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Harindranath S, Varghese J, Afzalpurkar S, Giri S. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepatogastroenterol 2023; 13:133-141. [PMID: 38222957 PMCID: PMC10785145 DOI: 10.5005/jp-journals-10018-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024] Open
Abstract
Patients with inflammatory bowel disease (IBD), both Crohn's disease and ulcerative colitis, frequently experience venous thromboembolism (VTE), a potentially fatal consequence. The pathophysiological mechanisms contributing to VTE include inflammation, modifications in coagulation factors, endothelial dysfunction, and platelet activation. Numerous pro-inflammatory cytokines and markers, such as tumor necrosis factor-alpha and interleukin-6, have a significant impact on the thrombotic cascade. Patients with IBD are more likely to suffer VTE for a variety of causes. Exacerbations of preexisting conditions, admission to the hospital, surgical intervention, immobilization, corticosteroid usage, central venous catheterization, and hereditary susceptibility all fit into this category. The mainstay of therapy for VTE in IBD patients includes anticoagulation that is individualized for each patient depending on the thrombosis site, severity, bleeding risk, and interaction with other drugs. In some high-risk IBD patients, such as those having major surgery or hospitalized with severe flare, preventive anticoagulation may play a role. However, the acceptance rate for this recommendation is low. Additionally, there is a subset of patients who would require extended thromboprophylaxis. The majority of the studies that looked into this question consisted of patients in the surgical setting. Emerging data suggest that risk factors other than surgery can also dictate the duration of anticoagulation. While extending anticoagulation in all patients may help reduce VTE-related mortality, identifying these risk factors is important. Hence, the decision to initiate prophylaxis should be individualized, considering the overall thrombotic and bleeding risks. This review explores the relationship between IBD and VTE, including risk factors, epidemiology, and prevention. A multifactorial approach involving aggressive management of underlying inflammation, identification of modifiable risk factors, and judicious use of anticoagulant therapy is essential for reducing the burden of VTE in this vulnerable population. How to cite this article Harindranath S, Varghese J, Afzalpurkar S, et al. Standard and Extended Thromboprophylaxis in Patients with Inflammatory Bowel Disease: A Literature Review. Euroasian J Hepato-Gastroenterol 2023;13(2):133-141.
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Affiliation(s)
- Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Jijo Varghese
- Department of Gastroenterology, NS Hospital, Kollam, Kerala, India
| | - Shivaraj Afzalpurkar
- Department of Gastroenterology, Nanjappa Multispecialty Hospital, Davangere, Karnataka, India
| | - Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Leow TW, Rashid A, Lewis-Lloyd CA, Crooks CJ, Humes DJ. Risk of Postoperative Venous Thromboembolism After Benign Colorectal Surgery: Systematic Review and Meta-analysis. Dis Colon Rectum 2023; 66:877-885. [PMID: 37134222 DOI: 10.1097/dcr.0000000000002915] [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] [Indexed: 05/05/2023]
Abstract
BACKGROUND Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign disease is limited. OBJECTIVE This meta-analysis aimed to quantify the venous thromboembolism risk after benign colorectal resection and determine its variability. DATA SOURCES Following Preferred Reporting Items for Systematic Review and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology Guidelines (PROSPERO: CRD42021265438), Embase, MEDLINE, and 4 other registered medical literature databases were searched from the database inception to June 21, 2021. STUDY SELECTION Inclusion criteria: randomized controlled trials and large population-based database cohort studies reporting 30-day and 90-day venous thromboembolism rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: patients undergoing colorectal cancer or completely endoscopic surgery. MAIN OUTCOME MEASURES Thirty- and 90-day venous thromboembolism incidence rates per 1000 person-years after benign colorectal surgery. RESULTS Seventeen studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day venous thromboembolism incidence rates after benign colorectal resection were 284 (95% CI, 224-360) and 84 (95% CI, 33-218) per 1000 person-years. Stratified by admission type, 30-day venous thromboembolism incidence rates per 1000 person-years were 532 (95% CI, 447-664) for emergency resections and 213 (95% CI, 100-453) for elective colorectal resections. Thirty-day venous thromboembolism incidence rates per 1000 person-years after colectomy were 485 (95% CI, 411-573) for patients with ulcerative colitis, 228 (95% CI, 181-288) for patients with Crohn's disease, and 208 (95% CI, 152-288) for patients with diverticulitis. LIMITATIONS High degree of heterogeneity was observed within most meta-analyses attributable to large cohorts minimizing within-study variance. CONCLUSIONS Venous thromboembolism rates remain high up to 90 days after colectomy and vary by indication for surgery. Emergency resections compared to elective benign resections have higher rates of postoperative venous thromboembolism. Further studies reporting venous thromboembolism rates by type of benign disease need to stratify rates by admission type to more accurately define venous thromboembolism risk after colectomy. REGISTRATION NO CRD42021265438.
