Systemic coagulation and fibrinolysis after laparoscopic and open gastric bypass

Application of the Caprini risk assessment model for deep vein thrombosis among patients undergoing laparoscopic surgery for colorectal cancer

Application of the Caprini risk assessment model was explored in patients with deep vein thrombosis (DVT) after laparoscopic colorectal cancer surgery.This study was a prospective study. The risk factors for DVT were assessed with a survey at baseline and on the morning of surgery, first day after surgery and sixth day by using repeated blood vessels on color Doppler ultrasound of the lower limbs, and the intraoperative and postoperative conditions were recorded.Among 148 surgical patients, 24.3% had asymptomatic DVT. According to the risk stratification, the incidence of DVT was related to the Caprini score (P < .001). The area under the curve of the Caprini model was 0.701 ± 0.047 (95% CI: 0.609-0.793, P<.001). The Youden index was 0.368, while the critical point was 10.5 in the Caprini model, corresponding to a sensitivity of 0.806 and a specificity of 0.563. Age, cardiovascular disease, intraoperative blood loss, postoperative fever, preoperative preparation, and hospital stay were higher in DVT patients than in patients without DVT. Moreover, the incidence of DVT in patients with a lithotomy position was higher than that in patients with a scissors position. In binary logistic regression analysis, the independent risk factors for DVT development were age, intraoperative blood loss, and preoperative preparation time.The Caprini model can be used for the prediction of venous thromboembolism in laparoscopic colorectal cancer surgery patients. The thrombosis risk assessment model must be established in line with patients undergoing endoscopic malignant tumor surgery.

Coronavirus (COVID-19), Coagulation, and Exercise: Interactions That May Influence Health Outcomes

The proinflammatory cytokine storm associated with coronavirus disease 2019 (COVID-19) negatively affects the hematological system, leading to coagulation activation and endothelial dysfunction and thereby increasing the risk of venous and arterial thrombosis. Coagulopathy has been reported as associated with mortality in people with COVID-19 and is partially reflected by enhanced D-dimer levels. Poor vascular health, which is associated with the cardiometabolic health conditions frequently reported in people with severer forms of COVID-19, might exacerbate the risk of coagulopathy and mortality. Sedentary lifestyles might also contribute to the development of coagulopathy, and physical activity participation has been inherently lowered due to at-home regulations established to slow the spread of this highly infectious disease. It is possible that COVID-19, coagulation, and reduced physical activity may contribute to generate a “perfect storm,” where each fuels the other and potentially increases mortality risk. Several pharmaceutical agents are being explored to treat COVID-19, but potential negative consequences are associated with their use. Exercise is known to mitigate many of the identified side effects from the pharmaceutical agents being trialled but has not yet been considered as part of management for COVID-19. From the limited available evidence in people with cardiometabolic health conditions, low- to moderate-intensity exercise might have the potential to positively influence biochemical markers of coagulopathy, whereas high-intensity exercise is likely to increase thrombotic risk. Therefore, low- to moderate-intensity exercise could be an adjuvant therapy for people with mild-to-moderate COVID-19 and reduce the risk of developing severe symptoms of illness that are associated with enhanced mortality.

Evaluation of selected parameters of the coagulation system during the perioperative period in patients undergoing endoscopic surgery of the paranasal sinuses

INTRODUCTION

The aim of the study was to evaluate selected parameters of the coagulation system during the perioperative period in patients undergoing endoscopic sinus surgery.

MATERIAL AND METHODS

The study involved 121 patients: group I - 42 patients who did not receive anticoagulatory or antiplatelet medications, qualified for endoscopic sinus surgery under total intravenous anaesthesia (TIVA); group II - 40 patients who received in the perioperative period low-molecular-weight heparins, qualified for endoscopic sinus surgery under TIVA; group III - 39 patients diagnosed according to a schedule, due to vertigo or loss of hearing. All the patients received a full laryngological examination and detailed audiological and otoneurological diagnostics, and examination of selected haemostatic parameters before the surgery/diagnostics.

RESULTS

The analysis of concentrations of coagulation parameters in groups I and II revealed a statistically significantly higher international normalized ratio value before surgery (I - 1.11; II - 1.08) and 48 h following surgery (I - 1.15; II - 1.10) in group I. The concentration of coagulation factor VII in the study patients was considerably higher in group I for all three measurements (481.93; 443.13; 486.02). The concentration of fibrinogen (coagulation factor I) was significantly lower in group I before surgery (3.2) and at 6 h after surgery (2.84). A significantly lower level of von Willebrand factor was found in group I before surgery (2.94). Comparing test results of groups I and III, who did not receive antiaggregants, statistically significant differences were observed in both tests for factors VII and VIII.

CONCLUSIONS

Concentrations of von Willebrand factor and prothrombin revealed statistically significant differences in between groups.

Coagulation System Disorders and Thrombosis Prophylaxis During Laparoscopic Fundoplications

BACKGROUND

The aim of this study was to assess and recommend the optimal deep vein thrombosis (DVT) prophylaxis regimen during and after laparoscopic fundoplication according to the blood coagulation disorders and the rate of DVT in 2 patient groups, receiving different DVT prophylaxis regimens.

MATERIALS AND METHODS

This was a prospective randomized, single-center clinical study. The study population, 121 patients, were divided into 2 groups: group I received low-molecular-weight heparin 12 hours before the operation; group II received low-molecular-weight heparin only 1 hour before the laparoscopic fundoplication. Both groups received intermittent pneumatic compression during the entire procedure. Bilateral Doppler ultrasound to exclude DVT was performed before the surgery. Venous phase computed tomographic images were acquired from the ankle to the iliac tubercles on the third postoperative day to determine the presence and location of DVT. Hypercoagulation state was assessed by measuring the prothrombin fragment F1+2 (F1+2), the thrombin-antithrombin complex (TAT), and tissue factor microparticles activity (MP-TF) in plasma. The hypocoagulation effect was evaluated by measuring plasma free tissue factor pathway inhibitor (fTFPI).

