Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery

Cumulative Incidence of Venous Thromboembolic Events In-Hospital, and at 1, 3, 6, and 12 Months After Metabolic and Bariatric Surgery: Systematic Review of 87 Studies and Meta-analysis of 2,731,797 Patients

Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13-0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33-0.70%); 0.51% (95% CI = 0.38-0.65%); 0.72% (95% CI = 0.13-1.52%); 0.78% (95% CI = 0-3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.

A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient's risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation.

The feasibility and safety of laparoscopic inguinal hernia repair as a 24-h day surgery for patients aged 80 years and older: a retrospective cohort study

INTRODUCTION

As the proportion of aging adults increases and inguinal hernia repair becomes increasingly popular as a day surgery, the demand for laparoscopic inguinal hernia repair as a day surgery is increasing among patients aged 80 years and older. Relevant research needs to be completed, so we aimed to evaluate laparoscopic inguinal hernia repair as a 24-h day surgery for this group of patients.

METHODS

In this retrospective cohort study, we utilized propensity score matching to analyze the data of patients who underwent laparoscopic inguinal hernia repair at a day surgery center between January 1, 2019, and March 1, 2022. Patients were divided into ≥ 80 years old and < 80 years old groups. We compared the perioperative laboratory results, perioperative outcomes, and 1-year complications between the two groups.

RESULT

A total of 554 patients were included in the study. After propensity score matching, 292 patients were included in the matched cohort (98 patients in the ≥ 80 years old group and 194 patients in the < 80 years old group). During hospitalization, there were significant differences in ASA classification, Caprini score, length of hospital stays, risk of thrombosis, and delayed discharge rate. No significant difference was found in the incidence of total postoperative complications between the two groups at the 1-year follow-up (HR: 0.96, 95% CI 0.36-2.54, P = 0.96).

CONCLUSION

In our study, LIHR as a 24-h day surgery was safe and effective for patients over 80 years old. However, to reduce the rate of delayed discharge, cautious perioperative evaluation is necessary.

Anticoagulation prophylaxis patterns following retroperitoneal lymph node dissection for testis cancer

INTRODUCTION

Retroperitoneal lymph node dissection (RPLND) is the standard of care for testicular cancer in various disease settings. Deep vein thrombosis (DVT) complications have been reported to occur in <1% of primary RPLND cases and up to 3% of postchemotherapy (PC-RPLND) cases. While prophylactic anticoagulation (AC) has been well-documented to reduce DVT rates in patients undergoing surgery in general, the benefit of prophylactic AC in RPLND has not been assessed. In this retrospective cohort study, we seek to address this unmet need by evaluating the rates and associated risk factors of DVT and pulmonary embolism (PE) with a national and institutional database, assess the changing patterns in DVT prophylaxis with postoperative AC following RPLND, and quantify the potential benefit of prophylactic AC in patients who have undergone RPLND using a risk-stratified approach.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent RPLND during the 10-year period from 2011 to 2021. An institutional database was queried for all patients undergoing RPLND from 2013 to 2022. Patient characteristics and operative outcomes were compared between the NSQIP and the institutional database. The institutional database was stratified by prior oncologic treatment (i.e., primary RPLND vs. PC-RPLND) and outcomes were compared. Postoperative AC rate was determined and trended by year. The use of postoperative AC and PE events were stratified by clinical stage. The absolute risk reduction (ARR) of AC prophylaxis on PE events and the number needed to treat (NNT) with AC prophylaxis to prevent a single PE event was determined.

RESULTS

In total, the NSQIP database query resulted in 779 patients and our institutional database query resulted in 188 patients. The rate of DVT and PE was 1.2% and 0.5% vs. 2.1% and 1.6% in the NSQIP and institutional cohort, respectively. The rate of postoperative AC following RPLND in patients from the institutional database increased from 5% in 2013 to 43% in 2022 (P = 0.01). There were no statistically significant differences in complication rates, including bleeding events, chyle leaks, or hospital readmissions amongst patients who were prescribed AC at discharge and those who were not. No stage I patients developed PEs and no stage I patients were prescribed AC. The ARR for AC prophylaxis for development of PE was found to be 0.023 for the clinical stage II and stage III cohorts. The NNT to prevent a single PE with AC was 44 and 43 for the stage II and stage III cohorts, respectively.

CONCLUSIONS

AC appears beneficial with minimal risk of harm after RPLND, especially in patients with higher risk of developing DVT/PE, highlighting the safety and efficacy of this regimen. There was a significant increase in the rate of AC prophylaxis at discharge amongst patients undergoing RPLND in the institutional database from 2013 to 2022. A risk-stratified protocol of postoperative AC following RPLND appears reasonable, and further prospective trials are warranted to formally confirm this recommendation.

Risk of venous thromboembolism in patients undergoing gastric cancer surgery: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common postoperative complication in patients undergoing surgery for gastric cancer (GC). Although VTE incidence may vary among cancers, guidelines rarely stratify preventive methods for postoperative VTE by cancer type. The risk of VTE in patients undergoing surgery for GC remains unclear.

METHODS

A systematic review and meta-analysis was undertaken to determine the risk of VTE after GC surgery and discuss the clinical value of pharmacological thromboprophylaxis in these cases. Medline, Embase, Web of Science, and Cochrane Library databases were searched for articles published from their inception to September 2022.

RESULTS

Overall, 13 studies (111,936 patients) were included. The overall 1-month incidence of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) after GC surgery was 1.8% (95% CI, 0.8-3.1%; I²=98.5%), 1.2% (95% CI, 0.5-2.1%; I²=96.1%), and 0.4% (95% CI, 0.1-1.1%; I²=96.3%), respectively. The prevalence of postoperative VTE was comparable between Asian and Western populations (1.8% vs. 1.8%; P > 0.05). Compared with mechanical prophylaxis alone, mechanical plus pharmacological prophylaxis was associated with a significantly lower 1-month rate of postoperative VTE and DVT (0.6% vs. 2.9% and 0.6% vs. 2.8%, respectively; all P < 0.05), but not PE (P > 0.05). The 1-month postoperative incidence of VTE was not significantly different between laparoscopic and open surgery (1.8% vs. 4.3%, P > 0.05).