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Affiliation(s)
- Tjun Wei Leow
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Adil Rashid
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Colin J Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
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Lewis‐Lloyd CA, Crooks CJ, West J, Peacock O, Humes DJ. Time trends in the incidence rates of venous thromboembolism following colorectal resection by indication and operative technique. Colorectal Dis 2022; 24:1405-1415. [PMID: 35733416 PMCID: PMC9796069 DOI: 10.1111/codi.16233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/30/2022] [Accepted: 06/14/2022] [Indexed: 12/30/2022]
Abstract
AIM It is important for patient safety to assess if international changes in perioperative care, such as the focus on venous thromboembolism (VTE) prevention and minimally invasive surgery, have reduced the high post colectomy VTE risks previously reported. This study assesses the impact of changes in perioperative care on VTE risk following colorectal resection. METHOD This was a population-based cohort study of colectomy patients in England between 2000 and 2019 using a national database of linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Within 30 days following colectomy, absolute VTE rates per 1000 person-years and adjusted incidence rate ratios (aIRRs) using Poisson regression for the per year change in VTE risk were calculated. RESULTS Of 183 791 patients, 1337 (0.73%) developed 30-day postoperative VTE. Overall, VTE rates reduced over the 20-year study period following elective (relative risk reduction 31.25%, 95% CI 5.69%-49.88%) but not emergency surgery. Similarly, yearly changes in VTE risk reduced following minimally invasive resections (elective benign, aIRR 0.93, 95% CI 0.90-0.97; elective malignant, aIRR 0.94, 95% CI 0.91-0.98; and emergency benign, aIRR 0.96, 95% CI 0.92-1.00) but not following open resections. There was a per year VTE risk increase following open emergency malignant resections (aIRR 1.02, 95% CI 1.00-1.04). CONCLUSION Yearly VTE risks reduced following minimally invasive surgeries in the elective setting yet in contrast were static following open elective colectomies, and following emergency malignant resections increased by almost 2% per year. To reduce VTE risk, further efforts are required to implement advances in surgical care for those having emergency and/or open surgery.
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Affiliation(s)
- Christopher A. Lewis‐Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - Colin J. Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - Joe West
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Population and Lifespan SciencesUniversity of Nottingham, School of MedicineNottinghamUK
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, MD Anderson Cancer CenterUniversity of TexasHoustonTexasUSA
| | - David J. Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
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Cost-Effectiveness of Aspirin for Extended Venous Thromboembolism Prophylaxis After Major Surgery for Inflammatory Bowel Disease. J Gastrointest Surg 2022; 26:1275-1285. [PMID: 35277799 DOI: 10.1007/s11605-022-05287-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Venous thromboembolism extended prophylaxis after inflammatory bowel disease surgery remains controversial. The purpose of this study was to evaluate if adopting an aspirin-based prophylaxis strategy may address current cost-effectiveness limitations. METHODS A decision analysis model was used to compare costs and outcomes of a reference case patient undergoing inflammatory bowel disease-associated colorectal surgery considered for post-discharge thromboembolism prophylaxis. Low-dose aspirin was compared to an enoxaparin regimen as well as no prophylaxis. Source estimates were obtained from aggregated existing literature. Secondary analysis included out-of-pocket costs. A 10,000-simulation Monte Carlo probabilistic sensitivity analysis accounted for uncertainty in model estimates. RESULTS An enoxaparin-based regimen compared to aspirin demonstrated an unfavorable incremental cost-effectiveness ratio of $908,268 per quality-adjusted life year. Sensitivity analysis supported this finding in > 75% of simulated cases; scenarios favoring enoxaparin included those with > 4% post-discharge event rates. Aspirin versus no prophylaxis demonstrated a favorable ratio of $106,601 per quality-adjusted life year. Findings were vulnerable to a post-discharge thromboembolism rate < 1%, aspirin-associated bleeding rate > 1%, median hospital costs of bleeding > 3 × , and decreased efficacy of aspirin (RR > 0.75). The average out-of-pocket cost of choosing an aspirin ePpx strategy increased by $54 per patient versus $708 per patient with enoxaparin. CONCLUSIONS Low-dose aspirin extended prophylaxis following inflammatory bowel disease surgery has a favorable cost-safety profile and may be an attractive alternative approach.
