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Ogilvie JW, Khan MT, Hayakawa E, Parker J, Luchtefeld MA. Low-Dose Rivaroxaban as Extended Prophylaxis Reduces Postdischarge Venous Thromboembolism in Patients With Malignancy and IBD. Dis Colon Rectum 2024; 67:457-465. [PMID: 38039346 DOI: 10.1097/dcr.0000000000003107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
BACKGROUND Despite guidelines suggesting the use of extended prophylaxis for prevention of venous thromboembolism in patients with colorectal cancer and perhaps IBD, routine use is low and scant data exist regarding oral forms of therapy. OBJECTIVE The purpose was to compare the incidence of postdischarge venous thromboembolism in patients given extended prophylaxis with low-dose rivaroxaban. DESIGN We used propensity matching to compare pre- and postintervention analyses from a 2-year period before instituting extended prophylaxis. SETTING All colorectal patients at a single institution were prospectively considered for extended prophylaxis. PATIENTS Patients with a diagnosis of IBD or colorectal cancer who underwent operative resection were included. INTERVENTIONS Those considered for extended prophylaxis were prescribed 10 mg of rivaroxaban for 30 days postsurgery. MAIN OUTCOME MEASURES The primary outcome was venous thromboembolism incidence 30 days postdischarge. The secondary outcome was bleeding rates, major or minor. RESULTS Of the 498 patients considered for extended prophylaxis, 363 were discharged with rivaroxaban, 81 on baseline anticoagulation, and 54 without anticoagulation. Propensity-matched cohorts based on stoma creation, operative approach, procedure type, and BMI were made to 174 historical controls. After excluding cases of inpatient venous thromboembolism, postoperative rates were lower in the prospective cohort (4.8% vs 0.6%, p = 0.019). In the prospective group, 36 episodes of bleeding occurred, 26 (7.2%) were discharged with rivaroxaban, 8 (9.9%) discharged on other anticoagulants, and 2 (3.7%) with no postoperative anticoagulation. Cases of major bleeding were 1.1% (4/363) in the rivaroxaban group, and each required intervention. LIMITATIONS The study was limited to a single institution and did not include a placebo arm. CONCLUSIONS Among patients with IBD and colorectal cancer, extended prophylaxis with low-dose rivaroxaban led to a significant decrease in postdischarge thromboembolic events with a low bleeding risk profile. See Video Abstract . RIVAROXABN EN DOSIS BAJAS COMO PROFILAXIS PROLONGADA REDUCE LA TROMBOEMBOLIA VENOSA POSTERIOR AL ALTA, EN PACIENTES CON NEOPLASIAS MALIGNAS Y ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:A pesar de las normas que sugieren el uso de profilaxis extendida para la prevención del tromboembolismo venoso en pacientes con cáncer colorrectal y tal vez enfermedad inflamatoria intestinal, el uso rutinario es bajo y existen escasos datos sobre las formas orales de terapia.OBJETIVO:Comparar la incidencia de tromboembolismo venoso posterior al alta, en pacientes que recibieron profilaxis prolongada con dosis bajas de rivaroxabán.DISEÑO:Utilizamos el emparejamiento de propensión para comparar un análisis previo y posterior a la intervención de un período de 2 años antes de instituir la profilaxis extendida.AJUSTE:Todos los pacientes colorrectales en una sola institución fueron considerados prospectivamente para profilaxis extendida.PACIENTES:Incluidos pacientes con diagnóstico de enfermedad inflamatoria intestinal o cáncer colorrectal sometidos a resección quirúrgica.INTERVENCIONES:A los considerados para profilaxis extendida se les prescribió 10 mg de rivaroxabán durante 30 días postoperatorios.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la incidencia de tromboembolismo venoso 30 días después del alta. El resultado secundario fueron las tasas de hemorragia, mayor o menor.RESULTADOS:De los 498 pacientes considerados para profilaxis extendida, 363 fueron dados de alta con rivaroxabán, 81 con anticoagulación inicial y 54 sin anticoagulación. Se realizaron cohortes emparejadas por propensión basadas en la creación de la estoma, abordaje quirúrgico, tipo de procedimiento y el índice de masa corporal en 174 controles históricos. Después de excluir los casos de tromboembolismo venoso hospitalizado, las tasas posoperatorias fueron más bajas en la cohorte prospectiva (4,8% frente a 0,6%, p = 0,019). En el grupo prospectivo ocurrieron 36 episodios de hemorragia, 26 (7,2%) fueron dados de alta con rivaroxaban, 8 (9,9%) fueron dados de alta con otros anticoagulantes y 2 (3,7%) sin anticoagulación posoperatoria. Los casos de hemorragia mayor fueron del 1,1% (4/363) en el grupo de rivaroxabán y cada uno requirió intervención.LIMITACIONES:Limitado a una sola institución y no incluyó un grupo de placebo.CONCLUSIONES:Entre los pacientes con enfermedad inflamatoria intestinal y cáncer colorrectal, la profilaxis extendida con dosis bajas de rivaroxabán condujo a una disminución significativa de los eventos tromboembólicos posteriores al alta, con un perfil de riesgo de hemorragia bajo. (Traducción-Dr. Fidel Ruiz Healy).
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Affiliation(s)
- James W Ogilvie
- Division of Colorectal Surgery, Corewell Health, Grand Rapids, Michigan
| | - Mariam T Khan
- Michigan State University General Surgery Residency, Grand Rapids, Michigan
| | - Emiko Hayakawa
- Michigan State University General Surgery Residency, Grand Rapids, Michigan
| | - Jessica Parker
- Division of Colorectal Surgery, Corewell Health, Grand Rapids, Michigan
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Hossain N, Kaur V, Mahran M, Quddus A, Mukhopadhyay S, Shah A, Agrawal S. Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients. Obes Surg 2024; 34:396-401. [PMID: 38168716 DOI: 10.1007/s11695-023-07021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation. METHODS This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020-July 2022) to those who did not (March 2011-March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation. RESULTS TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death. CONCLUSIONS This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.
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Affiliation(s)
- Naveed Hossain
- Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Vasha Kaur
- Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Mostafa Mahran
- Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Abdul Quddus
- Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Santanu Mukhopadhyay
- Department of Anaesthesia, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Akshat Shah
- Department of Anaesthesia, Homerton University Hospital, Homerton Row, London, E9 6SR, UK
| | - Sanjay Agrawal
- Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK.