RESULTS

F1+2, TAT, and MP-TF indexes increased significantly, whereas fTFPI levels decreased significantly during and after laparoscopic fundoplication, when molecular-weight heparin was administered 12 hours before the operation. Computed tomography venography revealed peroneal vein thrombosis in 2 group I patients on the third postoperative day. Total postsurgical DVT frequency was 1.65%: 3.6% in group I, with no DVT in group II.

CONCLUSION

Molecular-weight heparin and intraoperative intermittent pneumatic compression controls the hypercoagulation effect more efficiently when it is administered 1 hour before surgery: it causes significant reduction of F1+2, TAT, and MP-TF indexes and significant increases of fTFPI levels during and after laparoscopic fundoplication.

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery

BACKGROUND

This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery.

OBJECTIVES

To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE.

SEARCH METHODS

We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies.

SELECTION CRITERIA

We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation.

DATA COLLECTION AND ANALYSIS

Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis.

MAIN RESULTS

We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I² = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I² = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I² = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis, which approached significance (M-H OR 0.30, 95% CI 0.08 to 1.11; I² = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I² = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity.

AUTHORS' CONCLUSIONS

Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery

BACKGROUND

This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery.

OBJECTIVES

To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE.

SEARCH METHODS

We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies.

SELECTION CRITERIA

We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation.

DATA COLLECTION AND ANALYSIS

Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications and mortality within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis.

MAIN RESULTS

We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I² = 28%; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I² = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I² = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I² = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (M-H OR 1.10, 95% CI 0.67 to 1.81; I² = 0%; moderate-quality evidence).No difference in mortality between the control and LMWH group was found, 3.8% and 3.9%, respectively (M-H OR 1.15, 95% CI 0.72 to 1.84; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity.

AUTHORS' CONCLUSIONS

Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications or mortality after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery

BACKGROUND

This an update of the review first published in 2009.Major abdominal and pelvic surgery carries a high risk of venous thromboembolism (VTE). The efficacy of thromboprophylaxis with low molecular weight heparin (LMWH) administered during the in-hospital period is well-documented, but the optimal duration of prophylaxis after surgery remains controversial. Some studies suggest that patients undergoing major abdominopelvic surgery benefit from prolongation of the prophylaxis up to 28 days after surgery.

OBJECTIVES

To evaluate the efficacy and safety of prolonged thromboprophylaxis with LMWH for at least 14 days after abdominal or pelvic surgery compared with thromboprophylaxis administered during the in-hospital period only in preventing late onset VTE.

SEARCH METHODS

We performed electronic searches on 28 October 2017 in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS and registered trials (Clinicaltrials.gov October 28, 2017 and World Health Organization International Clinical Trials Registry Platform (ICTRP) 28 October 2017). Abstract books from major congresses addressing thromboembolism were handsearched from 1976 to 28 October 2017, as were reference lists from relevant studies.

SELECTION CRITERIA

We assessed randomized controlled clinical trials (RCTs) comparing prolonged thromboprophylaxis (≥ fourteen days) with any LMWH agent with placebo, or other methods, or both to thromboprophylaxis during the admission period only. The population consisted of persons undergoing abdominal or pelvic surgery for both benign and malignant pathology. The outcome measures included VTE (deep venous thrombosis (DVT) or pulmonary embolism (PE)) as assessed by objective means (venography, ultrasonography, pulmonary ventilation/perfusion scintigraphy, spiral computed tomography (CT) scan or autopsy). We excluded studies exclusively reporting on clinical diagnosis of VTE without objective confirmation.

DATA COLLECTION AND ANALYSIS

Review authors identified studies and extracted data. Outcomes were VTE (DVT or PE) assessed by objective means. Safety outcomes were defined as bleeding complications within three months after surgery. Sensitivity analyses were also performed with unpublished studies excluded, and with study participants limited to those undergoing solely open and not laparoscopic surgery. We used a fixed-effect model for analysis.

MAIN RESULTS

We identified seven RCTs (1728 participants) evaluating prolonged thromboprophylaxis with LMWH compared with control or placebo. The searches resulted in 1632 studies, of which we excluded 1528. One hundred and four abstracts, eligible for inclusion, were assessed of which seven studies met the inclusion criteria.For the primary outcome, the incidence of overall VTE after major abdominal or pelvic surgery was 13.2% in the control group compared to 5.3% in the patients receiving out-of-hospital LMWH (Mantel Haentzel (M-H) odds ratio (OR) 0.38, 95% confidence interval (CI) 0.26 to 0.54; I² = 28%; seven studies, n = 1728; moderate-quality evidence).For the secondary outcome of all DVT, seven studies, n = 1728, showed prolonged thromboprophylaxis with LMWH to be associated with a statistically significant reduction in the incidence of all DVT (M-H OR 0.39, 95% CI 0.27 to 0.55; I² = 28%; moderate-quality evidence).We found a similar reduction when analysis was limited to incidence in proximal DVT (M-H OR 0.22, 95% CI 0.10 to 0.47; I² = 0%; moderate-quality evidence).The incidence of symptomatic VTE was also reduced from 1.0% in the control group to 0.1% in patients receiving prolonged thromboprophylaxis (M-H OR 0.30, 95% CI 0.08 to 1.11; I² = 0%; moderate-quality evidence).No difference in the incidence of bleeding between the control and LMWH group was found, 2.8% and 3.4%, respectively (HM-H OR 1.10, 95% CI 0.67 to 1.81; I² = 0%; seven studies, n = 2239; moderate-quality evidence).Estimates of heterogeneity ranged between 0% and 28% depending on the analysis, suggesting low or unimportant heterogeneity.