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Leeds IL, Canner JK, DiBrito SR, Safar B. Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients? Dis Colon Rectum 2022; 65:702-712. [PMID: 34840290 PMCID: PMC8995329 DOI: 10.1097/dcr.0000000000002056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique. OBJECTIVE This study aimed to assess the cost-effectiveness of extended prophylaxis in postoperative ulcerative colitis patients. DESIGN A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon. SETTING Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality. MAIN OUTCOME MEASURES Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities. RESULTS Using reference parameters, the individual expected societal total cost of care was $957 without and $1775 with prophylaxis (not cost-effective; $257,280 per quality-adjusted life year). Preventing a single mortality with prophylaxis would cost $5 million (number needed to treat: 6134 individuals). Adjusting across a range of scenarios upheld these conclusions 77% of the time. With further sensitivity testing, venous thromboembolism cumulative risk (>1.5%) and ePpx regimen pricing (<$299) were the 2 parameters most sensitive to uncertainty. LIMITATIONS Recommendations of decision analysis methodology are limited to group decision-making, not an individual risk profile. CONCLUSION Routine ePpx in postoperative ulcerative colitis patients is not cost-effective. This finding is sensitive to higher-than-average rates of venous thromboembolism and low-cost prophylaxis opportunities. See Video Abstract at http://links.lww.com/DCR/B818. SE APLICAN LAS LIMITACIONES DE COSTOS DE LA PROFILAXIS PROLONGADA DESPUS DE LA CIRUGA A LOS PACIENTES CON COLITIS ULCEROSA ANTECEDENTES:Los pacientes de cirugía colorrectal con colitis ulcerosa tienen un mayor riesgo de tromboembolismo venoso posoperatorio. La profilaxis extendida para la prevención de la tromboembolia se ha utilizado en pacientes con cirugía colorrectal, aunque ha sido criticada por su falta de rentabilidad. Sin embargo, la rentabilidad de la profilaxis prolongada para los pacientes posoperados con colitis ulcerosa puede ser aceptable.OBJETIVO:Evaluar la rentabilidad de la profilaxis prolongada en pacientes posoperados con colitis ulcerosa.DISEÑO:Un análisis de decisiones comparó los costos y beneficios en pacientes posoperados con colitis ulcerosa con y sin profilaxis prolongada de por vida.AJUSTE:Los supuestos para el análisis de decisiones se identificaron a partir de la literatura disponible para el riesgo de trombosis de un paciente con colitis ulcerosa típica, la edad al momento de la cirugía, el tipo de trombosis, la reducción del riesgo con profilaxis, las complicaciones hemorrágicas y la mortalidad.PRINCIPALES MEDIDAS DE RESULTADO:Los costos ($) y los beneficios (año de vida ajustado por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la principal medida de resultado, la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilística multivariable modeló la incertidumbre en probabilidades, costos y desutilidades.RESULTADOS:Utilizando parámetros de referencia, el costo total de atención social esperado individual fue de $957 sin profilaxis y $1775 con profilaxis (no rentable; $257,280 por año de vida ajustado por calidad). La prevención de una sola mortalidad con profilaxis costaría $5.0 millones (número necesario a tratar: 6.134 personas). El ajuste en una variedad de escenarios mantuvo estas conclusiones el 77% de las veces. Con más pruebas de sensibilidad, el riesgo acumulado de TEV (>1,5%) y el precio del régimen de ePpx (<$299) fueron los dos parámetros más sensibles a la incertidumbre.LIMITACIONES:Las recomendaciones de la metodología de análisis de decisiones se limitan a la toma de decisiones en grupo, no a un perfil de riesgo individual.CONCLUSIÓN:La profilaxis extendida de rutina en pacientes posoperados con colitis ulcerosa no es rentable. Este hallazgo es sensible a tasas de TEV superiores al promedio y oportunidades de profilaxis de bajo costo. Consulted Video Resumen en http://links.lww.com/DCR/B818. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Chakraborty P, Jacob A. Extended chemothromboprophylaxis use in colorectal cancer surgery: a literature review. ANZ J Surg 2022; 92:1644-1650. [DOI: 10.1111/ans.17454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Priyanka Chakraborty
- Department of General Surgery Royal Perth Hospital Perth Western Australia Australia
| | - Abraham Jacob
- Department of General Surgery Royal Perth Hospital Perth Western Australia Australia