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Hyman DW, Brennan ER, Spaulding AC, Colibaseanu DT, Akram Hussain MW, Muraleedharan D, Casler JD, Schreier DJ, Thompson KM, Edwards MA. The Impact of Caprini Guideline Indicated Venous Thromboembolism Prophylaxis in Colorectal Surgery Patients: Experience of a Single Health System. Am Surg 2023; 89:4720-4733. [PMID: 36192381 DOI: 10.1177/00031348221129514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is the most common cause of preventable mortality following colorectal surgery (CRS), occurring in about 2% of patients. As a result, prophylaxis including discharge chemoprophylaxis is recommended. While VTE risk assessment tools are available, the consistent adoption and utilization of these tools remains elusive. Our study objectives were to determine the utilization and impact of risk adjusted VTE prophylaxis in CRS patients. STUDY DESIGN CRS cases performed between 1/1/2016 and 5/31/2021 were retrospectively analyzed. Caprini score and implemented VTE prophylaxis measures were determined. The primary outcome measure was receiving Caprini guideline indicated VTE prophylaxis. Secondary outcomes included VTE and bleeding. Categorical variables were compared by chi-square and Fisher's exact tests, and continuous variables by Kruskal-Wallis test. Logistic regression models were used to determine predictors of receiving appropriate VTE prophylaxis or experiencing postoperative VTE and bleeding. RESULTS 10,422 CRS cases were analyzed and 90.6% were high risk for VTE. In-hospital appropriate prophylaxis rates in low, moderate, high, and very high-risk category patients were 91.2%, 56.1%, 61.0%, and 63.1%, respectively. Inpatient VTE was reduced by 75% in those receiving appropriate VTE prophylaxis. At discharge, 5.8% of patients received appropriate prophylaxis, in whom there were no VTE events at 30- and 90 days from discharge. Increasing Caprini score positively correlated with VTE risk in both the inpatient and discharge cohorts, but inversely correlated with the likelihood of receiving appropriate prophylaxis at discharge (OR .31, P <.0001). CONCLUSION Caprini guideline indicated VTE prophylaxis in CRS patients reduced VTE events without increasing bleeding complications.
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Affiliation(s)
- David W Hyman
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Emily R Brennan
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | - Dorin T Colibaseanu
- Department of Surgery, Division of Colorectal Surgery, Jacksonville, Mayo Clinic, FL, USA
| | - Md Walid Akram Hussain
- Department of Surgery, Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Divya Muraleedharan
- Department of Surgery, Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - John D Casler
- Department of Ears, Nose and Throat, Mayo Clinic, Jacksonville, Jacksonville, FL, USA
| | | | | | - Michael A Edwards
- Department of Surgery, Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, USA
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Wei Q, Wei ZQ, Jing CQ, Li YX, Zhou DB, Lin MB, He XL, Li F, Liu Q, Zheng JY, Wang GY, Tu SL, Wang ZJ, Li A, Xiao G, Zhuang J, Bai L, Huang H, Li Y, Song W, Liang ZL, Shen ZL, Liu FL, Dai Y, Zhou XJ, Dong M, Wang H, Qiu J, Zhou L, Li XX, Wang ZQ, Zhang H, Wang Q, Pang MH, Wei HB, Hu ZQ, Yan YD, Che Y, Gu ZC, Yao HW, Zhang ZT. Incidence, prevention, risk factors, and prediction of venous thromboembolism in Chinese patients after colorectal cancer surgery: a prospective, multicenter cohort study. Int J Surg 2023; 109:3003-3012. [PMID: 37338597 PMCID: PMC10583908 DOI: 10.1097/js9.0000000000000553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common and serious complication after colorectal cancer (CRC) surgery. Few large-sample studies have reported VTE incidence and management status after CRC surgery in China. This study aimed to investigate the incidence and prevention of VTE in Chinese patients after CRC surgery, identify risk factors for developing VTE, and construct a new scoring system for clinical decision-making and care planning. METHODS Participants were recruited from 46 centers in 17 provinces in China. Patients were followed up for 1 month postoperatively. The study period was from May 2021 to May 2022. The Caprini score risk stratification and VTE prevention and incidence were recorded. The predictors of the occurrence of VTE after surgery were identified by multivariate logistic regression analysis, and a prediction model (CRC-VTE score) was developed. RESULTS A total of 1836 patients were analyzed. The postoperative Caprini scores ranged from 1 to 16 points, with a median of 6 points. Of these, 10.1% were classified as low risk (0-2 points), 7.4% as moderate risk (3-4 points), and 82.5% as high risk (≥5 points). Among these patients, 1210 (65.9%) received pharmacological prophylaxis, and 1061 (57.8%) received mechanical prophylaxis. The incidence of short-term VTE events after CRC surgery was 11.2% (95% CI 9.8-12.7), including deep venous thrombosis (DVT) (11.0%, 95% CI 9.6-12.5) and pulmonary embolism (PE) (0.2%, 95% CI 0-0.5). Multifactorial analysis showed that age (≥70 years), history of varicose veins in the lower extremities, cardiac insufficiency, female sex, preoperative bowel obstruction, preoperative bloody/tarry stool, and anesthesia time at least 180 min were independent risk factors for postoperative VTE. The CRC-VTE model was developed from these seven factors and had good VTE predictive performance ( C -statistic 0.72, 95% CI 0.68-0.76). CONCLUSIONS This study provided a national perspective on the incidence and prevention of VTE after CRC surgery in China. The study offers guidance for VTE prevention in patients after CRC surgery. A practical CRC-VTE risk predictive model was proposed.