CONCLUSION

Patients undergoing GC surgery do not have a high risk of VTE. The incidence of VTE after GC surgery is not significantly different between Eastern and Western patients. Mechanical plus pharmacological prophylaxis is more effective than mechanical prophylaxis alone in postoperative VTE prevention. The VTE risk is comparable between open and laparoscopic surgery for GC.

Caprini assessment utilization and impact on patient safety in gynecologic surgery

PURPOSE

Postoperative venous thromboembolism (VTE) can potentially be associated with significant morbidity, mortality, and healthcare costs. The aim of this study was to determine the utilization of Caprini guideline indicated VTE in elective gynecologic surgery patients and its impact on postoperative VTE and bleeding complications.

METHODS

This was a retrospective cohort study of elective gynecologic surgical procedures performed between January 1, 2016, and May 31, 2021. Two study cohorts were generated: (1) those who received and (2) those who did not receive VTE prophylaxis based on Caprini score risk stratification. Outcome measures were then compared between the study cohorts and included the development of a VTE up to 90-days postoperatively. Secondary outcome measures included postoperative bleeding events.

RESULTS

A total of 5471 patients met inclusion criteria and the incidence of VTE up to 90 days postoperatively was 1.04%. Overall, 29.6% of gynecologic surgery patients received Caprini score-based guideline VTE prophylaxis. 39.2% of patients that met high-risk VTE criteria (Caprini > 5) received appropriate Caprini score-based prophylaxis. In multivariate regression analysis, the American Society of Anesthesiologists (ASA) score (OR 2.37, CI 1.27-4.45, p < 0.0001) and Caprini score (OR 1.13, CI 1.03-1.24, p = 0.008) predicted postoperatively VTE occurrence. Increasing Charlson comorbidity score (OR 1.39, CI 1.31-1.47, P < 0.001) ASA score (OR 1.36, CI 1.19-1.55, P < 0.001) and Caprini score (OR 1.10, CI 1.08-1.13, P < 0.001) were associated with increased odds of receiving appropriate inpatient VTE prophylaxis.

CONCLUSION

While the overall incidence of VTE was low in this cohort, enhanced adherence to risk-based practice guidelines may provide more patient benefit than harm to postoperative gynecologic patients.

Venous thromboembolism (VTE) after open hepatectomy compared to minimally invasive liver resection: a systematic review and meta-analysis

BACKGROUND

Even though the risk of postoperative venous thromboembolism (VTE) after liver resection is well recognized, the association between surgical approach and VTE risk is unknown. This study aims to compare VTE rates following open liver resection (OLR) and minimally invasive liver resection (MILR).

METHODS

MEDLINE, Web Of Sciences and EMBASE databases were interrogated to identify eligible studies published between February 2016 and August 2022. Studies were considered suitable if they reported a comparison between OLR and MILR (including laparoscopic liver resection [LLR] or robotic liver resection [RLR]).

RESULTS

Fourteen studies including 11 356 patients met the inclusion criteria. 5622 patients underwent OLR and 5734 patients underwent MILR. The VTE rate was higher among patients who underwent OLR compared to MILR (2.8% vs 1.4%, OR (95% CI) = 1.84, p=<00001). Similarly, the subgroup analysis showed a higher rate of deep venous thrombosis (DVT) (1.4% vs 0.7%, OR (95% CI) = 1.98, p = 0.02) and pulmonary embolism (PE) (1.3% vs 0.7%, OR (95% CI) = 1.88, p = 0.002) in patients who underwent OLR compared to MILR.

DISCUSSION

Patients who undergo open hepatectomy have a higher incidence of postoperative VTE when compared to those undergoing minimally invasive liver resection. This finding was consistent for both DVT and PE.

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

BACKGROUND

Major abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery.

METHODS

Analysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery.

RESULTS

Overall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis.

CONCLUSION

Chemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Risk factors associated with venous thromboembolism in laparoscopic surgery in non-obese patients with benign disease

INTRODUCTION

Few studies have focused on intraoperative positioning as a risk factor for venous thromboembolism (VTE). Positioning that places the legs in a dependent position may be a risk factor. We theorized that the reverse-Trendelenburg position specifically would increase the risk of postoperative VTE.

METHODS AND PROCEDURES

374,017 subjects undergoing laparoscopic surgery in the 2015-2018 NSQIP database were included. Diagnosis of cancer and BMI ≥ 30 were excluded. Subjects were grouped based on positioning: reverse-Trendelenburg (RT), supine (S), and Trendelenburg (T).

RESULTS

The RT, S, and T groups consisted of 117,887, 66,511, and 189,619 subjects, respectively. Overall median BMI was 25.7, and 82.8% of subjects were non-smokers. VTE within 30 days postoperative was seen in 0.25% RT, 0.23% S, and 0.4% T (p < 0.0001); 30-day mortality was 0.34% RT, 0.25% S, and 0.19% T (p < 0.0001). After adjusting for potential confounders and other risk factors, RT position was associated with a lower risk of VTE compared to S (OR 1.49 with 95% CI 1.16, 1.93) and T (OR 1.34 with 95% CI 1.15, 1.56) positions. VTE risk was significantly different across the three groups (p = 0.0001). Inpatient procedures had a higher VTE risk vs outpatient (OR 2.49 with 95% CI 2.10, 2.95). Increasing operative time was associated with higher VTE risk [4th (> 106 min) vs 1st (≤ 40 min) quartiles (OR 3.54 with 95% CI 2.79, 4.48)].