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Boo M, Sykes P, Simcock B. Use of direct oral anticoagulants for postoperative venous thromboembolism prophylaxis after surgery for gynecologic malignancies. Int J Gynecol Cancer 2022; 32:189-194. [PMID: 34992129 DOI: 10.1136/ijgc-2021-003006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022] Open
Abstract
Venous thromboembolism is a preventable cause of postoperative mortality in patients undergoing surgery for malignancy. Current standard of care based on international guideline recommends 28 days of extended thromboprophylaxis after major abdominal and pelvic surgery for malignancies with unfractionated heparin or low molecular weight heparin. Direct oral anticoagulants have been approved for the treatment of venous thromboembolism in the general population. This regimen has a significant advantage over other types of anticoagulation regimens, particularly being administered by non-parenteral routes and without the need for laboratory monitoring. In this review, we evaluate the role of direct anticoagulation and provide an update on completed and ongoing clinical trials.
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Affiliation(s)
- Marilyn Boo
- Gynaecologic Oncology, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Peter Sykes
- Gynaecologic Oncology, Christchurch Women's Hospital, Christchurch, New Zealand.,University of Otago Christchurch, Christchurch, New Zealand
| | - Bryony Simcock
- Gynaecologic Oncology, Christchurch Women's Hospital, Christchurch, New Zealand
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Olivera PA, Zuily S, Kotze PG, Regnault V, Al Awadhi S, Bossuyt P, Gearry RB, Ghosh S, Kobayashi T, Lacolley P, Louis E, Magro F, Ng SC, Papa A, Raine T, Teixeira FV, Rubin DT, Danese S, Peyrin-Biroulet L. International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 2021; 18:857-873. [PMID: 34453143 PMCID: PMC8395387 DOI: 10.1038/s41575-021-00492-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 12/11/2022]
Abstract
Patients with inflammatory bowel disease (IBD) are at increased risk of thrombotic events. Therapies for IBD have the potential to modulate this risk. The aims of this Evidence-Based Guideline were to summarize available evidence and to provide practical recommendations regarding epidemiological aspects, prevention and drug-related risks of venous and arterial thrombotic events in patients with IBD. A virtual meeting took place in May 2020 involving 14 international IBD experts and 3 thrombosis experts from 12 countries. Proposed statements were voted upon in an anonymous manner. Agreement was defined as at least 75% of participants voting as 'fully agree' or 'mostly agree' with each statement. For each statement, the level of evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Consensus was reached for 19 statements. Patients with IBD harbour an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization of any cause in patients with IBD. Disease activity is a modifiable risk factor in patients with IBD, and physicians should aim to achieve deep remission to reduce the risk. Exposure to steroids should be limited. Antitumour necrosis factor agents might be associated with a reduced risk of thrombotic events.
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Affiliation(s)
- Pablo A Olivera
- Gastroenterology Section, Department of Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Stephane Zuily
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre-lès-Nancy, France
- University of Lorraine, INSERM, DCAC, Nancy, France
| | - Paulo G Kotze
- IBD outpatient clinics, Colorectal Surgery Unit, Catholic University of Paraná (PUCPR), Curitiba, Brazil
| | | | - Sameer Al Awadhi
- Gastroenterology Division, Rashid Hospital, Dubai Health Authority, Dubai, UAE
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Subrata Ghosh
- NIHR Biomedical Research Centre, University of Birmingham and University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | | | - Edouard Louis
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Fernando Magro
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alfredo Papa
- Division of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
- Catholic University of Rome, Rome, Italy
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David T Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and INSERM NGERE U1256, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France.