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Affiliation(s)
- Qi Wei
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Chang-Qing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province
| | - Yong-Xiang Li
- Department of General Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province
| | - Dong-Bing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, Sichuan Province
| | - Mou-Bin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai
| | - Xian-Li He
- Department of General Surgery, Tangdu Hospital, The Air Force Medical University, Xi’an, Shannxi Province
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Jian-Yong Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Military Medical University, Xi’an, Shaanxi Province
| | - Gui-Ying Wang
- Department of General Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province
| | - Shi-Liang Tu
- General Surgery, Cancer Center, Department of Colorectal Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang Province
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing
| | - Gang Xiao
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing
| | - Jing Zhuang
- Department of General Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan Province
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing
| | - He Huang
- Department of Gastrointestinal Surgery, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province
| | - Yong Li
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People’s Hospital, Guangzhou, Guangdong Province
| | - Wu Song
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Zhong-Lin Liang
- Department of Colorectal and Anal Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Zhan-Long Shen
- Department of Gastroenterological Surgery, Peking University People’s Hospital, Beijing
| | - Fan-Long Liu
- First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province
| | - Yong Dai
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong Province
| | - Xiao-Jun Zhou
- Department of General Surgery, First Affiliated Hospital of Soochow University, Soochow, Jiangsu Province
| | - Ming Dong
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, Shenyang, Liaoning Province
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Jian Qiu
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, Shaanxi Province
| | - Lei Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing
| | - Xin-Xiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai
| | - Zi-Qiang Wang
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province
| | - Hong Zhang
- Department of Colorectal Oncology, Fourth General Surgery Department, Shengjing Hospital, China Medical University, Shenyang, Liaoning Province
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, Jilin Province
| | - Ming-Hui Pang
- Department of Geriatric Surgery; Department of Gastrointestinal Surgery, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan Province
| | - Hong-Bo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province
| | - Zhi-Qian Hu
- Department of Gastrointestinal Surgery, Tongji Hospital, Medical College of Tongji University, Shanghai
| | - Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yan Che
- NHC Key Lab of Reproduction Regulation, Shanghai Institute for Biomedical and Pharmaceutical Technologies, Shanghai, People’s Republic of China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hong-Wei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing
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Patel SV, Liberman SA, Burgess PL, Goldberg JE, Poylin VY, Messick CA, Davis BR, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Reduction of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum 2023; 66:1162-1173. [PMID: 37318130 DOI: 10.1097/dcr.0000000000002975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | | | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Joel E Goldberg
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vitaliy Y Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig A Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | | | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Leow TW, Rashid A, Lewis-Lloyd CA, Crooks CJ, Humes DJ. Risk of Postoperative Venous Thromboembolism After Benign Colorectal Surgery: Systematic Review and Meta-analysis. Dis Colon Rectum 2023; 66:877-885. [PMID: 37134222 DOI: 10.1097/dcr.0000000000002915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign disease is limited. OBJECTIVE This meta-analysis aimed to quantify the venous thromboembolism risk after benign colorectal resection and determine its variability. DATA SOURCES Following Preferred Reporting Items for Systematic Review and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology Guidelines (PROSPERO: CRD42021265438), Embase, MEDLINE, and 4 other registered medical literature databases were searched from the database inception to June 21, 2021. STUDY SELECTION Inclusion criteria: randomized controlled trials and large population-based database cohort studies reporting 30-day and 90-day venous thromboembolism rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: patients undergoing colorectal cancer or completely endoscopic surgery. MAIN OUTCOME MEASURES Thirty- and 90-day venous thromboembolism incidence rates per 1000 person-years after benign colorectal surgery. RESULTS Seventeen studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day venous thromboembolism incidence rates after benign colorectal resection were 284 (95% CI, 224-360) and 84 (95% CI, 33-218) per 1000 person-years. Stratified by admission type, 30-day venous thromboembolism incidence rates per 1000 person-years were 532 (95% CI, 447-664) for emergency resections and 213 (95% CI, 100-453) for elective colorectal resections. Thirty-day venous thromboembolism incidence rates per 1000 person-years after colectomy were 485 (95% CI, 411-573) for patients with ulcerative colitis, 228 (95% CI, 181-288) for patients with Crohn's disease, and 208 (95% CI, 152-288) for patients with diverticulitis. LIMITATIONS High degree of heterogeneity was observed within most meta-analyses attributable to large cohorts minimizing within-study variance. CONCLUSIONS Venous thromboembolism rates remain high up to 90 days after colectomy and vary by indication for surgery. Emergency resections compared to elective benign resections have higher rates of postoperative venous thromboembolism. Further studies reporting venous thromboembolism rates by type of benign disease need to stratify rates by admission type to more accurately define venous thromboembolism risk after colectomy. REGISTRATION NO CRD42021265438.
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Affiliation(s)
- Tjun Wei Leow
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Adil Rashid
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Colin J Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
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Yapa AKDS, Humes DJ, Crooks CJ, Lewis-Lloyd CA. Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study. Langenbecks Arch Surg 2023; 408:203. [PMID: 37212868 PMCID: PMC10203000 DOI: 10.1007/s00423-023-02920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/29/2023] [Indexed: 05/23/2023]
Abstract
AIM This study reports venous thromboembolism (VTE) rates following colectomy for diverticular disease to explore the magnitude of postoperative VTE risk in this population and identify high risk subgroups of interest. METHOD English national cohort study of colectomy patients between 2000 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type, absolute incidence rates (IR) per 1000 person-years and adjusted incidence rate ratios (aIRR) were calculated for 30- and 90-day post-colectomy VTE. RESULTS Of 24,394 patients who underwent colectomy for diverticular disease, over half (57.39%) were emergency procedures with the highest VTE rate seen in patients ≥70-years-old (IR 142.27 per 1000 person-years, 95%CI 118.32-171.08) at 30 days post colectomy. Emergency resections (IR 135.18 per 1000 person-years, 95%CI 115.72-157.91) had double the risk (aIRR 2.07, 95%CI 1.47-2.90) of developing a VTE at 30 days following colectomy compared to elective resections (IR 51.14 per 1000 person-years, 95%CI 38.30-68.27). Minimally invasive surgery (MIS) was shown to be associated with a 64% reduction in VTE risk (aIRR 0.36 95%CI 0.20-0.65) compared to open colectomies at 30 days post-op. At 90 days following emergency resections, VTE risks remained raised compared to elective colectomies. CONCLUSION Following emergency colectomy for diverticular disease, the VTE risk is approximately double compared to elective resections at 30 days while MIS was found to be associated with a reduced risk of VTE. This suggests advancements in postoperative VTE prevention in diverticular disease patients should focus on those undergoing emergency colectomies.
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Affiliation(s)
- Anjali K D S Yapa
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK.