AUTHORS' CONCLUSIONS

Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery. This finding also holds true for DVT alone, and for both proximal and symptomatic DVT. The quality of the evidence is moderate and provides moderate support for routine use of prolonged thromboprophylaxis. Given the low heterogeneity between studies and the consistent and moderate evidence of a decrease in risk for VTE, our findings suggest that additional studies may help refine the degree of risk reduction but would be unlikely to significantly influence these findings. This updated review provides additional evidence and supports the previous results reported in the 2009 review.

Efficacy of CO2 insufflation during thoracoscopic esophagectomy in the left lateral position

OBJECTIVE

Thoracoscopic esophagectomy (TE) is widely performed as a minimally invasive technique in the management of esophageal cancer. The aim of this study was to estimate the efficacy of intrathoracic carbon dioxide (CO₂) insufflation during TE in the left lateral position.

METHODS

From January 2010 to April 2016, 58 patients with esophageal cancer underwent TE without intrathoracic CO₂ insufflation (Group N) and 37 patients with esophageal cancer underwent TE with intrathoracic CO₂ insufflation (Group C). The operation results and respiratory parameters during the thoracic procedure were compared in both groups.

RESULTS

A satisfactory surgical field was obtained by CO₂ insufflation. There was no difference in the duration of the thoracic procedure or number of dissected mediastinal lymph nodes between the two groups. The amount of thoracic blood loss in Group C was significantly less than that in Group N (P < 0.05). Intrathoracic CO₂ insufflation did not affect oxygenation during single-lung ventilation. However, both end-tidal CO₂ (ETCO₂) 1 h after single-lung ventilation and maximum ETCO₂ in Group C were significantly higher than those in Group N. Intraoperative hypercapnia in Group C was permissive. The rate of extubation in the operation room, mortality and morbidity were not different between the two groups.

CONCLUSIONS

Intrathoracic CO₂ insufflation is beneficial to make satisfactory surgical field and to reduce thoracic blood loss in TE. Application of intrathoracic CO₂ insufflation may contribute to the widespread adoption of TE in the left lateral position.

Thromboelastographic changes during laparoscopic fundoplication

Introduction

Thromboelastography (TEG) is a technique that measures coagulation processes and surveys the properties of a viscoelastic blood clot, from its formation to lysis.

Aim

To determine the possible hypercoagulability state and the effect of antithrombotic prophylaxis on thromboelastogram results and development of venous thrombosis during laparoscopic fundoplication.

Material and methods

The study was performed on 106 patients who were randomized into two groups. The first group received low-molecular-weight heparin (LMWH) 12 h before the operation, and 6 and 30 h after it. The second group received LMWH only 1 h before the laparoscopic fundoplication. The TEG profile was collected before LMWH injection, 1 h after the introduction of the laparoscope and 15 min after the surgery was completed.

Results

There was no significant difference in thromboelastography R-time between the groups before low-molecular-weight heparin injection. In group I preoperative R-values significantly decreased 1 h after the introduction of the laparoscope, after the end of surgery and on the third postoperative day. K-time values decreased significantly on the third postoperative day compared with the results before low-molecular-weight heparin injection, and after the operation. In group II, preoperative R-values significantly decreased 1 h after the introduction of the laparoscope, and after surgery. K-time values did not change significantly during or after the laparoscopic operation.

Conclusions

Our study results demonstrated that the hypercoagulation state (according to the TEG results) was observed during and after laparoscopic fundoplication in patients when LMWH was administered 12 h before the operation together with intraoperative intermittent pneumatic compression. The optimal anticoagulation was obtained when LMWH was administered 1 h before fundoplication.

Impact of artificial capnothorax on coagulation in patients during video-assisted thoracoscopic esophagectomy for squamous cell carcinoma

BACKGROUND

Compared with the lung isolation using double-lumen endobronchial tube intubation, the artificial capnothorax using single-lumen endotracheal tube intubation has shown to be a safe, more convenient, and cost-effective procedure for thoracoscopic esophagectomy. However, the impact of capnothorax on coagulation is not well defined. Herein, we evaluate the impact of a capnothorax on coagulation and fibrinolysis in patients who undergoing thoracoscopic esophagectomy.

METHODS

Between March 2014 and August 2014, 24 patients underwent thoracoscopic esophagectomies for esophageal cancer with the procedure of artificial capnothorax (group P); we also performed 24 thoracoscopic esophagectomy cases without using capnothorax (group N). The demographics and arterial blood gas, as well as the parameters of coagulation and fibrinolysis, of the two groups were analyzed.

RESULTS

The pH value of group P after CO2 insufflation was significantly lower than in group N (P < 0.05), and the partial pressure of carbon dioxide (PaCO2) was significantly increased compared with group N (P < 0.05). The R and K values after CO2 insufflation were significantly longer than before anesthesia (P < 0.05), and both α angle and MA value after CO2 insufflation were significantly lower than those before anesthesia (P < 0.05). No significant differences in R value, K value, α angle, or MA value were observed between pre-anesthesia and termination of capnothorax. No significant difference in LY30 data was found between different groups (P > 0.05).

CONCLUSION

Artificial capnothorax in patients receiving endoscopic resection of esophageal carcinoma had a significant impact on coagulation. These patients showed significant impairments in coagulation not observed in patients without artificial capnothorax.