CONCLUSIONS

Among other risk factors, inpatient procedures and longer operative times are associated with higher VTE risk in laparoscopic surgery performed for benign disease in non-obese patients. The risk was significantly different across the three positioning groups with lowest risk in the RT group and highest risk in the S group.

Risk of deep vein thrombosis and pulmonary embolism after gynecological day surgery

OBJECTIVE

To investigate the risk of venous thromboembolism (VTE) in Danish women operated within a day surgery setting and to evaluate whether the current use of thromboprophylaxis without using graduated elastic compression stockings (GCS) is an appropriate treatment to prevent VTE.

STUDY DESIGN

A retrospective cohort study including women who underwent laparoscopic hysterectomy or vaginal prolapse operation for benign disease from January 2014 to December 2017 at the Gynecology Day Surgery Unit, Regional Hospital of Randers, Denmark. The primary outcome was VTE diagnosed within three months postoperatively. Only one dose of pharmacological thromboprophylaxis (PTP) was given to women stratified at high risk of VTE. None of the women used GCS.

RESULTS

A total of 671 women were included. Vaginal prolapse operations were performed on 626 women, and laparoscopic hysterectomy on 45 women. PTP was used for only 220 (32.8%) of these women. A total of 346 (51.5%) women were stratified as at high risk of VTE according to the national recommendations. Only 218 (63%) of these women received PTP, while 128 women (37%) did not receive PTP. The incidence of VTE within three months postoperatively was 0%. Only 13 (1.9%) of the women were readmitted within 14 days postoperatively due to hemorrhaging or hematoma; six out of these 13 women (46%) received PTP postoperatively. Re-operation was performed in seven (1%) women due to hemorrhaging, and three out of the seven (42.9%) had PTP postoperatively.

CONCLUSION

The risk of VTE in Danish women operated within a day surgery setting is probably very low since we found no cases of VTE in our setup. The beneficial effect of routine use of GCS and one dose of PTP postoperatively given to all women who had undergone MIS in a day surgery setting are questioned. One dose of PTP postoperatively without GCS can be considered to only women stratified as high-risk of VTE until there is more evidence whether these women actually need thromboprophylaxis postoperatively at all.

PRECIS

The incidence of VTE in women undergoing laparoscopic hysterectomy or vaginal prolapse operation in a day surgery setting without using graduated elastic compression stockings is very low.

Association Between Operative Approach and Venous Thromboembolism Rate Following Hepatectomy: a Propensity-Matched Analysis

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.

Incidence of and Risk Factors for Postoperative Venous Thromboembolism in Benign Hysterectomy

STUDY OBJECTIVE

Describe the incidence of and risk factors associated with postoperative venous thromboembolism (VTE) in patients undergoing hysterectomy for benign indications with emphasis on the impact of route of surgery.

DESIGN

Retrospective cohort.

SETTING

National Surgical Quality Improvement Project Database.

PARTICIPANTS

Data of women aged 18 years and older who underwent hysterectomy for benign indications between 2014 and 2018 were abstracted.

INTERVENTIONS

Cases were identified by Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, American Society of Anesthesiologists (ASA) classification system scores, total operating time, length of stay, readmission, reoperation, VTE including deep vein thrombosis and pulmonary embolism were collected. Cases were stratified by route of hysterectomy.

MEASUREMENTS AND MAIN RESULTS

t test and multivariable logistic regression were used for analysis. A total of 94 940 patients underwent hysterectomy, of which 23 081 (24.3%) underwent abdominal hysterectomy, 56 656 (59.7 %) laparoscopic hysterectomy, and 15 203 (16.0%) vaginal hysterectomy. The overall incidence of VTE was 0.4%. The incidence of VTE was higher for abdominal (0.7%), than laparoscopic (0.3%, p <.001), and vaginal hysterectomy (0.2%, p <.001). Higher ASA classification was independently associated with postoperative VTE. Age, race, body mass index, uterine weight, operative time, multiple medical comorbidities, and smoking status were not independently associated with increased risk of VTE.

CONCLUSION

Postoperative VTE after hysterectomy for benign indications is rare. The risk of postoperative VTE is higher in patients undergoing abdominal hysterectomy compared with minimally invasive hysterectomy including laparoscopic and vaginal routes of surgery. In addition, the risk of VTE may be higher with higher ASA class.

Liver Injury Among Japanese Patients Treated Using Prophylactic Enoxaparin After Colorectal Surgery

BACKGROUND

Enoxaparin, a low molecular weight heparin, has been used to prevent thrombotic events during major surgery without increasing the rate of hemorrhage. On the other hand, it was reported to cause liver injury, but the details of liver injury induced by prophylactic enoxaparin after abdominal surgery remain unclear.

AIMS

This study aimed to clarify the relationship between prophylactic enoxaparin and liver injury after colorectal surgery, and characterize the injury profile.

METHODS

We retrospectively reviewed 732 Japanese patients who underwent elective resection of the colorectum, and compared their clinicopathological background, details of surgery, postoperative complications, including liver injury, and the type of liver injury according to prophylactic use of enoxaparin. Univariate and multivariate analyses were performed to identify risk factors for liver injury during the postoperative period.

RESULTS

The rate of liver injury was 8.9% for patients treated by prophylactic enoxaparin and 1.4% for those who did not receive enoxaparin after colorectal surgery (p < 0.0001). The median onset of liver injury among patients receiving enoxaparin was seven days, and the majority demonstrated the hepatocellular pattern. Enoxaparin was one of the independent risk factors for postoperative liver injury by multivariate analysis (odds ratio: 7.63, p < 0.0001).

CONCLUSIONS

Prophylactic use of enoxaparin markedly increased the rate of postoperative liver injury in patients who underwent colorectal surgery. Our study confirmed that close monitoring of liver function parameters is essential for patients receiving enoxaparin during the postoperative period.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy

BACKGROUND

Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy.