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Colin J Crooks
- Gastrointestinal & Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, UK
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Mankarious MM, Portolese AC, Kazzaz SA, Deutsch MJ, Jeganathan NA, Scow JS, Kulaylat AS. Changing disposition patterns in the era of COVID-19 after colon resections: A National Surgical Quality Improvement Program colectomy study. Surgery 2023:S0039-6060(23)00182-4. [PMID: 37188583 PMCID: PMC10113599 DOI: 10.1016/j.surg.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/21/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The COVID-19 pandemic severely impacted post-hospitalization care facilities in the United States and hindered their ability to accept new patients for various reasons. This study aimed to assess the impact of the pandemic on discharge disposition after colon surgery and associated postoperative outcomes. METHODS A retrospective cohort study was performed using the National Surgical Quality Improvement Participant Use File and targeted colectomy. Patients were divided into the following 2 cohorts: (1) pre-pandemic (2017-2019) and (2) pandemic (2020). The primary outcomes included discharge disposition-post-hospitalization facility versus home. The secondary outcomes were rates of 30-day readmissions and other postoperative outcomes. The multivariable analysis assessed for confounders and effect modification on discharge to home. RESULTS Discharge to posthospitalization facilities decreased by 30% in 2020 compared to 2017 to 2019 (7% vs 10%, P < .001). This occurred despite an increase in emergency cases (15% vs 13%, P < .001) and open surgical approach (32% vs 31%, P < .001) in 2020. Multivariable analysis revealed that patients in 2020 had 38% lower odds of going to post-hospitalization facilities (odds ratio 0.62, P < .001) after adjusting for surgical indications and underlying comorbidities. This decrease in patients going to a post-hospitalization facility was not associated with an increased length of stay or an increase in 30-day readmissions or postoperative complications. CONCLUSION During the pandemic, patients undergoing colonic resection were less likely to be discharged to a post-hospitalization facility. This shift was not associated with an increase in 30-day complications. This should prompt further research to assess the reproducibility of these associations, especially in a setting without a global pandemic.
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Affiliation(s)
- Marc M Mankarious
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA. https://twitter.com/MarcMMankarious
| | - Austin C Portolese
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA
| | - Sarah A Kazzaz
- Pennsylvania State University, College of Medicine, Hershey, PA
| | - Michael J Deutsch
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA. https://twitter.com/MikeDeutschMD
| | - Nimalan A Jeganathan
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA. https://twitter.com/arjunjeg
| | - Jeffrey S Scow
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA.
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9
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Wu D, Gu H, Tang Y, Peng L, Liu H, Jiang Y, Xu Z, Wei Q, Wang Y. Predictive factors on postoperative venous thromboembolism after minimally invasive colorectal cancer surgery: a retrospective observational study. BMC Surg 2023; 23:85. [PMID: 37041489 PMCID: PMC10091640 DOI: 10.1186/s12893-023-01992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/06/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious and preventable postoperative complication. However, the predictive significance of perioperative biochemical parameters for VTE after minimally invasive colorectal cancer surgery remains unclear. METHODS A total of 149 patients undergoing minimally invasive colorectal cancer surgery were collected between October 2021 and October 2022. Biochemical parameters related to preoperative and postoperative day 1, day 3, and day 5 were collected, including D-Dimer, mean platelet volume (MPV), and maximum amplitude (MA) of thromboelastography (TEG). Receiver operating characteristic (ROC) curves were used to explore the predictive powers of meaningful biochemical parameters for postoperative VTE, and calibration curves were used to assess predictive accuracy. RESULTS The overall cumulative incidence of VTE was 8.1% (12/149). The preoperative and postoperative day 3 D-Dimer, postoperative day 3, and day 5 MPV, and postoperative day 1, day 3, and day 5 TEG-MA was significantly higher in the VTE group than in the non-VTE group (P < 0.05). The results of both the ROC curve and the calibration curve indicated that these meaningful D-Dimer, MPV, and TEG-MA had moderate discrimination and consistency for postoperative VTE. CONCLUSIONS D-Dimer, MPV, and TEG-MA may predict postoperative VTE in patients undergoing minimally invasive surgery for colorectal cancer at specific times in the perioperative period.
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Affiliation(s)
- Dabin Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Haitao Gu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yunhao Tang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Linglong Peng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Hang Liu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yahui Jiang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zhiquan Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Qi Wei
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yaxu Wang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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10
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McKenna NP, Bews KA, Behm KT, Habermann EB, Cima RR. Postoperative Venous Thromboembolism in Colon and Rectal Cancer: Do Tumor Location and Operation Matter? J Am Coll Surg 2023; 236:658-665. [PMID: 36728394 DOI: 10.1097/xcs.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. STUDY DESIGN Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. RESULTS A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. CONCLUSIONS When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals.
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Affiliation(s)
- Nicholas P McKenna
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
| | - Katherine A Bews
- The Robert D and Patricia E Kern Center for the Science of Health Care Delivery (Bews, Habermann), Mayo Clinic, Rochester, MN
| | - Kevin T Behm
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- The Robert D and Patricia E Kern Center for the Science of Health Care Delivery (Bews, Habermann), Mayo Clinic, Rochester, MN
| | - Robert R Cima
- From the Division of Colon and Rectal Surgery (McKenna, Behm, Cima), Mayo Clinic, Rochester, MN
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11
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Ore AS, Vigna C, Fabrizio A, Cataldo TE, Messaris E, Crowell K. Are IBD Patients Underscored when Determining Postoperative VTE Risk? J Gastrointest Surg 2023; 27:347-353. [PMID: 36394799 DOI: 10.1007/s11605-022-05525-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism (VTE) following colorectal surgery and there is currently no consensus on post-surgical VTE prevention or specific VTE risk assessment tools. We sought to evaluate VTE risk after colorectal surgery and determine if known risk factors used in risk assessment tools adequate correlate with VTE risk in IBD patients. METHODS Retrospective cohort study using the National Surgical Quality Improvement Project (NSQIP) Participant User File from 2010 to 2018. RESULTS A total of 27,679 patients were included; 19,015 (68.7%) had Crohn's disease (CD) and 8664 (31.3%) ulcerative colitis (UC). Of these, 16,749 (60.5%) underwent abdominopelvic procedures, 10,178 (36.8%) complex pelvic procedures, and 752 (2.7%) small bowel operations. The overall VTE rate was 2.3%. The VTE rate in patients with CD and UC was 1.8% and 3.6% (p < 0.001) respectively. Overall median time to VTE was 9 days after surgery. VTE rate was highest in patients who underwent complex pelvic procedures (3.6%; 361/10,178). A risk score was calculated using 16/40 available variables from the Caprini VTE Risk Assessment tool; risk score ranged from 3 to 12 points. Most patients that developed a VTE had a score between 3 and 5 points (75.6%), and only 24.5% had a score of 6 or higher. Patients with higher risk scores did not have a higher VTE incidence. CONCLUSION Post-surgical VTE rates are high in IBD patients. Over half of the events occurred following discharge and in patients with an apparent low-risk score. Additional studies are warranted to define a recommended postoperative VTE prophylaxis regimen for patients with IBD.