Prevention of venous thromboembolism in patients undergoing bariatric surgery

Bariatric surgical procedures are now a common method of obesity treatment with established effectiveness. Venous thromboembolism (VTE) events, which include deep vein thrombosis and pulmonary embolism, are an important source of postoperative morbidity and mortality among bariatric surgery patients. Due to an understanding of the frequency and seriousness of these complications, bariatric surgery patients typically receive some method of VTE prophylaxis with lower extremity compression, pharmacologic prophylaxis, or both. However, the optimal approach in these patients is unclear, with multiple open questions. In particular, strategies of adjusted-dose heparins, postdischarge anticoagulant prophylaxis, and the role of vena cava filters have been evaluated, but only to a limited extent. In contrast to other types of operations, the literature regarding VTE prophylaxis in bariatric surgery is notable for a dearth of prospective, randomized clinical trials, and current professional guidelines reflect the uncertainties in this literature. Herein, we summarize the available evidence after systematic review of the literature regarding approaches to VTE prevention in bariatric surgery. Identification of risk factors for VTE in the bariatric surgery population, analysis of the effectiveness of methods used for prophylaxis, and an overview of published guidelines are presented.

Complications of laparoscopic versus open bariatric surgical interventions in obesity management

With the epidemic of obesity fast spreading its grasp throughout the world, the medical professionals of diverse facilities need to be called on for better management to prevent its further progression. In particular, the gastroenterologists have a major role to play in all aspects of obese patient care. They should be able to recognize and treat obesity and associated disorders through the understanding and assessment of the various benefits and risks linked with a particular type of obesity treatment option. While treating these problems, a better understanding of the physiologic and anatomic alterations that might be associated with the treatment procedure and the weight loss-linked problems in association with the method of surgical intervention need to be weighed. Morbid obesity has been efficaciously treated by bariatric surgery promoting weight loss considerably and reducing the obesity-associated risks such as certain cancers, diabetes, cardiovascular disease, and all-cause mortality. Bariatric surgery has been performed traditionally through open method or, the more recent and popular form, laparoscopically that involves only a small incision in the abdomen. The laparoscopic bariatric surgery has become the surgical method of choice since its introduction in 1993 and has immediately crossed open surgery in terms of popularity. Drastic numbers came out when the two methods were compared for their applicability during a 3-year period in the United States. Only 6,000 reported open gastric bypass surgeries were recorded, but the number soared to nearly 16,000 for laparoscopic gastric bypass surgeries. The laparoscopic method has been found to be associated with much reduced complications and hospital stay along with lower cases of mortality as suggested by small randomized controlled trials and observational studies. However, these facts need to be reassessed through large-sized controlled trials and population-based studies. In addition, the previously ignored complications associated with laparoscopic methods should be studied in detail. Since the cases of obesity have been ever increasing and bariatric surgery is also gaining in popularity, it is important that the safest procedure should be identified. The main objective of this review was to compare the benefits and risks associated with open versus laparoscopic mode of bariatric surgery with a greater focus on the laparoscopic method. Although there are few reviews that have compared the two methods, none have focused on the complications of the two approaches. All these aspects have been dealt in detail here.

Haematological considerations in urology: A systematic review

Deep venous thrombosis (DVT) remains a serious and common complication of surgical procedures and is therefore an issue of importance for all urologists. In the UK, pulmonary embolism (PE) following DVT in hospitalised patients causes 32,000 deaths each year. DVT and PE represent the outcome of venous thromboembolism (VTE). The total cost for management of VTE in 2005 was approximately ₤640 million. Early risk assessment and optimising modifiable risks are paramount in order to reduce the incidence of VTE. In this article we review common risk factors for VTE and emphasise specific risk factors for urological procedures. The perioperative management of urological patients who are chronically anticoagulated is discussed. We review the literature regarding anticoagulation and its relevance to all urological procedures and mention the problems associated with new anticoagulant agents. All urologists should be familiar with the new range of anticoagulant agents due to the increasing number of patients taking them.

Alterations in homeostasis after open surgery. A prospective randomized study

INTRODUCTION

Alterations in homeostasis, and a subsequent increased risk for postoperative thromboembolic complications, are observed as a result of open surgery. Additionally, the stress response to surgical trauma precipitates a transient hypercoagulable state as well as inflammation. This study was conducted to evaluate the patterns in postoperative alterations of blood coagulation, and to detect their correlations with inflammatory markers.

PATIENTS AND METHODS

The study included 50 patients with comparable demographic data, who were randomly assigned to undergo abdominal surgery. No previous coagulation disorders were noted. Blood samples were collected preoperatively and 72 h postoperatively. The following parameters were measured: prothrombin time (PT) and activated partial thromboplastin time (APTT); fibrinogen (FIB), D-dimer (D-D), and C-reactive protein (CRP) levels; and platelet (PLT) count. Prophylactic doses of low molecular weight heparin were administered to all patients.

RESULTS

The PT mean value significantly changed from 90.38% before surgery to 81.25% after surgery. No statistical difference was observed between APTT values before and after surgery. FIB levels significantly increased from 381.50 mg/dL preoperatively to 462.57 mg/dL postoperatively. Mean D-D levels also significantly increased from 235.54 μg/L preoperatively to 803.59 μg/L postoperatively. PLT count significantly declined after surgery. Mean CRP levels significantly increased from 12.33 mg/L preoperatively to 44.28 mg/L postoperatively. A strong correlation was observed between D-D and C-RP levels after surgery.

CONCLUSION

These results indicate that, despite administering antithromboembolic prophylaxis, a hypercoagulable state was observed following surgery. This state was enhanced by inflammation.

