Venous thromboembolic disease in colorectal patients

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern

BACKGROUND

Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%.

OBJECTIVE

To estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools.

METHODS

A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19%( 95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists' (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy.

CONCLUSION

VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates.

Fondaparinux Sodium Compared With Low-Molecular-Weight Heparins for Perioperative Surgical Thromboprophylaxis: A Systematic Review and Meta-analysis

Background

Fondaparinux sodium has been compared with low‐molecular‐weight heparins (LMWH) in randomized controlled trials for perioperative surgical thromboprophylaxis. However, the results from these studies are inconsistent in terms of efficacy and safety to reach a clinical decision. The objective of this study was to systematically review the randomized controlled trials comparing the efficacy and safety of fondaparinux and LMWH for perioperative surgical thromboprophylaxis.

Methods and Results

Systematic search in various databases was done to identify randomized controlled trials comparing fondaparinux and LMWH published during the years 2000 to 2017. Outcomes of interest in this study included venous thromboembolism up to day 15, all‐cause mortality up to day 90, major bleeding, and minor bleeding during the treatment period. Analyses were performed with the relative odds based on a random‐effects model using Mantel‐Haenszel statistics. Results were presented as odds ratios with their 95% CIs. The assessment of study quality was performed as per Cochrane collaboration. After screening 10 644 articles, 12 randomized controlled trials including 14 906 patients were included in the final analyses. Pooled analyses showed the odds of venous thromboembolism in the fondaparinux group were 0.49 times the odds in LMWH group (OR=0.49 [0.38–0.64]). However, the odds of major bleeding in the fondaparinux group were 1.48 times the odds in the LMWH group (OR=1.48 [1.15–1.90]).

Conclusions

Fondaparinux was associated with a superior efficacy in terms of reduction of venous thromboembolism in this meta‐analysis. However, it was also associated with increased odds of major bleeding.

Global incidence and case fatality rate of pulmonary embolism following major surgery: a protocol for a systematic review and meta-analysis of cohort studies

BACKGROUND

Pulmonary embolism (PE) is a life-threatening condition common after major surgery. Although the high incidence (0.3-30%) and mortality rate (16.9-31%) of PE in patients undergoing major surgical procedures is apparent from findings of contemporary observational studies, there is a lack of a summary and meta-analysis data on the epidemiology of postoperative PE in this same regard. Hence, we propose to conduct the first systematic review to summarise existing data on the global incidence, determinants and case fatality rate of PE following major surgery.

METHODS

Electronic databases including MEDLINE, EMBASE, SCOPUS, WHO global health library (including LILACS), Web of Science and Google scholar from inception to April 30, 2017, will be searched for cohort studies reporting on the incidence, determinants and case fatality rate of PE occurring after major surgery. Data from grey literature will also be assessed. Two investigators will independently perform study selection and data extraction. Included studies will be evaluated for risk of bias. Appropriate meta-analytic methods will be used to pool incidence and case fatality rate estimates from studies with identical features, globally and by subgroups of major surgical procedures. Random-effects and risk ratio with 95% confidence interval will be used to summarise determinants and predictors of mortality of PE in patients undergoing major surgery.

DISCUSSION

This systematic review and meta-analysis will provide the most up-to-date epidemiology of PE in patients undergoing major surgery to inform health authorities and identify further research topics based on the remaining knowledge gaps.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017065126.

Analysis of Postoperative Venous Thromboembolism in Patients With Chronic Ulcerative Colitis: Is It the Disease or the Operation?

BACKGROUND

Patients with IBD have a higher baseline risk of venous thromboembolism, which further increases with surgery. Therefore, extended venous thromboembolism chemoprophylaxis has been suggested in certain high-risk cohorts.

OBJECTIVE

The purpose of this study was to determine whether the underlying diagnosis, operative procedure, or both influence the incidence of postoperative venous thromboembolism.

DESIGN

This was a retrospective review.

SETTINGS

The American College of Surgeons-National Surgical Quality Improvement Project database was analyzed.