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Affiliation(s)
- Ana Sofia Ore
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Carolina Vigna
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Anne Fabrizio
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Thomas E Cataldo
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Evangelos Messaris
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Kristen Crowell
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
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12
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Cheong JY, Connelly TM, Russell T, Valente M, Bhama A, Lightner A, Hull T, Steele SR, Holubar SD. Venous thromboembolism risk stratification for patients undergoing surgery for IBD using a novel six factor scoring system using NSQIP-IBD registry. ANZ J Surg 2023. [PMID: 36645783 DOI: 10.1111/ans.18242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/06/2022] [Accepted: 12/17/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing colorectal surgery for inflammatory bowel disease (IBD) are recognized to have an increased risk of venous thromboembolism (VTE). The aim of this study was to determine the perioperative risk factors for VTE and to create a predictive scoring system for VTE in the IBD cohort. METHODS The NSQIP-IBD Collaboration Registry from 2017 to 2020 was used to identify patients. Demographics, operative and outcomes data of IBD patients undergoing surgeries for IBD were analysed. A logistic multivariate regression model was performed using all significant variables to develop a predictive scoring system of VTE. RESULTS Five-thousand and three patients (51.9% male, mean age: 42.7, 42.7% ulcerative colitis) were included in the study. 125 (2.49%) developed VTE. On multivariate analysis ASA grade, ulcerative colitis, sepsis, serum sodium <139 mmol/L, an open abdomen and preoperative inter hospital transfer were associated with greater risk of VTE. Using these 6 significant factors, a risk model was constructed. The risk of VTE with one risk factor was 0.7% and 1.8% with two risk factors. The risk of VTE increased to 3.6% and 4.5% with three and four risk factors respectively. With five and six risk factors, the risk of VTE increased exponentially to 10.9% and 25% respectively. CONCLUSION This study shows that there are cumulative risk factors which increase the risk of VTE after surgery for IBD. The risk increases exponentially with more than five risk factors, and extended chemoprophylaxis may not be enough in reducing this risk.
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Affiliation(s)
- Ju Yong Cheong
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara M Connelly
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara Russell
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Valente
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anuradha Bhama
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy Lightner
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Ma Y, Wang B, He P, Qi W, Xiang L, Maswikiti EP, Chen H. Coagulation- and fibrinolysis-related genes for predicting survival and immunotherapy efficacy in colorectal cancer. Front Immunol 2022; 13:1023908. [PMID: 36532065 PMCID: PMC9748552 DOI: 10.3389/fimmu.2022.1023908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background Colorectal cancer (CRC) is a common cancer and has a poor prognosis. The coagulation system and fibrinolysis system are closely related to the progression of malignant tumors and is also related to the immunotherapy of malignant tumors. Herein, we tried to predict survival and the immunotherapy effect for patients with CRC using a novel potential prognostic model. Methods Through online data of TCGA and GEO, we screened significantly differentially expressed genes (DEGs) to construct a prognostic model, followed by obtaining immune-related genes (IRGs) from the ImmPort database and coagulation- and fibrinolysis-related genes (CFRGs) from the GeneCards database. The predictive power of the model is assessed by Kaplan-Meier survival curves as well as the time-dependent ROC curve. Moreover, univariate and multivariate analyses were conducted for OS using Cox regression models, and the nomogram prognostic model was built. In the end, we further studied the possibility that CXCL8 was associated with immunocyte infiltration or immunotherapy effect and identified it by immunohistochemistry and Western blot. Results Five DEGs (CXCL8, MMP12, GDF15, SPP1, and NR3C2) were identified as being prognostic for CRC and were selected to establish the prognostic model. Expression of these genes was confirmed in CRC samples using RT-qPCR. Notably, those selected genes, both CFRGs and IRGs, can accurately predict the OS of CRC patients. Furthermore, CXCL8 is highly correlated with the tumor microenvironment and immunotherapy response in CRC. Conclusion Overall, our established IRGPI can very accurately predict the OS of CRC patients. CXCL8 reflects the immune microenvironment and reveals the correlation with immune checkpoints among CRC patients.
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Affiliation(s)
- Yanling Ma
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Bofang Wang
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Puyi He
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wenbo Qi
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Ling Xiang
- Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | | | - Hao Chen
- Department of Cancer Center, Lanzhou University Second Hospital, Lanzhou, China,*Correspondence: Hao Chen,
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14
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Poulos CM, Althoff AL, Scott RB, Wakefield D, Lewis R. A novel scoring system for identifying patients at risk for venous thromboembolism undergoing diverticular resection: an American College of Surgeons-National Surgical Quality Improvement Program Study. Surg Endosc 2022; 36:8415-8420. [PMID: 35229213 DOI: 10.1007/s00464-022-09129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
Following colorectal surgery, venous thromboembolism (VTE) is a serious complication occurring at an estimated incidence of 2-4%. There is a significant body of literature stratifying risk of VTE in specific populations undergoing colorectal resection for cancer or inflammatory bowel disease. There has been little research characterizing patients undergoing colorectal surgery for other indications, e.g. diverticulitis. We hypothesize that there exists a subgroup of patients with identifiable risk factors undergoing resection for diverticulitis that has relatively higher risks for VTE. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Project database from 2006 to 2017 who underwent colorectal resection for diverticulitis. Patients with a primary indication for resection other than diverticulitis were excluded. Multivariate logistic regression modeling was conducted to determine the risk of VTE for each independent variable. A novel scoring system was developed and a receiver-operating-characteristic curve was generated. The rate of VTE was 1.49%. An 7-point scoring system was developed using identified significant variables. Patients scoring ≥ 6 on the developed scoring scale had a 3.12% risk of 30-day VTE development. A simple scoring system based on identified significant risk factors was specifically developed to predict the risk of VTE in patients undergoing diverticular colorectal resection. These patients are at significantly higher risk and may justify increased vigilance regarding VTE events, similar to patients undergoing colorectal resection for cancer or inflammatory bowel disease.