Pulmonary embolism and deep venous thrombosis following laparoscopic cholecystectomy

There is considerable uncertainty related to the thromboembolic risk after laparoscopic cholecystectomy. Patients with pulmonary embolism (PE), deep venous thrombosis (DVT), or venous thromboembolism (VTE) at hospital discharge following laparoscopic cholecystectomy were identified from the Nationwide Inpatient Sample. From 1998 through 2009, 4 107 430 laparoscopic cholecystectomies were performed. The in-hospital prevalence of PE was 0.15%, DVT was 0.40%, and VTE was 0.53%. The prevalence of PE increased from 0.04% in patients aged 21 to 30 years to 0.31% in patients aged 71 to 80 years. Deaths due to in-hospital PE were 780 (0.02%) of the 4 107 430 laparoscopic cholecystectomies. The rate of death increased with age. The prevalence of VTE following laparoscopic cholecystectomy is low and fatal PE is rare. The risk of VTE increased with age, as did the risk of death in those who had PE. These data may be useful in assessing the use of thromboprophylaxis in patients undergoing laparoscopic cholecystectomy.

Coagulation and fibrinolysis activation after single-incision versus standard laparoscopic cholecystectomy: a single-center prospective case-controlled pilot study

Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.

Recent advances in laparoscopic surgery

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A PubMed search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined.

Actual situation of thromboembolic prophylaxis in obesity surgery: data of quality assurance in bariatric surgery in Germany

Background. Evidence-based data on optimal approach for prophylaxis of deep venous thrombosis (VTE) and pulmonary embolism (PE) in bariatric operations is discussed. Using antithrombotic prophylaxis weight adjusted the risk of VTE and its complications have to be balanced with the increased bleeding risk. Methods. Since 2005 the current situation for bariatric surgery has been examined by quality assurance study in Germany. As a prospective multicenter observational study, data on the type, regimen, and time course of VTE prophylaxis were documented. The incidences of clinically diagnosed VTE or PE were derived during the in-hospital course and follow up. Results. Overall, 11,835 bariatric procedures were performed between January 2005 and December 2010. Most performed procedures were 2730 gastric banding (GB); 4901 Roux-en-Y-gastric bypass (RYGBP) procedures, and 3026 sleeve gastrectomies (SG). Study collective includes 72.5% (mean BMI 48.1 kg/m(2)) female and 27.5% (mean BMI 50.5 kg/m(2)) male patients. Incidence of VTE was 0.06% and of PE 0.08%. Conclusion. VTE prophylaxis regimen depends on BMI and the type of procedure. Despite the low incidence of VTE and PE there is a lack of evidence. Therefore, prospective randomized studies are necessary to determine the optimal VTE prophylaxis for bariatric surgical patients.

Role of thrombolestagrophy in monitoring perioperative coagulation status and effect of thromboprophylaxis in bariatric surgery

BACKGROUND

Thromboelastography is a technique that surveys the properties of viscoelastic blood clot. The purpose of this paper was to evaluate the hypercoagulability state and the effect of antithrombotic prophylaxis on thromboelastogram (TEG) results in bariatric surgery.

METHODS

Twenty-five patients enrolled received 0.8 ml of nodraparin starting on the day before surgery and continuing postoperatively. TEG profile was collected before induction of anesthesia, on the first and third postoperative days. Each sample was run also in a cup added with heparinase to eliminate the interference of antithrombotic prophylaxis.

RESULTS

TEG analysis with heparinase showed a tendency to reduce the r-time (rate of initial fibrin formation) and k-time (time to clot firmness) and increase the alpha angle (rate of clot growth), while an increase of maximal amplitude (MA, a measure of maximal stiffness of the clot; p = 0.01) and GI or shear elastic modules strength (p = 0.03)was observed from basal to postoperative day 3 (POD3). TEG without heparinase evidenced and increase of r-time (p = 0.02) and k-time (p = 0.05), a reduction of the alpha angle (p = 0.03), and an increase of MA (p = 0.01) and GI (p = 0.03) from basal to POD3. The comparison of TEG techniques showed that normal TEGs had lower values of r-time and k-time and higher values of alpha angles and MA than TEG with heparinase. No differences were evident for basal and POD1 samples and the G values comparing the two TEG technique. No correlation was observed between the variation of normal TEG parameters and dosage of anticoagulant used in each patient.

CONCLUSIONS

Our patients presented a tendency to hypercoagulability determined most by MA and GI. Comparison between TEGs indicates that low-molecular-weight heparin not titrated on weight is able to determine a reduction of hypercoabulable tendency in the early postoperative period with few effects on increasing MA and GI.

Markers of coagulation activation after hepatic resection for cancer: evidence of sustained upregulation of coagulation

We investigated the possibility that despite postoperative derangements of routine laboratory coagulation tests, markers of coagulation activation and thrombin generation would be normal or increased in patients undergoing hepatic resection for cancer In addition to the conventional coagulation tests prothrombin time and activated partial thromboplastin time, we measured select markers of coagulation activation prothrombin fragments 1 and 2 (PF1 + 2), thrombin-antithrombin complexes and plasma von Willebrand Factor antigen in 21 patients undergoing hepatic resection. The impact of hepatic resection on coagulation and fibrinolysis was studied with thromboelastography. Preoperatively, routine laboratory coagulation and liver function tests were normal in all patients. On the first postoperative day, prothrombin time was prolonged (range 16 to 22 seconds) in eight patients (38%). For these patients, thromboelastography was normal in six (75%), PF1 + 2 was elevated in four (50%), and thrombin-antithrombin complexes and von Willebrand Factor antigen were elevated in all, which was evidence of acute phase reaction, sustained coagulation factor turnover and activation. By the fifth postoperative day, despite normalisation of prothrombin time, markers of increased coagulation activity remained greater than 85% of baseline values. The findings indicate that in patients undergoing liver resection for cancer, there is significant and prolonged postoperative activation of the haemostatic system despite routine coagulation tests being normal or even prolonged. Before considering therapeutic interventions an integrated approach to interpreting haematological data with clinical correlation is essential.

Factors Predictive of Venous Thromboembolism in Bariatric Surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.

