dabigatran (Pradaxa) Is Safe for Extended Venous Thromboembolism Prophylaxis After Surgery for Pancreatic Cancer. J Gastrointest Surg 2019; 23:1166-1171. [PMID: 30187331 DOI: 10.1007/s11605-018-3936-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Chest Physicians and American Hepato-Pancreato-Biliary Association recommend using low-molecular-weight heparin for 28 days postoperatively for venous thromboembolism prophylaxis after cancer surgery. Dabigatran is a once daily oral anticoagulant that is FDA approved for venous thromboembolism prophylaxis after orthopedic surgery, uses fixed dosing, and has an antidote. METHODS Patients undergoing surgery for malignant pancreatic tumors (neuroendocrine excluded) from January 2017 to January 2018 were converted to dabigatran 220 mg daily on discharge until postoperative day 28; patients with medical or insurance contraindications were converted to enoxaparin or another direct oral anticoagulant. The primary endpoint was bleeding complications through 90 days. RESULTS A total of 134 patients were considered for this study (median age 67 ± 10; 58.9% male). Eighty-seven (82.9%) patients received dabigatran and 18 (17.1%) received another form of anticoagulation. There were 19 (4.2%) patients not prescribed dabigatran due to medical or inpatient contraindications. Four patients experienced bleeding complications after discharge while on dabigatran. Two (2%) were major bleeds (Clavien-Dindo IV and V), and 2 (2%) were minor (Clavien-Dindo I). Patient compliance was excellent, with 93% of prescribed patients fully completing their prophylaxis. There were 2 patients that developed symptomatic deep vein thrombosis. CONCLUSION The use of a direct oral anticoagulant as extended venous thromboembolism prophylaxis after major gastrointestinal surgery has not been studied to date. These results show dabigatran to be a safe alternative to low-molecular-weight heparin for extended venous thromboembolism prophylaxis with regard to bleeding complications.
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19
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Day RW, Aloia TA. Enhanced recovery in liver surgery. J Surg Oncol 2019; 119:660-666. [PMID: 30802314 DOI: 10.1002/jso.25420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 12/11/2022]
Abstract
Enhanced recovery in liver surgery has been shown to improve outcomes including patient-reported outcomes, length of stay, return to intended oncology therapy, and cost. The goal of this chapter will be to review the elements of a modern enhanced recovery pathway that is utilized across the entire episode of care in liver surgery.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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20
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Warner SG, Jutric Z, Fong Y. Response to Comment on: Early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2018; 7:65-67. [PMID: 29531951 PMCID: PMC5835605 DOI: 10.21037/hbsn.2018.01.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/23/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Susanne G. Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Zeljka Jutric
- Division of Hepatobiliary Surgery, Department of Surgery, University of California, Irvine, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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21
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Blasi A, Beltran J. Comment on: Early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2018; 7:63-64. [PMID: 29532808 PMCID: PMC5835598 DOI: 10.21037/hbsn.2017.12.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 08/30/2023]
Affiliation(s)
- Annabel Blasi
- Department of Anesthesia, Clinic Hospital, Barcelona, Spain
| | - Joan Beltran
- Department of Anesthesia, Clinic Hospital, Barcelona, Spain
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22
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Prediction of thromboembolic complications after liver resection for cholangiocarcinoma. Blood Coagul Fibrinolysis 2018; 29:61-66. [DOI: 10.1097/mbc.0000000000000672] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Kim BJ, Aloia TA. What Is "Enhanced Recovery," and How Can I Do It? J Gastrointest Surg 2018; 22:164-171. [PMID: 29067620 PMCID: PMC5784849 DOI: 10.1007/s11605-017-3605-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/28/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery (ER) and fast-track protocols were initially implemented in the perioperative management of the surgical patient over 20 years ago. These standardized protocols are now broadly implemented across most surgical specialties for its many benefits. ER is well known for its positive effects on decreasing length of stay and complications. However, patient-centric outcomes for adequate pain control, functional recovery, costs, and overall patient experience are less considered. HOW I DO IT A successful ER foundation stands on the pillars of several perioperative care principles: early feeding, early ambulation, goal-directed fluid therapy, and opiate-sparing analgesia. Moreover, it requires a multi-disciplinary team buy-in (including patient and family) that must also be thoughtfully executed. The following is a review of key elements within successful evidence-based ER protocols and relevant concepts to consider when starting a successful enhanced recovery program.