OBJECTIVE

This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach.

STUDY DESIGN

We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable.

RESULTS

A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively).

CONCLUSION

Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Impact of pulmonary embolism on morbidity and mortality in patients undergoing pancreatic surgery

PURPOSE

Postoperative pulmonary embolism (PE) after pancreatic surgery is a potentially life-threatening complication. However, the magnitude of morbidity and mortality of PE is still uncertain. The present study aims to assess the incidence of PE after pancreatic surgery and analyze its impact on the outcome.

METHODS

We conducted a retrospective study including all patients who underwent pancreatic resections between 2005 and 2017. The development of PE was analyzed for a 90-day period following surgery. Risk factors were evaluated using regression models.

RESULTS

The study investigated 947 patients undergoing pancreatic surgery. Overall, 26 (2.7%) patients developed PE. The median body mass index (BMI) of patients with PE was significantly higher (28.1 kg/m² [24.7-31.8] vs. 24.8 kg/m² [22.4-27.8], p < 0.001). Patients with PE had a significantly increased duration of the operation and more often underwent multivisceral resections. The lowest incidence of PE was found after distal or total pancreatectomy (2%). In median, PE occurred on the fifth postoperative day (interquartile range: 3-9). Increased BMI, duration of operation, and postoperative deep venous thrombosis were found to be multivariate risk factors for the development of PE. Importantly, postoperative complications (53.8% vs. 15.1%, p < 0.001) and the 30-day mortality rate were significantly increased in the PE group (19.2% vs. 3.3%, p < 0.001).

CONCLUSIONS

Patients with increased BMI, a history of deep venous thrombosis, and multivisceral resections are a high-risk group for PE after pancreatic surgery. While the absolute incidence and related mortality of PE after pancreatic surgery is low, it is associated with severe sequelae.

Comparison of postoperative plasma D-dimer levels between patients undergoing laparoscopic resection and conventional open resection for colorectal cancer

INTRODUCTION

D-dimer is widely used in clinical pretests for venous thromboembolism exclusion, and its elevation suggests the presence of thrombus. The extent of hypercoagulability after colorectal surgery has not been systematically compared between patients who have undergone laparoscopic surgery and open surgery. The present study measured D-dimer levels sequentially in patients undergoing colorectal surgery and compared the extent of hypercoagulability between laparoscopic surgery and open surgery.

METHODS

A prospective cohort study involving 169 patients who underwent resection of colorectal cancer at Saitama Medical Center, Dokkyo Medical University, was conducted between January 2013 and September 2014. To measure D-dimer level, peripheral blood was obtained on postoperative day (POD) 1, POD4, and POD7. Enoxaparin sodium was administered twice daily as the routine prophylactic anticoagulant therapy on POD2 to 7.

RESULTS

D-dimer levels on POD1, POD4, and POD7 were significantly higher after open surgery than after laparoscopic surgery. Older age, pathologically advanced stage cancer, greater intraoperative blood loss and higher preoperative D-dimer levels were significantly associated with higher D-dimer levels on POD1, POD4, and POD7. Patients who completed the course of postoperative enoxaparin injections had significantly lower D-dimer levels on POD7 than those who did not receive postoperative enoxaparin injections. Multiple regression analyses of postoperative D-dimer level showed that laparoscopic surgery was a significant and independent factor affecting D-dimer level on POD4 and POD7.

CONCLUSION

This study showed that postoperative D-dimer levels were lower after laparoscopic surgery than after open surgery. The limited invasiveness of laparoscopic surgery may be beneficial to reduce the risk of postoperative deep vein thrombosis.

Intermittent pneumatic compression versus additional prophylaxis with enoxaparin for prevention of venous thromboembolism after laparoscopic surgery for gastric and colorectal malignancies: multicentre randomized clinical trial

Background

The role of antithrombotic chemoprophylaxis in prevention of venous thromboembolism (VTE) in laparoscopic surgery for gastric and colorectal malignancies is unknown. This study compared the addition of enoxaparin following intermittent pneumatic compression (IPC) with IPC alone in patients undergoing laparoscopic surgery for gastrointestinal malignancy.

Methods

In this multicentre RCT, eligible patients were older than 40 years and had a WHO performance status of 0 or 1. Exclusion criteria were prescription of antiplatelet or anticoagulant drugs and history of VTE. Patients were allocated to IPC or to ICP with enoxaparin in a 1 : 1 ratio. Stratification factors included sex, location of cancer, age 61 years and over, and institution. Enoxaparin was administered on days 1–7 after surgery. Primary outcome was VTE, evaluated by multidetector CT on day 7.

Results

Of 448 patients randomized, 208 in the IPC group and 182 in the IPC with enoxaparin group were evaluated. VTE occurred in ten patients (4·8 per cent) in the IPC group and six (3·3 per cent) in the IPC with enoxaparin group (P = 0·453). Proximal deep vein thrombosis and/or pulmonary embolism occurred in seven patients (3·4 per cent) in the IPC group and one patient (0·5 per cent) in the IPC with enoxaparin group (P = 0·050). All VTE events were asymptomatic and non‐fatal. Bleeding occurred in 11 of 202 patients in the IPC with enoxaparin group, and one patient needed a transfusion. All bleeding events were managed by discontinuation of the drug.

Conclusion

IPC with enoxaparin after laparoscopic surgery for gastric and colorectal malignancies did not reduce the rate of VTE. Registration number: UMIN000011667 ( https://www.umin.ac.jp/).

Laparoscopic surgery in patients with interstitial lung disease: A single-center retrospective observational cohort study

INTRODUCTION

Laparoscopic surgery requiring longer operative times and artificial pneumoperitoneum may affect pulmonary function; its feasibility in patients with interstitial lung disease remains unknown. Therefore, we examined the feasibility of laparoscopic surgery in patients with interstitial lung disease.