Venous thromboembolism and use of prophylaxis among women undergoing laparoscopic hysterectomy

OBJECTIVE

To examine the risk of venous thromboembolism and the use of venous thromboembolism prophylaxis in women undergoing laparoscopic hysterectomy.

METHODS

Results of women recorded in a health outcomes, resource utilization, and quality database from 2003 to 2007 who underwent laparoscopic hysterectomy were analyzed. The rate and predictors of venous thromboembolism as well as patterns of venous thromboembolism prophylaxis were examined. Multivariable logistic regression models were developed to determine the incidence of venous thromboembolism and use of any prophylaxis, as well as pharmacologic prophylaxis.

RESULTS

Among 60,013 women, a total of 579 (1.0%) venous thromboembolism events were noted. Venous thromboembolism was diagnosed in 2.1% of women aged 60 years or older and in 2.3% of those with cancer. Women older than 60 years (OR 1.64, 95% CI 1.19-2.26) and with more medical comorbidities (OR 3.07, 95% CI 2.23-4.23) were most likely to have a venous thromboembolism develop. A total of 23,562 (39.3%) patients received no venous thromboembolism prophylaxis, 29,288 (48.8%) received mechanical prophylaxis, and 7,163 (11.9%) received pharmacologic prophylaxis. Women aged 60 years or older (OR 1.56, 95% CI 1.41-1.73), women with more medical comorbidities (OR 1.93, 95% CI 1.71-2.17), those with cancer (OR 3.08, 95% CI 2.75-3.45), and patients treated by high-volume surgeons (OR 1.42, 95% CI 1.33-1.52) were more likely to receive pharmacologic prophylaxis.

CONCLUSION

Whereas patients undergoing laparoscopic hysterectomy are overall at low risk for venous thromboembolism, older women, those with medical comorbidities, and women with cancer are at substantial risk. Venous thromboembolism prophylaxis is highly variable and often not utilized.

Venous thromboembolism prophylaxis in a general hospital

OBJECTIVE

To evaluate the use of venous thromboembolism (VTE) prophylaxis in a general hospital.

METHODS

A cross-sectional cohort study at the Hospital Nossa Senhora da Conceição, located in the city of Porto Alegre, Brazil, involving a random sample of patients admitted between October of 2008 and February of 2009. We included patients over 18 years of age and hospitalized for more than 48 h. The exclusion criteria were anticoagulant use, pregnancy, puerperium, and a history of thromboembolic disease. The adequacy of prophylaxis was evaluated in accordance with a protocol created by the Hospital and principally based on the American College of Chest Physicians guidelines, eighth edition.

RESULTS

We included 262 patients. The mean age was 59.1 ± 16.6 years. The most common risk factors were immobilization (in 70.6%), infection (in 44.3%), cancer (in 27.5%), obesity (in 23.3%), and major surgery (in 14.1%). The risk of VTE was classified as high and moderate in 143 (54.6%) and 117 (44.7%) of the patients, respectively. Overall, 46.2% of the patients received adequate prophylaxis, 25% of those with > three risk factors for VTE and 18% of those with cancer, the differences between these last two groups and their counterparts (patients with < three risk factors and those without cancer) being statistically significant (p < 0.001 for both).

CONCLUSIONS

Our data reveal that nearly all patients at our hospital were at risk for VTE, and that less than half received adequate VTE prophylaxis, which is in agreement with the literature. It is surprising that inadequate prophylaxis is more common in high-risk patients.

Kinetics of D-dimer after general surgery

D-dimers may be elevated after surgery. However, the kinetics of postoperative D-dimers remains unknown hampering the use of D-dimer testing in surgical patients with suspected venous thromboembolism. D-dimer levels were prospectively measured in 154 patients after general surgery at predefined time points (kinetics were determined in an initial cohort of 108 patients; for validation, these findings were applied to a second cohort of 46 patients). Clinical factors influencing the peak of D-dimers were analyzed using multivariate regression. Surgical operations were stratified based on severity (type I: not entering abdominal cavity; type II: intraabdominal; type III: retroperitoneal/liver surgery). D-dimer levels increased postoperatively reaching a peak on day 7. After type I surgery, peak D-dimer levels did not exceed normal range (300 ng/ml, 100-500). After type II procedures, peak D-dimer level was 1500 ng/ml (200-7800) and returned to normal values after 25 days (+/-14). Peak level was 4000 ng/ml (500-14 400) after type III surgery normalizing within 38 days (+/-11). Clearance of D-dimer was exponential after having reached the peak with 6.0% per day (95% confidence interval 4.8-7.1%). By this clearance, D-dimer values could be adequately predicted in the validation cohort after day 7 (r2 = 0.63). Peak D-dimer levels were independently influenced by the type of surgery (P < 0.001), the operation time (P < 0.001) and by preoperatively elevated D-dimer levels (P < 0.001). Based on this data, duration of postoperative D-dimer elevation after abdominal surgery is predictable. This study indicates for the first time when D-dimers may be used again in the diagnostic algorithm for venous thromboembolism exclusion after surgery in patients with low or moderate clinical probability.