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Affiliation(s)
- Bradford J. Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A. Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kim BJ, Day RW, Davis CH, Narula N, Kroll MH, Tzeng CWD, Aloia TA. Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective. J Thromb Haemost 2017; 15:2158-2164. [PMID: 28846822 PMCID: PMC5673571 DOI: 10.1111/jth.13814] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Indexed: 12/11/2022]
Abstract
Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective. SUMMARY Background The incidence of venous thromboembolism (VTE) after liver surgery remains high. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis after liver surgery for the prevention of VTE. Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included thromboembolic deterrent hoses and sequential compression devices. Once hemostasis had been ensured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the duration of hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued to receive anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) minor/minimally invasive approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1%, and 10.5%, respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and on POD 1 for 84 (67.7%) patients. During 90 days of follow-up, no postoperative symptomatic deep vein thrombosis or pulmonary embolic events were diagnosed. Standard-protocol computed tomography scans of the chest, abdomen and pelvis that were obtained for 112 (90.3%) study patients showed no pulmonary emboli, or other thoracic, splanchnic or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.
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Affiliation(s)
- Bradford J. Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ryan W. Day
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Catherine H. Davis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nisha Narula
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael H. Kroll
- Section of Benign Hematology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A. Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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25
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Baltatzis M, Low R, Stathakis P, Sheen AJ, Siriwardena AK, Jamdar S. Efficacy and safety of pharmacological venous thromboembolism prophylaxis following liver resection: a systematic review and meta-analysis. HPB (Oxford) 2017; 19:289-296. [PMID: 28162922 DOI: 10.1016/j.hpb.2017.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/28/2016] [Accepted: 01/01/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current guidelines recommend pharmacological prophylaxis for patients undergoing abdominal surgery for malignancy. Liver resection exposes patients to risk factors for venous thromboembolism, but there is a risk of bleeding. The aim of this study is to evaluate the evidence base supporting the use of pharmacological thromboprophylaxis in liver surgery. METHODS An electronic search was carried out for studies reporting the incidence of VTE following liver resection comparing patients receiving pharmacological prophylaxis with those who did not. The search resulted in 990 unique citations. Following the application of strict eligibility criteria 5 studies comprise the final study population. RESULTS Included studies report on 3675 patients undergoing liver resection between 1999 and 2013. 2256 patients received chemical thromboprophylaxis, 1412 had mechanical prophylaxis only and 7 received no prophylaxis. Meta-analysis revealed lower VTE rates in patients receiving chemical thromboprophylaxis (2.6%) compared to without prophylaxis (4.6%) (Dichotomous correlation test, odds ratio: 0.631 [95% Cl: 0.416-0.959], Fixed model, p = 0.030). Data regarding bleeding could not be pooled for meta-analysis, but chemical thromboprophylaxis was reported as safe in four studies. CONCLUSION This systematic review and meta-analysis of retrospective studies indicates that the use of perioperative chemical thromboprophylaxis reduces VTE incidence following liver surgery without an apparent increased risk of bleeding.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - Ryan Low
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - Panagiotis Stathakis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK; Department of Healthcare Science, Manchester Metropolitan University, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, M13 9WL, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK.
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Lemke M, Beyfuss K, Hallet J, Coburn NG, Law CHL, Karanicolas PJ. Patient Adherence and Experience with Extended Use of Prophylactic Low-Molecular-Weight Heparin Following Pancreas and Liver Resection. J Gastrointest Surg 2016; 20:1986-1996. [PMID: 27688212 DOI: 10.1007/s11605-016-3274-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective. METHODS An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH. RESULTS There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome. CONCLUSION Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines.
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Affiliation(s)
- Madeline Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Kaitlyn Beyfuss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Calvin H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada
| | - Paul J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
- Division of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, T2-016, Toronto, ON, M4N 3M5, Canada.
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The INR is only one side of the coagulation cascade: time to watch the clot. Anaesthesia 2016; 71:613-7. [DOI: 10.1111/anae.13480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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