METHODS

We conducted a retrospective observational cohort study and examined the clinical data of patients with interstitial lung disease who had undergone abdominal surgery under general anesthesia. The primary end-point was the incidence of pulmonary complications. The secondary end-points were non-pulmonary complications and in-hospital mortality.

RESULTS

Twenty-nine patients who had undergone abdominal surgery were diagnosed with interstitial lung disease after a review of their clinical and imaging records. Laparoscopic surgery and open surgery were performed in 11 and 18 patients, respectively. Acute exacerbation occurred in one (9%) patient in the laparoscopic group and three patients (17%) in the open group; all had undergone emergency surgery. Postoperative pneumonia did not occur in any patients. Non-pulmonary complications occurred in one patient (9%) in the laparoscopic group and two patients (11%) in the open group. One patient in each group died of acute exacerbation during hospitalization.

CONCLUSION

Neither acute exacerbation nor pulmonary complications occurred after elective laparoscopic or open surgery in patients with interstitial lung disease. The risk of acute exacerbation after elective laparoscopic surgery may not be as high as that after elective thoracic surgery.

Risk of venous thromboembolism, use of enoxaparin and clinical outcomes in obese patients undergoing laparoscopic adjustable gastric band surgery: A retrospective study

There is a lack of clear guidance for the prophylactic use of anticoagulants for patients undergoing laparoscopic adjustable gastric banding (LAGB) surgery.This study aimed to evaluate the risk of venous thromboembolism (VTE), prophylactic use of enoxaparin and clinical outcomes in patients undergoing primary and revisional LAGB procedures.A retrospective study evaluated the prophylactic use of enoxaparin in adult patients who underwent primary and revisional (band and port) LAGB procedures. The incidence of VTE and major bleeding was investigated during a 90-day follow-up period. Descriptive and inferential statistics were used for data analysis.We included 112 and 100 patients who had undergone primary and revisional (24 band procedures and 76 port procedures) LAGB surgery, respectively. The majority of patients (97%) had a mild risk of VTE development using a post-discharge VTE risk calculator tool published from the Cleveland Clinic. All primary procedure patients received prophylactic enoxaparin, compared to 79% and 20% of revisional patients who underwent band and port procedures, respectively (P < .001). The overall VTE incidence was 0.9%, with no significant difference between patients who did or did not receive chemoprophylaxis (0.7% and 1.5%, respectively; P = .58). No major bleeding events were observed.Chemoprophylaxis may not be required in all patients undergoing low-risk LAGB surgery unless there are additional risk factors, such as the presence of super-super-morbid obesity or concomitant hormone replacement therapy. More studies are needed on the prophylactic use and dosing of enoxaparin in patients undergoing LAGB procedures to provide high-level evidence.

Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY

BACKGROUND

The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern.

METHODS

PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups.

DISCUSSION

The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.

Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population

With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.

Minimally Invasive Surgery is Associated with an Increased Risk of Postoperative Venous Thromboembolism After Distal Pancreatectomy

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality following distal pancreatectomy (DP). However, the influence of operative technique on VTE risk after DP is unknown.

OBJECTIVE

The purpose of this study was to examine the association between the MIS technique versus the open technique and the development of postoperative VTE after DP.

METHODS

Patients who underwent DP from 2014 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program pancreas-specific database. Multivariable logistic regression was then used to identify independent associations with the development of postoperative VTE after DP.

RESULTS

A total of 3558 patients underwent DP during this time period. Of these cases, 47.8% (n = 1702) were performed via the MIS approach. After adjusting for significant covariates, the MIS approach was independently associated with the development of any VTE (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.06-2.40; p = 0.025), as well as increasing the risk of developing a postdischarge VTE (OR 1.80, 95% CI 1.05-3.08; p = 0.033) when compared with the open approach. There was an association between VTE and the development of numerous postoperative complications, including pneumonia, unplanned intubation, need for prolonged mechanical ventilation, and cardiac arrest.

CONCLUSION

Compared with the open approach, the MIS approach is associated with higher rates of postoperative VTE in patients undergoing DP. The majority of these events are diagnosed after hospital discharge.

Minimally invasive cancer surgery is associated with a lower risk of venous thromboembolic events

BACKGROUND

Venous thromboembolism (VTE) is a significant source of postoperative morbidity and mortality in patients undergoing common oncologic procedures. We sought to estimate the effect of surgical approach on the risk of developing a VTE.

METHODS

IBM Watson Health Marketscan Database was used to conduct this retrospective study. In total, 12 938 patients who underwent either a radical prostatectomy, partial colectomy, or hysterectomy via a minimally invasive or open approach. We used a propensity-weighted logistic regression analysis to assess the independent effect of surgical approach on VTE. The primary outcome of interest was the 90-day rate of VTE after surgery.

RESULTS

Patients undergoing minimally invasive surgery across all three surgical procedures were noted to have a lower odds of developing a VTE: (radical prostatectomy, odds ratio [OR]: 0.667, 95% confidence interval [CI]: 0.500-0.891; P = .006 |partial colectomy: OR, 0.620, 95% CI: 0.477-0.805; P < .001| hysterectomy: OR, 0.549 95% CI: 0.353-0.854; P = .008).

CONCLUSION

We found that a minimally invasive approach was associated with significantly lower odds of VTE compared with undergoing the same open procedure. This study highlights how surgical approach may be an independent risk factor for development of VTE and may elucidate potential risk mitigation strategy.