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Affiliation(s)
- Constantine M Poulos
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA.
| | - Ashley L Althoff
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA
| | - Rachel B Scott
- Colon and Rectal Surgeons of Greater Hartford, Bloomfield, CT, 06002, USA
| | - Dorothy Wakefield
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA
| | - Robert Lewis
- Colon and Rectal Surgeons of Greater Hartford, Bloomfield, CT, 06002, USA
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15
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Lewis‐Lloyd CA, Crooks CJ, West J, Peacock O, Humes DJ. Time trends in the incidence rates of venous thromboembolism following colorectal resection by indication and operative technique. Colorectal Dis 2022; 24:1405-1415. [PMID: 35733416 PMCID: PMC9796069 DOI: 10.1111/codi.16233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/30/2022] [Accepted: 06/14/2022] [Indexed: 12/30/2022]
Abstract
AIM It is important for patient safety to assess if international changes in perioperative care, such as the focus on venous thromboembolism (VTE) prevention and minimally invasive surgery, have reduced the high post colectomy VTE risks previously reported. This study assesses the impact of changes in perioperative care on VTE risk following colorectal resection. METHOD This was a population-based cohort study of colectomy patients in England between 2000 and 2019 using a national database of linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Within 30 days following colectomy, absolute VTE rates per 1000 person-years and adjusted incidence rate ratios (aIRRs) using Poisson regression for the per year change in VTE risk were calculated. RESULTS Of 183 791 patients, 1337 (0.73%) developed 30-day postoperative VTE. Overall, VTE rates reduced over the 20-year study period following elective (relative risk reduction 31.25%, 95% CI 5.69%-49.88%) but not emergency surgery. Similarly, yearly changes in VTE risk reduced following minimally invasive resections (elective benign, aIRR 0.93, 95% CI 0.90-0.97; elective malignant, aIRR 0.94, 95% CI 0.91-0.98; and emergency benign, aIRR 0.96, 95% CI 0.92-1.00) but not following open resections. There was a per year VTE risk increase following open emergency malignant resections (aIRR 1.02, 95% CI 1.00-1.04). CONCLUSION Yearly VTE risks reduced following minimally invasive surgeries in the elective setting yet in contrast were static following open elective colectomies, and following emergency malignant resections increased by almost 2% per year. To reduce VTE risk, further efforts are required to implement advances in surgical care for those having emergency and/or open surgery.
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Affiliation(s)
- Christopher A. Lewis‐Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - Colin J. Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - Joe West
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Population and Lifespan SciencesUniversity of Nottingham, School of MedicineNottinghamUK
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, MD Anderson Cancer CenterUniversity of TexasHoustonTexasUSA
| | - David J. Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK,Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), School of Medicine, Queen's Medical Centre)Nottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
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16
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Lewis-Lloyd CA, Humes DJ, West J, Peacock O, Crooks CJ. The Duration and Magnitude of Postdischarge Venous Thromboembolism Following Colectomy. Ann Surg 2022; 276:e177-e184. [PMID: 35838409 PMCID: PMC9362343 DOI: 10.1097/sla.0000000000005563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the impact of current guidelines by reporting weekly postoperative postdischarge venous thromboembolism (VTE) rates. SUMMARY BACKGROUND DATA Disparity exists between the postoperative thromboprophylaxis duration colectomy patients receive based on surgical indication, where malignant resections routinely receive 28 days extended thromboprophylaxis into the postdischarge period and benign resections do not. METHODS English national cohort study of colectomy patients between 2010 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type and surgical indication, absolute incidence rates (IRs) per 1000 person-years and adjusted incidence rate ratios (aIRRs) for postdischarge VTE were calculated for the first 4 weeks following resection and postdischarge VTE IRs for each postoperative week to 12 weeks postoperative. RESULTS Of 104,744 patients, 663 (0.63%) developed postdischarge VTE within 12 weeks after colectomy. Postdischarge VTE IRs per 1000 person-years for the first 4 weeks postoperative were low following elective resections [benign: 20.66, 95% confidence interval (CI): 13.73-31.08; malignant: 28.95, 95% CI: 23.09-36.31] and higher following emergency resections (benign: 47.31, 95% CI: 34.43-65.02; malignant: 107.18, 95% CI: 78.62-146.12). Compared with elective malignant resections, there was no difference in postdischarge VTE risk within 4 weeks following elective benign colectomy (aIRR=0.92, 95% CI: 0.56-1.50). However, postdischarge VTE risks within 4 weeks following emergency resections were significantly greater for benign (aIRR=1.89, 95% CI: 1.22-2.94) and malignant (aIRR=3.13, 95% CI: 2.06-4.76) indications compared with elective malignant colectomy. CONCLUSIONS Postdischarge VTE risk within 4 weeks of colectomy is ∼2-fold greater following emergency benign compared with elective malignant resections, suggesting emergency benign colectomy patients may benefit from extended VTE prophylaxis.
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Affiliation(s)
- Christopher A. Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre, Nottingham, UK
| | - David J. Humes
- Gastrointestinal Surgery, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre, Nottingham, UK
| | - Joe West
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre, Nottingham, UK
- Lifespan and Population Health, University of Nottingham, School of Medicine, Nottingham, UK
| | - Oliver Peacock
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Colin J. Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Queen’s Medical Centre, Nottingham, UK
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17
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Marcucci M, Etxeandia-Ikobaltzeta I, Yang S, Germini F, Gupta S, Agarwal A, Ventresca M, Tang S, Morgano GP, Wang M, Ahmed MM, Neumann I, Izcovich A, Criniti J, Popoff F, Devereaux PJ, Dahm P, Anderson D, Lavikainen LI, Tikkinen KAO, Guyatt GH, Schünemann HJ, Violette PD. Benefits and harms of direct oral anticoagulation and low molecular weight heparin for thromboprophylaxis in patients undergoing non-cardiac surgery: systematic review and network meta-analysis of randomised trials. BMJ 2022; 376:e066785. [PMID: 35264372 PMCID: PMC8905353 DOI: 10.1136/bmj-2021-066785] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients undergoing non-cardiac surgery. DESIGN Systematic review and network meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), up to August 2021. REVIEW METHODS Randomised controlled trials in adults undergoing non-cardiac surgery were selected, comparing low molecular weight heparin (prophylactic (low) or higher dose) with direct oral anticoagulants or with no active treatment. Main outcomes were symptomatic venous thromboembolism, symptomatic pulmonary embolism, and major bleeding. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for network meta-analyses. Abstracts and full texts were screened independently in duplicate. Data were abstracted on study participants, interventions, and outcomes, and risk of bias was assessed independently in duplicate. Frequentist network meta-analysis with multivariate random effects models provided odds ratios with 95% confidence intervals, and GRADE (grading of recommendations, assessment, development, and evaluation) assessments indicated the certainty of the evidence. RESULTS 68 randomised controlled trials were included (51 orthopaedic, 10 general, four gynaecological, two thoracic, and one urological surgery), involving 45 445 patients. Low dose (odds ratio 0.33, 95% confidence interval 0.16 to 0.67) and high dose (0.19, 0.07 to 0.54) low molecular weight heparin, and direct oral anticoagulants (0.17, 0.07 to 0.41) reduced symptomatic venous thromboembolism compared with no active treatment, with absolute risk differences of 1-100 per 1000 patients, depending on baseline risks (certainty of evidence, moderate to high). None of the active agents reduced symptomatic pulmonary embolism (certainty of evidence, low to moderate). Direct oral anticoagulants and low molecular weight heparin were associated with a 2-3-fold increase in the odds of major bleeding compared with no active treatment (certainty of evidence, moderate to high), with absolute risk differences as high as 50 per 1000 in patients at high risk. Compared with low dose low molecular weight heparin, high dose low molecular weight heparin did not reduce symptomatic venous thromboembolism (0.57, 0.26 to 1.27) but increased major bleeding (1.87, 1.06 to 3.31); direct oral anticoagulants reduced symptomatic venous thromboembolism (0.53, 0.32 to 0.89) and did not increase major bleeding (1.23, 0.89 to 1.69). CONCLUSIONS Direct oral anticoagulants and low molecular weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent. Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low molecular weight heparin. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018106181.