PATIENTS

The NSQIP database was queried for patients with chronic ulcerative colitis and non-IBD undergoing colorectal resections using surgical Current Procedural Terminology codes modeled after the 3 stages used for the surgical management of chronic ulcerative colitis from 2005 to 2013.

MAIN OUTCOME MEASURES

We measured 30-day postoperative venous thromboembolism risk in patients with chronic ulcerative colitis based on operative stage and risk factors for development of venous thromboembolism.

RESULTS

A total of 18,833 patients met inclusion criteria, with an overall rate of venous thromboembolism of 3.8. Among procedure risk groups, venous thromboembolism rates were high risk, 4.4%; intermediate risk, 1.6%; and low risk, 0.7% (across risk groups, p < 0.01). Emergent case subjects exhibited a higher rate of venous thromboembolism than their elective counterparts (6.9% vs 3.1%). Factors significantly associated with venous thromboembolism on adjusted analysis included emergent risk case (adjusted OR = 7.85), high-risk elective case (adjusted OR = 5.07), intermediate-risk elective case (adjusted OR = 2.69), steroid use (adjusted OR = 1.54), and preoperative albumin <3.5 g/dL (adjusted OR = 1.45).

LIMITATIONS

Because of its retrospective nature, correlation between procedures and venous thromboembolism risk can be demonstrated, but causation cannot be proven. In addition, data on inpatient and extended venous thromboembolism prophylaxis use are not available.

CONCLUSIONS

Emergent status and operative procedure are the 2 highest risk factors for postoperative venous thromboembolism. Extended venous thromboembolism prophylaxis might be appropriate for patients undergoing these high-risk procedures or any emergent colorectal procedures. See Video Abstract at http://links.lww.com/DCR/A339.

Venous thromboembolism following colorectal resection

AIM

The study investigated the rate of significant venous thromboembolism (VTE) following colorectal resection during the index admission and over 1 year following discharge. It identifies risk factors associated with VTE and considers the length of VTE prophylaxis required.

METHOD

All adult patients who underwent colorectal resections in England between April 2007 and March 2008 were identified using Hospital Episode Statistics data. They were studied during the index admission and followed for a year to identify any patients who were readmitted as an emergency with a diagnosis of deep venous thrombosis or pulmonary embolism.

RESULTS

In all, 35 997 patients underwent colorectal resection during the period of study. The VTE rate was 2.3%. Two hundred and one (0.56%) patients developed VTE during the index admission and 571 (1.72%) were readmitted with VTE. Following discharge from the index admission, the risk of VTE in patients with cancer remained elevated for 6 months compared with 2 months in patients with benign disease. Age, postoperative stay, cancer, emergency admission and emergency surgery for patients with inflammatory bowel disease (IBD) were all independent risk factors associated with an increased risk of VTE. Patients with ischaemic heart disease and those having elective minimal access surgery appear to have lower levels of VTE.

CONCLUSION

This study adds to the benefits of minimal access surgery and demonstrates an additional risk to patients undergoing emergency surgery for IBD. The majority of VTE cases occur following discharge from the index admission. Therefore, surgery for cancer, emergency surgery for IBD and those with an extended hospital stay may benefit from extended VTE prophylaxis. This study demonstrates that a stratified approach may be required to reduce the incidence of VTE.

Risk Factors of a Pulmonary Thromboembolism After Colorectal Surgery

Purpose

Previous studies have revealed that predictors and risk factors of pulmonary thromboembolism (PTE) are malignancy, immobilization, diabetes, and obesity in the postoperative patients. However, in patients undergoing colorectal cancer, studies of PTE have not been enough. Thus, we investigated the risk factors of PTE related to colorectal surgery.

Methods

From January 2009 to October 2014, 312 patients received colorectal surgery without other organ resection. The postoperative patients with PTE were 14 (4.5%), and they were classified by sex, age, and stage as a 1:3 paired match to the control group. A multiple logistic regression was performed to identify which factors were associated with PTE.