[Prevention of venous thromboembolic disease in general surgery]

Postoperative venous thromboembolic disease (VTED) affects approximately one in four general surgery patients who do not receive preventive measures. In addition to the risk of pulmonary embolism, which is often fatal, patients with VTED may develop long-term complications such as post-thrombotic syndrome or chronic pulmonary hypertension. In addition, postoperative VTED is usually asymptomatic or produces clinical manifestations that are attributed to other processes and consequently this complication is often unnoticed by the surgeon who performed the procedure. Thus, the most effective strategy consists of effective prevention of VTED using the most appropriate prophylactic measures against the patient's thromboembolic risk. There is sufficient evidence that VTED can be prevented by pharmacological methods, especially heparin and its derivatives and with mechanical methods such as support tights or intermittent pneumatic compression of the lower extremities. To reduce the incidence of VTED as far as possible, strategies have been proposed that include a combination of drugs and mechanical methods, new antithrombotic drugs, or prolonging the duration of prophylaxis in patients at very high risk, such as those who have undergone surgery for cancer. Another important aspect is the optimal moment to initiate prophylaxis with anticoagulant drugs with the aim of achieving an adequate equilibrium between antithrombotic efficacy and the risk of hemorrhagic complications. The present article reviews the available evidence to attempt to optimize prevention of VTED in general surgery and in some special groups, such as laparoscopic surgery, short-stay surgery and obesity.

Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial

BACKGROUND

Tissue injury poses increased risk for postoperative thromboembolic complications. Laparoscopic surgery, by causing limited tissue injury, is associated with lower risk for thromboembolism than is open surgery. We conducted a prospective randomized study in order to detect potentially existing differences in activation of coagulation and fibrinolytic pathways between open and laparoscopic surgery.

METHODS

Forty patients with chronic cholelithiasis were randomly assigned to undergo open (group A) or laparoscopic cholecystectomy (group B). Blood samples were taken preoperatively, at the end of the procedure, and at 24 and 72 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), platelets (PLT), soluble fibrin monomer complexes (F.S. test), fibrin degradation products (FDP), D-dimers (D-D), and fibrinogen (FIB) were measured and compared within each group and between groups: Thrombin-antithrombin complexes (TAT) and prothrombin fragments (F1 + 2) were measured at 24 and 72 h postoperatively.

RESULTS

Demographics were comparable between groups. Immediately postoperatively, TAT and F1 + 2 were significantly higher in group A (p < 0.05). They also increased significantly postoperatively as compared with preoperative levels within each group (p < 0.05). D-dimers were significantly higher in group A (p < 0.01) immediately postoperatively. D-dimers also increased significantly postoperatively in group B as compared with preoperative levels (p < 0.001). FIB decreased slightly in both groups at 24 h postoperatively but there was a significant increase in group A (p < 0.01). Soluble fibrin monomer complexes (SFMC) were detected twice in group A and only once in group B. FDP levels over 5 μg/ml were detected more often in group A (p < 0.05). There was not any case of thromboembolism or abnormal bleeding.

CONCLUSIONS

Open surgery leads to higher activation of the clotting system than do laparoscopic procedures. Although of a lower degree, hypercoagulability is still observed in patients undergoing laparoscopic surgery and therefore routine thromboembolic prophylaxis should be considered.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy

INTRODUCTION

Although laparoscopic cholecystectomy appears to be less traumatic to the patients than open surgery, decreased venous return from lower extremities and hypercoagulability occurring in patients undergoing elective laparoscopic cholecystectomy with CO(2) pneumoperitoneum makes it a potent risk factor for deep venous thrombosis.

METHODS

The observational study of 50 patients undergoing elective laparoscopic cholecystectomy was designed to study alteration in PT, APTT, D-dimer and antithrombin III, which were measured preoperatively, 6 and 24h postoperatively. It was accompanied by color duplex ultrasound of bilateral lower limbs preoperatively and 7th day postoperatively to look for evidence of deep venous thrombosis.

RESULTS

Significant postoperative decrease in APTT and antithrombin III suggested activation of coagulation while decrease in d-dimer suggested activation of fibrinolysis. Values of PT had no statistically significant postoperative changes. Age, body mass index and duration of pneumoperitoneum were found to correlate with significant activation of coagulation and fibrinolysis. None of the patients developed clinical or radiological evidence of deep venous thrombosis in the postoperative period.

CONCLUSIONS

CO(2) pneumoperitoneum enhances the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. Patients with risk factors like old age, obesity or with expected long duration of laparoscopic surgery are likely to have significant activation of coagulation, making them a vulnerable risk group for development of postoperative deep vein thrombosis, warranting some form of thromboprophylaxis.

Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery

BACKGROUND

There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner.

METHODS

Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors' (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures.

RESULTS

The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates.

CONCLUSIONS

Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

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

BACKGROUND

Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures.

OBJECTIVE

To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period.

PATIENTS AND INTERVENTIONS

Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery.

RESULTS

During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01).

CONCLUSIONS

Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.

The incidence of pulmonary embolism in open versus laparoscopic gastric bypass

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI] > 55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI > 55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI > 55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P < 0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI > 55 kg/m(2) might be at an increased risk for PE independent of operative approach.

The incidence of venous thromboembolism following gynecologic laparoscopy: a multicenter, prospective cohort study

BACKGROUND

Information on the incidence of venous thromboembolism (VTE) following laparoscopic procedures is inadequate and there is currently no solid evidence to guide the use of thromboprophylaxis in this setting. Gynecologic laparoscopy is a common procedure, and is frequently performed in low-risk patients. To our knowledge, there are no clinical studies specifically designed to assess the incidence of VTE in this setting.

METHODS

In a prospective cohort study, consecutive patients undergoing gynecologic laparoscopy underwent compression ultrasonography (CUS) and clinical assessment to evaluate the incidence of clinically relevant VTE. CUS was performed 7 +/- 1 and 14 +/- 1 days postoperatively. A subsequent telephone contact was scheduled at 30 and 90 days. No patient received pharmacologic or mechanical prophylaxis. Patients with malignancy or previous VTE were excluded from the study.