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Affiliation(s)
- Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Stephen Yang
- Department of Anaesthesia, Jewish General Hospital, Montreal, QC, Canada
| | - Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shyla Gupta
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Arnav Agarwal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Ventresca
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shaowen Tang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mengxiao Wang
- Department of Science, McMaster University, Hamilton, ON, Canada
- Department of Mathematics, University of Waterloo, Waterloo, ON, Canada
| | | | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Ariel Izcovich
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Juan Criniti
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Federico Popoff
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Philipp Dahm
- Minneapolis Veterans Affair Health Care System, Urology Section, Minneapolis, MN, USA
- University of Minnesota, Department of Urology, Minneapolis, MN, USA
| | - David Anderson
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael DeGroote Cochrane Canada Centre-Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philippe D Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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18
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Donohue K, Rossi A, Patel NM. The agony of acute anastomotic leak. Managing the emotional impact. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Takeda C, Yamashita Y, Takeuchi M, Yonekura H, Dong L, Hamada M, Hirotsu A, Ono K, Kawakami K, Fukuda K, Morimoto T, Kimura T, Mizota T. Incidence, clinical characteristics and long-term prognosis of postoperative symptomatic venous thromboembolism: a retrospective cohort study. BMJ Open 2022; 12:e055090. [PMID: 35173005 PMCID: PMC8852734 DOI: 10.1136/bmjopen-2021-055090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the incidence, clinical characteristics and prognosis of postoperative symptomatic venous thromboembolism (VTE) in Japan. DESIGN Retrospective observational study. Two data sets, Contemporary ManageMent AND outcomes in patients with Venous ThromboEmbolism (COMMAND VTE) Registry and Japanese Society of Anesthesiologists (JSA) annual report, were used for current analyses. SETTING Eighteen of 29 centres participated in the COMMAND VTE Registry. PARTICIPANTS Acute symptomatic patients with VTE who had undergone surgery 2 months prior to the diagnosis at 18 centres from January 2010 to December 2013 were identified in the COMMAND VTE Registry. From each centre's JSA annual report, the overall population that had received anaesthetic management during this period was retrieved. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the incidences and clinical characteristics of postoperative symptomatic VTE. The secondary outcomes were recurrent VTE, major bleeding and all-cause death. RESULTS We identified 137 patients with postoperative symptomatic VTE, including 57 patients with pulmonary embolism. The incidences of postoperative symptomatic VTE and pulmonary embolism were 0.067% and 0.028%, respectively, based on data from 2 03 943 patients who underwent surgery, managed by anaesthesiologists, during the study period. The incidences of postoperative symptomatic VTE varied widely, depending on surgical and anaesthetic characteristics. Postoperative symptomatic VTE occurred at a median of 8 days after surgery, with 58 patients (42%) diagnosed within 7 days. The cumulative incidence, 30 days after VTE, of recurrent VTE, major bleeding, and all-cause death was 3.0%, 5.2%, and 3.7%, respectively. CONCLUSION This study, combining the large real-world VTE and anaesthesiology databases in Japan revealed the incidence, clinical features and prognosis of postoperative symptomatic VTE, providing useful insights for all healthcare providers involved in various surgeries. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Faculty of Medicine, Kyoto, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Graduate School of Medicine Faculty of Medicine, Tsu, Mie, Japan
| | - Li Dong
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Miho Hamada
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Akiko Hirotsu
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Faculty of Medicine, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Kazuhiko Fukuda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Faculty of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Faculty of Medicine, Kyoto, Japan
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
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20
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Veeranki SP, Xiao Z, Levorsen A, Sinha M, Shah B. A Real-World Comparative Effectiveness Analysis of Thromboprophylactic Use of Enoxaparin Versus Unfractionated Heparin in Abdominal Surgery Patients in a Large U.S. Hospital Database. Hosp Pharm 2022; 57:121-129. [PMID: 35521006 PMCID: PMC9065531 DOI: 10.1177/0018578720987141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Little is known about outcomes associated with enoxaparin versus unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in abdominal surgery patients in U.S. clinical practice. The purpose of this study was to compare VTE, all-cause mortality, PE-related in-hospital mortality, and hospital costs during abdominal surgery hospitalization and the 90 days post-discharge between patients who received enoxaparin versus UFH prophylaxis. Materials and Methods: Using the Premier Healthcare Database, abdominal surgery patients who received at least 1 day of VTE prophylaxis with enoxaparin or UFH were identified between January 1, 2010 and September 30, 2016. Clinical outcomes were assessed using multivariable logistic regression models and cost outcomes were assessed using generalized linear models. Results: Of 363,669 patients identified, 59% received enoxaparin and 41% UFH. In adjusted analyses, there were statistically significant lower odds of VTE (OR 0.80; 95% CI 0.65-0.97), all-cause mortality (OR 0.67; 95% CI 0.60-0.75), and major bleeding (OR 0.88; 95% CI 0.82-0.94) during the hospitalization for enoxaparin versus UFH, but no differences during the 90-days post-discharge or for PE-related mortality. There was a statistically significant lower total hospital cost with enoxaparin versus UFH during index hospitalization ($8,913 vs $9,017, P < .0001), but not post-discharge ($3,342 vs $3,368, P = .42). Unadjusted rates of heparin-induced thrombocytopenia (index:0.1% vs 0.3%; post-discharge: 0.02% vs 0.06%) were reported for enoxaparin and UFH, respectively. Conclusion: In contemporary U.S. hospital practice, statistically significant lower odds of VTE, all-cause mortality and major bleeding with enoxaparin versus UFH prophylaxis were found during abdominal surgery hospitalizations.