Results

One patient was in stage I, 3 in stage II, 9 in stage III, and 1 in stage IV. In the binary logistic regression analysis, history of diabetes mellitus (odds ratio, 6.498; P = 0.031) and being overweight (odds ratio, 10.018; P = 0.014) were independent risk factors for PTE in patients undergoing colorectal cancer.

Conclusion

A history of diabetes mellitus and being overweight were independent risk factors of PTE after colorectal cancer.

A nationwide analysis of postoperative deep vein thrombosis and pulmonary embolism in colon and rectal surgery

There are limited data regarding predictive factors of postoperative venous thromboembolism (VTE) in patients undergoing colorectal resection. We sought to identify associations between patient comorbidities and postoperative VTE in colorectal resection. The National Surgical Quality Improvement Program (NSQIP) database was used to examine clinical data of patients experiencing postoperative VTE after colorectal resection from 2005 to 2011. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE. We sampled 116,029 patients undergoing colorectal resection. The rate of VTE was 2 % (2,278) with 0.2 % (182) having deep vein thrombosis (DVT) and pulmonary embolism (PE). The first week after operation was the most common time for postoperative VTE. A significant number of patients suffering DVT and PE were diagnosed after index hospital discharge (PE 34.6 %, DVT 29.3 %). The most important risk factors identified for DVT include (P < 0.05) ASA score >2 (adjusted odds ratio (AOR) 1.77) and hypoalbuminemia (serum albumin level <3.5 mg/dl) (AOR 1.69). The most important factors had associations with PE include (P < 0.05) DVT (AOR 14.60) and disseminated cancer (AOR 1.70). Ulcerative colitis (AOR 1.48, P = 0.01) and stage 4 cancer (AOR 1.29, P = 0.02) have associations with DVT. Open colorectal procedures have higher risk of DVT compared to laparoscopic procedures (AOR 1.33, P < 0.01). Postoperative VTE occurs in 2 % of colorectal resections. Thirty percent of VTE events were diagnosed after discharge. Prophylactic treatment of VTE after discharge may have benefits in high-risk patients. Thirteen and eleven perioperative risk factors have associations with DVT and PE, respectively. Emergent admission, open procedures, ulcerative colitis, and stage 4 cancer patients have increased risk of DVT.

Surgical management of Crohn's disease

Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.

Timing and perioperative risk factors for in-hospital and post-discharge venous thromboembolism after colorectal cancer resection

INTRODUCTION

We postulated that the risk of venous thromboembolic disease (VTE) may persist after discharge and tested this hypothesis in patients undergoing colorectal resection for cancer.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program database was queried for patients undergoing colorectal resections for cancer from 2005 to 2009. The outcome analyzed was a 30-day deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Multivariable forward stepwise regression was used to identify independent predictors of VTE.

RESULTS

The database contained 21 943 colorectal cancer resections. The 30-day DVT rate was 1.4% (306 of 21 943), 29% (89 of 306) were diagnosed post-discharge. The 30-day PE rate was 0.8% (180 of 21 943), 33% (60 of 180) was diagnosed post-discharge, the combined DVT/PE rate was 2.0% (446 of 21 943). The median time to diagnosis of VTE was 9 days (interquartile range 4-16) after surgery. Post-discharge VTE rates in patients with length of stay (LOS) less than 1 week (0.6%) were similar to patients with LOS greater than 1 week (0.7%, Fisher exact P not significant). Independent risk factors for post-discharge VTE were preoperative steroid use for chronic condition (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.51-5.57, P = .001) and preoperative systemic inflammatory response syndrome (OR 2.26, 95% CI 1.24-4.10, P = .008).

CONCLUSIONS

Diagnosis of almost one third of postoperative VTE in this patient population occurred after discharge. The duration of the prothrombotic stimulus of surgery is not well defined, and patients with malignancy are at high risk of VTE; thromboprophylaxis after discharge should be considered for these patients.