RESULTS

We enrolled 266 consecutive patients; mean age was 36.3 years, range: 18-72. The most common indications for laparoscopy were ovarian cysts in 25.6% of patients, endometriosis in 21.0% of patients, unexplained adnexal masses in 12.4% of patients, and infertility in 7.5% of patients. The mean duration of the procedure was 60.5 min (range: 10-300 min). In particular, in 55.6% of patients the duration exceeded 45 min. There were neither episodes of CUS detected DVT (0/247; 0%, 95% CI 0-1.51%) or clinically relevant VTE after follow-up (0/256; 0%, 95% CI 0-1.48%). No patient died of fatal pulmonary embolism (0/266; 0%, 95% CI 0-1.42%).

CONCLUSIONS

Gynecologic laparoscopy in non-cancer patients is a low-risk procedure for postoperative VTE.

What Happens to Patients who Do Not Follow-Up after Bariatric Surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are “lost to follow-up” are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome ( i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Cellular, hemostatic, and inflammatory parameters of the surgical stress response in pigs undergoing partial pericardectomy via open thoracotomy or thoracoscopy

BACKGROUND

Thoracoscopy has been shown to reduce the inflammatory and immunologic response to surgical stress, as compared with corresponding open procedures in humans. The influence on the hemostatic system, however, has not been thoroughly evaluated. The current study aimed to compare the perioperative and immediate postoperative changes in cellular, hemostatic, and inflammatory parameters after a partial pericardectomy performed by either thoracoscopy or thoracotomy.

METHODS

For this study, 16 pigs were randomly assigned to have a partial pericardectomy performed thoracoscopically or by thoracotomy. Blood was collected intraoperatively, then 10 min, 3 h, and 6 h after surgery. Whole ethylenediaminetetraacetic acid (EDTA)-stabilized blood and plasma were examined for cellular, hemostatic, and inflammatory parameters, respectively, and thromboelastography (TEG) was performed on citrated whole blood.

RESULTS

No significant difference in any of the parameters measured was found between the two groups except for the TEG parameter R-time, which was significantly shorter in the thoracoscopic group 3 h postoperatively. In both groups, a significant postoperative state of hypercoagulability and increase in inflammatory parameters was found. Additionally, pig blood showed a high degree of hypercoagulability in preoperative measurements, as compared with other species.

CONCLUSIONS

Partial pericardectomy performed by thoracotomy or thoracoscopy in pigs produces a surgical stress response of equal magnitude, as measured by cellular, hemostatic, and inflammatory changes.

Unexpected pathology during laparoscopic bariatric surgery

BACKGROUND

The popularity of bariatric surgery has increased in recent years with the escalating incidence of morbid obesity in our society. The improvement in minimally invasive technology and the increased number of laparoscopic bariatric procedures being performed have resulted in the discovery of unexpected pathology not suspected preoperatively. The authors hypothesized that the occurrence of unexpected pathology is not associated with immediate adverse outcomes during laparoscopic bariatric procedures.

METHODS

From December 2002 to June 2004, 398 patients underwent laparoscopic bariatric surgery for morbid obesity. A retrospective chart review was performed to determine the incidence of unexpected findings and their effect on patient results.

RESULTS

Nine unexpected pathologic lesions were found in eight patients (2%). The findings included lesions on the small bowel (n = 3), stomach (n = 4), and liver (n = 2). In all cases except one (for which a biopsy was performed), the abnormalities were found and removed laparoscopically. The final pathology showed gastric leiomyomas (n = 2), gastric gastrointestinal stromal cell tumors (n = 2), ectopic pancreatic tissue (n = 2), arteriovenous malformation (n = 1), biliary adenoma (n = 1), and fibrosed hemangioma (n = 1). The planned bariatric procedures were completed for all the patients without incident. No complications occurred postoperatively, and all were discharged in 1 to 3 days (mean, 2 days).

CONCLUSIONS

Unexpected findings occur with relative frequency during laparoscopic bariatric procedures. Biopsy or removal of these lesions usually does not increase complications nor preclude continuation of the planned bariatric procedure.

The effect of obesity surgery on obesity comorbidity

Obesity is epidemic in the modern world. It is becoming increasingly clear that obesity is a major cause of cardiovascular disease, diabetes, and renal disease, as well as a host of other comorbidities. There are at present no generally effective long-term medical therapies for obesity. Surgical therapy for morbid obesity is not only effective in producing long-term weight loss but is also effective in ameliorating or resolving several of the most significant complications of obesity, including diabetes, hypertension, dyslipidemia, sleep apnea, gastroesophageal reflux disease, degenerative joint disease, venous stasis, pseudotumor cerebri, nonalcoholic steatohepatitis, urinary incontinence, fertility problems, and others. The degree of benefit and the rates of morbidity and mortality of the various surgical procedures vary according to the procedure.

Coagulation, inflammatory, and stress responses in a randomized comparison of open and laparoscopic repair of recurrent inguinal hernia

BACKGROUND

In previous comparisons of inflammatory and stress responses to open (OR) and laparoscopic (LR) hernia repair, all operations were performed under general anesthesia. Since local anesthesia is widely used for OR, a comparison of this approach with LR seemed relevant.

METHODS

Patients with recurrent inguinal hernia were randomized to OR under local anesthesia (n = 30) or LR under general anesthesia (n = 31). The magnitude of the surgical trauma was assessed by measuring markers of coagulation (prothrombin fragment 1 + 2), endothelial activation (von Willebrand factor), inflammation [leukocytes, interleukin-6, -8 and -10, granulocyte macrophage colony-stimulating factor, and C-reactive protein (CRP)], and endocrine stress (cortisol) in blood collected before operation, 4 h postincision, and on postoperative day 2.

RESULTS

Leukocyte counts and interleukin-6 and CRP levels increased in both groups, with the CRP increase being significantly greater in the OR group. The other markers did not increase significantly.

CONCLUSION

The acute phase response was more pronounced after OR, even when this was done under local anesthesia. Both techniques seemed rather atraumatic.