Incidence and risk of venous thromboembolism in patients following appendectomy: a nationwide cohort study

Surgery may lead to poor blood flow and hypercoagulation. Few studies have investigated the incidence of venous thromboembolism (VTE) in Asian patients following appendectomy. We conducted a nationwide cohort study to investigate the risk of VTE in patients who underwent appendectomy compared with those who did not in Taiwan. We studied the entire hospitalized population in Taiwan from 2000 to 2012, with a follow-up period extending to the end of 2013. We identified patients who underwent appendectomy in Taiwan's National Health Insurance Research Database as the appendectomy cohort, and selected a nonappendectomy cohort from the general population that was 4:1 frequency-matched by age (5-year interval), sex, and index year for each appendectomy case. We used Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for symptomatic VTE in the appendectomy cohort for comparison with the nonappendectomy cohort. The appendectomy cohort exhibited a higher incidence of symptomatic VTE than the nonappendectomy cohort (5.90 vs. 3.29 per 10,000 person-years). After adjustment for covariates, a 1.68-fold HR for symptomatic VTE was observed in the appendectomy cohort (95% CI 1.56-1.81). Compared with the nonappendectomy cohort, the patients who underwent open appendectomy had a 1.73-fold increased adjusted HR for symptomatic VTE (95% CI 1.61-1.87). Laparoscopic appendectomy was not significantly associated with symptomatic VTE. An 8.15-fold higher adjusted HR for VTE was observed in patients who underwent appendectomy within the first month after surgery compared with the nonappendectomy cohort. Open appendectomy carried an increased risk of symptomatic VTE. Laparoscopic appendectomy was not significantly associated with symptomatic VTE.

Prolonged operating room time in emergency general surgery is associated with venous thromboembolic complications

BACKGROUND

We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS).

METHODS

We reviewed six common EGS procedures in the 2013-2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions.

RESULTS

Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5-16] for DVTs and 8 days [5-16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12-2.21]) and PE (OR:1.25 [1.11-2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis.

CONCLUSION

Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation.

Coagulation and deep vein flow changes following laparoscopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) is a serious complication encountered in surgical practice. The purpose of this study was to identify changes in coagulation status and deep vein flow parameters, within 24 h postoperatively, for patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP).

METHODS

For 144 patients undergoing TEP, coagulation markers including prothrombin time (PT), partial thromboplastin time, thrombin time, D-dimer, fibrinogen, fibrin degradation products (FDP), and international normalized ratio (INR) were monitored preoperatively and in the first morning postoperatively. Echo-Doppler recordings preoperatively and again within 24 h postoperatively were completed for 23 patients to monitor lower extremity deep vein flow parameters including speed of flow (cm/s), diameter (cm), and cross-sectional area (cm²). Clinically significant VTE and other complications were recorded.

RESULTS

No significant VTE were diagnosed. Significant increases were seen in the first morning postoperatively for PT, D-dimer, FDP, and INR (P < 0.05). Stratified by age, except for those < 50 years, the ratio of value-outside-the-normal-range (VONR) for D-dimer and FDP increased significantly postoperatively for all age groups. Stratified by operation duration, a significant difference in the ratio of VONR in D-dimer was identified postoperatively between those with an operation duration < 60 min and ≥ 60 min. There were significant decreases in the iliac and common femoral vein flow velocity of the ipsilateral extremity postoperatively (P < 0.05).

CONCLUSIONS

Activated hypercoagulability and hampered lower extremity deep vein flow were observed immediately after TEP. DVT formation was more pronounced in older patients and for those with operation duration ≥ 60 min. Proper VTE risk stratification for laparoscopic inguinal hernia repair (LIHR) and prophylaxis early after LIHR should be important clinical considerations.

Risk factors for post-discharge venous thromboembolism in patients undergoing colorectal resection: a NSQIP analysis

BACKGROUND

Extended thromboprophylaxis after abdominal and pelvic cancer surgery to prevent venous thromboembolic events (VTE) is recommended but adherence is sub-optimal. Identifying patients at highest risk for post-discharge events may allow for selective extended thromboprophylaxis. The aim of our study was to identify the different risk factors of venous thromboembolism for in-hospital and post-discharge events.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2016 database was queried for all patients having colorectal resection. Primary outcome was postoperative VTE occurrence within 30 days. A multinomial logistic regression was performed to identify in-hospital and post-discharge predictors of VTE, adjusting for potential confounders.

RESULTS

Out of 260,258 patients, 5381 (2.1%) developed VTE. A total of 3442 (1.3%) were diagnosed during the initial hospital stay and 1929 (0.8%) post-discharge. Risk factors for in-hospital and post-discharge VTE were different as patients with an in-hospital event were more likely to be older, male, known for preoperative steroid use, have poor functional status, significant weight loss, preoperative sepsis, prolonged operative time, undergoing an emergency operation. In the post-discharge setting, steroid use, poor functional status, preoperative sepsis, and postoperative complications remained significant. Postoperative complications were the strongest predictor of in-hospital and post-discharge VTE. Patients with inflammatory bowel disease had a higher risk of VTE than patients with malignancy for both in-patient and post-discharge events.

CONCLUSIONS

Patients at high-risk for post-discharge events have different characteristics than those who develop VTE in-hospital. Identifying this specific subset of patients at highest risk for post-discharge VTE may allow for the selective use of prolonged thromboprophylaxis.

Analysis of National Trends in Hospital Acquired Conditions Following Major Urologic Surgery Before and After Implementation of the Hospital Acquired Condition Reduction Program

OBJECTIVE

To define the rates of common hospital acquired conditions (HACs) in patients undergoing major urologic surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs.

METHODS

Using American College of Surgeons National Surgical Quality Improvement Program data, we determined rates of HACs in patients undergoing major inpatient urologic surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs laparoscopic and/or robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs.

RESULTS

We identified 39,257 patients undergoing major urologic surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (2.6%) was the most common, followed by surgical site infection (2.5%) and venous thrombotic events (0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and American Society of Anesthesiology class were among the variables associated with higher likelihood of HAC. We observed a nonsignificant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction program.

CONCLUSION

HACs occurred at a rate of 5.9% after major urologic surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by National Reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs.