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Ludbrook GL. The Hidden Pandemic: the Cost of Postoperative Complications. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:1-9. [PMID: 34744518 PMCID: PMC8558000 DOI: 10.1007/s40140-021-00493-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/17/2022]
Abstract
Purpose of Review Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing. Recent Findings Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change. Summary Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.
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Affiliation(s)
- Guy L. Ludbrook
- The University of Adelaide, and Royal Adelaide Hospital, C/O Royal Adelaide Hospital, 3G395, 1 Port Road, Adelaide, South Australia 5000 Australia
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Lee KE, Lim F, Colombel JF, Hur C, Faye AS. Cost-effectiveness of Venous Thromboembolism Prophylaxis After Hospitalization in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 28:1169-1176. [PMID: 34591970 PMCID: PMC9890631 DOI: 10.1093/ibd/izab246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have a 2- to 3-fold greater risk of venous thromboembolism (VTE) than patients without IBD, with increased risk during hospitalization that persists postdischarge. We determined the cost-effectiveness of postdischarge VTE prophylaxis among hospitalized patients with IBD. METHODS A decision tree compared inpatient prophylaxis alone vs 4 weeks of postdischarge VTE prophylaxis with 10 mg/day of rivaroxaban. Our primary outcome was quality-adjusted life years (QALYs) over 1 year, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (in 2020 $USD), incremental cost-effectiveness ratios (ICERs) and number needed to treat (NNT) to prevent 1 VTE and VTE death were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS Prophylaxis with rivaroxaban resulted in 1.68-higher QALYs per 1000 persons compared with no postdischarge prophylaxis at an incremental cost of $185,778 per QALY. The NNT to prevent a single VTE was 78, whereas the NNT to prevent a single VTE-related death was 3190. One-way sensitivity analyses showed that higher VTE risk >4.5% and decreased cost of rivaroxaban ≤$280 can reduce the ICER to <$100,000/QALY. Probabilistic sensitivity analyses favored prophylaxis in 28.9% of iterations. CONCLUSIONS Four weeks of postdischarge VTE prophylaxis results in higher QALYs compared with inpatient prophylaxis alone and prevents 1 postdischarge VTE among 78 patients with IBD. Although postdischarge VTE prophylaxis for all patients with IBD is not cost-effective, it should be considered in a case-by-case scenario, considering VTE risk profile, costs, and patient preference.
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Affiliation(s)
- Kate E Lee
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francesca Lim
- Department of Medicine, Division of Digestive and Liver Diseases, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Adam S Faye
- Address correspondence to: Adam S. Faye, MD MS, Assistant Professor of Medicine & Population Health, NYU Langone Division of Gastroenterology, New York University, New York, NY, USA, 303 East 33rd Street, New York, NY 10016, USA ()
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Tessler RA, Watson AR, Holder-Murray J. The Incisionless Totally Laparoscopic Total Abdominal Colectomy: How I Do It? J Laparoendosc Adv Surg Tech A 2021; 31:850-854. [PMID: 34152848 DOI: 10.1089/lap.2020.0958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Laparoscopic total abdominal colectomy (TAC) is the optimal operative approach for patients with medically refractory inflammatory bowel disease and other benign colon conditions. Minimally invasive techniques for TAC are safe, appropriate, and associated with faster recovery than open surgery. This may be of particular importance in patients who ultimately undergo proctectomy with or without intestinal pouch reconstruction. We describe approaches to the laparoscopic TAC.