Efficacy and safety of thromboembolism prophylaxis with fondaparinux in Japanese colorectal cancer patients undergoing laparoscopic surgery: A phase II study

PURPOSE

We aimed to assess the safety and efficacy of fondaparinux (FPNX) for patients undergoing laparoscopic colorectal surgery (LAC).

METHODS

Patients scheduled for LAC received once-daily subcutaneous injections of FPNX 1.5-2.5 mg for 4-8 days. The primary endpoint was the incidence of bleeding events. The secondary endpoint was the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).

RESULTS

Among 128 patients evaluable for efficacy, 119 patients were administered FPNX. Nine patients were excluded owing to intraoperative events, including conversion to open surgery among others. Thirteen patients discontinued treatment owing to anastomotic bleeding (n = 5), anastomotic leakage (n = 3), bleeding at drain insertion site (n = 2), subcutaneous bleeding (n = 1), drug-induced rash (n = 1), and sepsis (n = 1). Among the FPNX discontinuations, there were eight cases of bleeding (6.7%), and two cases of major bleeding (1.7%). In multivariate analysis, operative time >300 min was identified as a risk factor for bleeding events (p = 0.001) secondary to FPNX. The incidence rate of DVT was 2.5% (3/119 cases); these patients were asymptomatic.

CONCLUSION

There were no cases of PE. It is necessary to establish strict criteria for VTE prophylaxis with FPNX after LAC for Japanese patients considering the incidence of bleeding events.

Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice

Bariatric surgery is currently the most effective treatment for morbid obesity and its associated metabolic complications. To ensure long-term postoperative success, patients must be prepared to adopt comprehensive lifestyle changes. This review summarizes the current evidence and expert opinions with regard to nutritional care in the perioperative and long-term postoperative periods. A literature search was performed with the use of different lines of searches for narrative reviews. Nutritional recommendations are divided into 3 main sections: 1) presurgery nutritional evaluation and presurgery diet and supplementation; 2) postsurgery diet progression, eating-related behaviors, and nutritional therapy for common gastrointestinal symptoms; and 3) recommendations for lifelong supplementation and advice for nutritional follow-up. We recognize the need for uniform, evidence-based nutritional guidelines for bariatric patients and summarize recommendations with the aim of optimizing long-term success and preventing complications.

Sudden death caused by acute pulmonary embolism after laparoscopic total extraperitoneal inguinal hernia repair: a case report and literature review

PURPOSE

Laparoscopic repair of inguinal hernias is an increasingly popular method of herniorrhaphy, providing advantages, including lower wound infection rates, faster recovery times and less postoperative pain compared with open procedures. The perioperative incidence of venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, in laparoscopic inguinal hernia repair is low, but VTE is still one of the most common causes of postoperative mortality. Moreover, the VTE risk assessment and prophylaxis in inguinal hernia patients is not well defined.

METHODS

We present an unusual case of sudden death owing to acute pulmonary embolism after undergoing total extraperitoneal inguinal hernia repair. Medline and PubMed databases were searched using the keywords mentioned below, and the literature on VTE risk assessment and prophylaxis in laparoscopic inguinal hernia repair is reviewed.

RESULTS

Laparoscopic inguinal hernia repair, which is regarded as a low risk procedure for VTE, has potential risks for VTE development in the perioperative period. The risks come from both surgical procedures and intrinsic patient characteristics.

CONCLUSIONS

Clinicians should consider both the strength of individual risk factors and the cumulative weight of all risk factors prior to surgery. A full VTE risk assessment is essential with proper prophylaxis measures especially in quality-of-life procedures.

Assessing the risk for development of Venous Thromboembolism (VTE) in surgical patients using Adapted Caprini scoring system

AIM

To determine the incidence, morbidity and mortality due to Venous Thromboembolism (VTE) in surgical patients, and to assess the validity and reliability of Adapted Caprini scoring in risk stratification for VTE prophylaxis.

METHODOLOGY

This was a prospective observational study in a tertiary care hospital of South India on patients who underwent both elective and emergency surgeries over a period of 9 months. An Adapted Caprini score was devised which included only the clinical criteria. The patients were scored by two persons independently at admission and followed up till the 30th post-operative day and primary and secondary end points were statistically analyzed.

RESULTS

Three hundred and one patients were included and the overall incidence of VTE at 30 days was 7.3%. The risk of developing VTE was found to be significantly higher among the >8 score group as compared to 3-4 group (OR = 153.5, p < 0.001), or the 5-6 group (OR = 52.9, p < 0.001) or the 7-8 group (OR = 2.3, p = 0.002). Patients with a score of 7-8 were more likely to develop VTE as compared to 3-4 group (OR = 67.5, p < 0.001) or the 5-6 group (OR = 23.2, p < 0.001).

CONCLUSION

The risk of developing VTE is less significant in the 5-6 score group compared to 7-8 or more score group. Further stratification of the highest risk groups is recommended to provide appropriate prophylaxis only to the patients with high scores, thereby reducing complications due to VTE prophylaxis.

28 day post-operative persisted hypercoagulability after surgery for benign diseases: a prospective cohort study

BACKGROUND

Surgery for benign disease is associated with a low-risk of developing venous thromboembolism (VTE). Despite a relatively low incidence of postoperative VTE in patients after elective cholecystectomy and abdominal hernia repair there are data proving hypercoagulability in the early postoperative period. We focused on assessment of the systemic inflammatory response and coagulation status in these surgical patients after hospital discharge.

METHODS

Prospectively, patients who underwent surgery for benign disease were included. Two hundred sixteen patients were enrolled - 90 patients in laparoscopic cholecystectomy (LC) group and 126 patients in hernia surgery (HS) group. Risk assessment of VTE according to the Caprini risk assessment model was performed in all patients. Prevalence of VTE in postoperative period was observed. Markers of systemic inflammatory response (IL-6, CRP, α-1-acid glycoprotein, transferrin) and coagulation markers (PLT, fibrinogen, prothrombin fragment F1 + 2 and D-dimer) were measured before surgery, on 7-10th postoperative day and on 28-30th postoperative day.

RESULTS

Clinically apparent deep vein thrombosis was diagnosed in only one patient - 0.46%. Statistically significant elevation of inflammatory markers IL-6, CRP and α-1-acid glycoprotein (p < 0.001; all) were proved in both groups of patients on 7-10th postoperative day. Statistically significant elevation of coagulation markers PLT, fibrinogen, prothrombin fragment F1 + 2 and D-dimer (p < 0.001; all) were proved in LC and HS groups on 7-10th postoperative day. No statistical difference was observed in IL-6, CRP and α-1-acid glycoprotein levels a month after surgery as compared with preoperative levels within each group. Statistically significant elevation of fibrinogen and prothrombin fragment F1 + 2 levels (p < 0.001; both) persisted on 28-30th postoperative day in both groups. Persisted elevation of D-dimer levels was proved only in HS group (p < 0.001), not in LC group (p = 0.138), a month after surgery.

CONCLUSIONS

Activated systemic inflammatory response and hypercoagulable condition were verified in patients after laparoscopic cholecystectomy and hernia surgery after their hospital discharge. Hypercoagulability persisted even a month after surgery. Nevertheless, we observed very low prevalence of clinically apparent VTE in patients with in-hospital postoperative VTE prophylaxis.

TRIAL REGISTRATION

Trials of the Czech Ministry of Health No. RVO-VFN64165 and NT 13251-4 .

Preoperative Hospitalization Is Independently Associated With Increased Risk for Venous Thromboembolism in Patients Undergoing Colorectal Surgery: A National Surgical Quality Improvement Program Database Study

BACKGROUND

An important factor in the pathophysiology of venous thromboembolism is blood stasis, thus, preoperative hospitalization length of stay may be contributory to risk.

OBJECTIVE

We assessed preoperative hospital length of stay as a risk factor for venous thromboembolism.

DESIGN

We performed a retrospective review of patients who underwent colorectal operations using univariate and multivariable propensity score analyses.

SETTINGS

This study was conducted at a tertiary referral hospital.

PATIENTS

Data on patients was obtained from the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 Participant Use Data Files.

MAIN OUTCOME MEASURES

Short-term (30-day) postoperative venous thromboembolism was measured.

RESULTS

Our analysis included 242,670 patients undergoing colorectal surgery (mean age, 60 years; 52.9% women); of these, 72,219 (29.9%) were hospitalized preoperatively. The overall rate of venous thromboembolism was 2.07% (1.4% deep vein thrombosis, 0.5% pulmonary embolism, and 0.2% both). On multivariable analysis, the most predictive independent risk factors for venous thromboembolism were return to the operating room (OR, 1.62 (95% CI, 1.44-1.81); p < 0.001) and chronic steroid use (OR, 1.59 (95% CI, 1.41-1.80); p < 0.001); preoperative hospitalization also independently predicted venous thromboembolism (OR, 1.39 (95% CI, 1.28-1.51); p < 0.001), whereas the use of laparoscopy was protective (OR, 0.75 (95% CI, 0.67-0.83); p < 0.001). Propensity score stratification (capped at 7 days, 100 strata, area under the curve = 0.73) indicated that each day of preoperative hospitalization increased the odds of venous thromboembolism (OR, 1.42 (95% CI, 1.32-1.53); p < 0.001). All of the analyses showed a dose-response relationship between preoperative lengths of stay and risk of postoperative venous thromboembolism (p < 0.001). Patients who experienced venous thromboembolism had a higher 30-day mortality rate (3.7% vs 8.9%; p < 0.001).

LIMITATIONS

This study has limited potential generalizability and a retrospective design.

CONCLUSIONS

Preoperative hospitalization is an independent risk factor for venous thromboembolism and its associated increase in mortality after colorectal surgery, whereas laparoscopy is a strong protective variable. Further research into preoperative screening for highest-risk patients is indicated.

Risk of venous thromboembolism in abdominal versus minimally invasive hysterectomy for benign conditions

OBJECTIVE

We sought to describe the incidence of venous thromboembolism (VTE) following hysterectomy for benign conditions and to estimate if VTE incidence differs for abdominal and minimally invasive hysterectomy.

STUDY DESIGN

Data for patients who underwent hysterectomy for benign conditions from 2010 through 2012 were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database. Cases of VTE were compared to those without VTE. Minimally invasive hysterectomy was defined as both vaginal and laparoscopic hysterectomy. Pearson χ2 test, Student t test, and binary logistic regression were used for analysis.

RESULTS

A total of 44,167 patients underwent hysterectomy; 12,733 (28.8%) underwent open hysterectomy, 22,559 (51.1%) underwent laparoscopic hysterectomy, and 8875 (20.1%) underwent vaginal hysterectomy. The incidence of VTE for open hysterectomy was higher (0.6%, 81/12,733) than minimally invasive hysterectomy (0.2% 73/31,434, P<.001). Open surgery (P<.001), body mass index (P=.006), race (P<.001), diabetes (P=.037), preoperative functional status (P<.001), American Society of Anesthesiologists class (P<.001), total operative time (P<.001), and time from surgery to discharge (P<.001) were each associated with VTE. Age, hypertension, current smoking, pack-year history, and year operation was performed were not associated with VTE. Using binary logistic regression, open surgery (P<.001), operative time (P<.001), and length of stay (P<.001) remained associated with VTE. The odds ratio for VTE after open hysterectomy compared with minimally invasive hysterectomy was 2.45 (95% confidence interval, 1.77-3.40).

CONCLUSION

In this large quality database, a minimally invasive approach to hysterectomy was independently associated with a decreased incidence of VTE when compared with open hysterectomy.