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Affiliation(s)
- Robert A Tessler
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew R Watson
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Lewis-Lloyd CA, Pettitt EM, Adiamah A, Crooks CJ, Humes DJ. Risk of Postoperative Venous Thromboembolism After Surgery for Colorectal Malignancy: A Systematic Review and Meta-analysis. Dis Colon Rectum 2021; 64:484-496. [PMID: 33496485 DOI: 10.1097/dcr.0000000000001946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal cancer has the second highest mortality of any malignancy, and venous thromboembolism is a major postoperative complication. OBJECTIVE This study aimed to determine the variation in incidence of venous thromboembolism after colorectal cancer resection. DATA SOURCES Following PRISMA and MOOSE guidelines (PROSPERO, ID: CRD42019148828), Medline and Embase databases were searched from database inception to August 2019 including 3 other registered medical databases. STUDY SELECTION Two blinded reviewers screened studies with a third reviewer adjudicating any discordance. Eligibility criteria: Patients post colorectal cancer resection aged ≥18 years. Exclusion criteria: Patients undergoing completely endoscopic surgery and those without cancer resection. Selected studies were randomized controlled trials and population-based database/registry cohorts. MAIN OUTCOME MEASURES Thirty- and 90-day incidence rates of venous thromboembolism per 1000 person-years following colorectal cancer surgery. RESULTS Of 6441 studies retrieved, 28 met inclusion criteria. Eighteen were available for meta-analysis reporting on 539,390 patients. Pooled 30- and 90-day incidence rates of venous thromboembolism following resection were 195 (95% CI, 148-256, I2 99.1%) and 91 (95% CI, 56-146, I2 99.2%) per 1000 person-years. When separated by United Nations Geoscheme Areas, differences in the incidence of postoperative venous thromboembolism were observed with 30- and 90-day pooled rates per 1000 person-years of 284 (95% CI, 238-339) and 121 (95% CI, 82-179) in the Americas and 71 (95% CI, 60-84) and 57 (95% CI, 47-69) in Europe. LIMITATIONS A high degree of heterogeneity was observed within meta-analyses attributable to large cohorts minimizing within-study variance. CONCLUSION The incidence of venous thromboembolism following colorectal cancer resection is high and remains so more than 1 month after surgery. There is clear disparity between the incidence of venous thromboembolism after colorectal cancer surgery by global region. More robust population studies are required to further investigate these geographical differences to determine valid regional incidence rates of venous thromboembolism following colorectal cancer resection.
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Affiliation(s)
- Christopher A Lewis-Lloyd
- Department of Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Ong CT, Leung E, Shah AP. Improving prescribing of extended prophylaxis for venous thromboembolism at discharge in patients who underwent surgery for colorectal cancer. Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 33263480 DOI: 10.12968/hmed.2020.0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS/BACKGROUND Prophylaxis at discharge is important in mitigating venous thromboembolism events from colorectal cancer and major abdominopelvic surgery, both of which are risk factors for venous thromboembolism. Foundation doctors frequently rotate between departments, and so rely on departmental induction and/or handing down of knowledge to prescribe extended venous thromboembolism prophylaxis upon discharge. METHODS A retrospective audit of all patients who underwent surgery for colorectal cancer at The County Hospital, Hereford, between 1 August 2018 and 31 August 2019, was undertaken to assess departmental compliance with guidance from the National Institute for Health and Care Excellence. RESULTS A total of 181 patients underwent elective surgery and 29 patients had emergency surgery. The initial audit revealed a cyclical 4-monthly decline that coincided with foundation doctors' rotations. Six multidisciplinary interventions were implemented. Reaudit demonstrated 100% compliance with prescribing of extended venous thromboembolism prophylaxis at discharge. No venous thromboembolism events 30 days post operation were noted. CONCLUSIONS A multidisciplinary approach involving educating health professionals about the importance of extended venous thromboembolis prophylaxis in patients who have undergone surgery for colorectal cancer can be effective in improving compliance with prescribing practices at discharge.
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Affiliation(s)
- Chea Tze Ong
- Department of Surgery, The County Hospital, Hereford, UK
| | - Edmund Leung
- Department of Surgery, The County Hospital, Hereford, UK
| | - Adarsh P Shah
- Department of Surgery, The County Hospital, Hereford, UK.,School of Surgery, Health Education England West Midlands, Birmingham, UK
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Clement E, Dang J, Laffin M, Wang H. Incidence of Venous Thromboembolism Following Proctectomy Is Greater in Ulcerative Colitis than in Malignancy or Crohn's Disease. J Gastrointest Surg 2020; 24:2664-2666. [PMID: 32705609 DOI: 10.1007/s11605-020-04738-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/02/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Elizabeth Clement
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada.
| | - Jerry Dang
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
| | - Micheal Laffin
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
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