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Affiliation(s)
- S. P. Veeranki
- Premier Applied Sciences, Premier Inc., Charlotte, NC, USA,University of Texas Medical Branch, Galveston, TX, USA,Precision HEOR, Los Angeles, CA, USA
| | | | - A. Levorsen
- Sanofi, Oslo, Norway,A. Levorsen, Global Health Economics and Value Assessment HTA Strategy, SANOFI, Professor Kohtsvei 5-17, Lysaker 1366, Norway.
| | - M. Sinha
- Premier Applied Sciences, Premier Inc., Charlotte, NC, USA
| | - B. Shah
- Livongo Health, Mountain View, CA, USA,Duke University, Durham, NC, USA
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21
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Paro A, Dalmacy D, Hyer JM, Tsilimigras DI, Diaz A, Pawlik TM. Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery. J Gastrointest Surg 2021; 25:3064-3073. [PMID: 34282525 DOI: 10.1007/s11605-021-05080-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. METHODS The Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. RESULTS Among 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194-1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04-6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39-30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11-1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04-1.13), nonelective surgery (HR 1.19, 95%CI 1.14-1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05-1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29-6.61) and non-cancer patients (HR 6.98, 95%CI 6.37-7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08-28.02), as well as non-cancer (HR 30.81, 95%CI 27.01-35.15) patients. CONCLUSIONS Patients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1-2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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22
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Zhang H, Wang X. Risk Factors of Venous Thromboembolism in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:693927. [PMID: 34262920 PMCID: PMC8273255 DOI: 10.3389/fmed.2021.693927] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Patients suffering from chronic inflammatory disorders, such as inflammatory bowel disorder, are at higher risk of developing thromboembolism. The chronic inflammatory nature of inflammatory bowel disease has been identified as a predominant reason for a state of Virchow's triad (i.e., endothelial dysfunction, stasis, and general hypercoagulability), eventually leading to the onset of venous thromboembolism. Recent studies show that certain factors, such as demographics, medication history, and history of surgical intervention may increase thromboembolism risk in patients with inflammatory bowel disease. However, to date, no study has attempted to evaluate the effect of different risk factors associated with the development of venous thromboembolism in inflammatory bowel disease patients. Objective: To evaluate the risk factors that can influence the incidence of venous thromboembolism in patients with inflammatory bowel disease. Methods: Academic literature was systematically searched based on the PRISMA guidelines across five databases: Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE. A random-effect meta-analysis was conducted to evaluate the hazard ratio for the risk factors (i.e., aging, gender, steroid therapy, surgery, and ulcerative colitis) that can influence the incidence of venous thromboembolism in patients with inflammatory bowel disease. Results: From a total of 963 studies, 18 eligible studies with 1,062,985 (44.59 ± 10.18 years) patients suffering from inflammatory bowel disease were included in the review. A meta-analysis revealed a higher risk of aging (Hazard's ratio: 2.19), steroids (1.87), surgery (1.48), and ulcerative colitis (2.06) on venous thromboembolism in patients with inflammatory bowel disease. We also found that the female gender (0.92) did not increase the incidence of venous thromboembolism in inflammatory bowel disease patients. Conclusion: The study provides preliminary evidence regarding high risks associated with ulcerative colitis, steroid consumption, and aging for the development of venous thromboembolism in patients with inflammatory bowel disease. The findings from this study may contribute to developing awareness among clinicians, better risk stratification and prevention of venous thromboembolic complications in patients with inflammatory bowel disease.
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Affiliation(s)
- Hua Zhang
- Department of Nursing, Xiangya Second Hospital of Central South University, Changsha, China
| | - Xuehong Wang
- Department of Gastroenterology, Xiangya Second Hospital of Central South University, Changsha, China
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23
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Zhu YJ, Zhou YP, Wei YP, Xu XQ, Yan XX, Liu C, Zhu XJ, Liu ZY, Sun K, Hua L, Jiang X, Jing ZC. Association Between Anticoagulation Outcomes and Venous Thromboembolism History in Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:628284. [PMID: 34095244 PMCID: PMC8175786 DOI: 10.3389/fcvm.2021.628284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The association between anticoagulation outcomes and prior history of venous thromboembolism (VTE) in chronic thromboembolic pulmonary hypertension (CTEPH) has not been established. This study aimed to compare the efficacy and safety of anticoagulation treatment in CTEPH patients with and without prior history of VTE. Methods: A total of 333 CTEPH patients prescribed anticoagulants were retrospectively included from May 2013 to April 2019. The clinical characteristics were collected at their first admission. Incidental recurrent VTE and clinically relevant bleeding were recorded during follow-up. The Cox proportional regression models were used to identify potential factors associated with recurrent VTE and clinically relevant bleeding. Results: Seventy patients (21%) without a prior history of VTE did not experience recurrent VTE during anticoagulation. Compared to CTEPH patients without a prior history of VTE, those with a prior history of VTE had an increased risk of recurrent VTE [2.27/100 person-year vs. 0/100 person-year; hazard ratio (HR), 8.92; 95% confidence interval (CI), 1.18–1142.00; P = 0.029] but a similar risk of clinically relevant bleeding (3.90/100 person-year vs. 4.59/100 person-year; HR, 0.83; 95% CI, 0.38–1.78; P = 0.623). Multivariate Cox analyses suggested that a prior history of VTE and interruption of anticoagulation treatments were significantly associated with an increased risk of recurrent VTE, while anemia and glucocorticoid use were significantly associated with a higher risk of clinically relevant bleeding. Conclusions: This study is the first to reveal that a prior history of VTE significantly increases the risk of recurrent VTE in CTEPH patients during anticoagulation treatment. This finding should be further evaluated in prospective studies.
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Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Jie Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Yi Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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24
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Lewis-Lloyd CA, Pettitt EM, Adiamah A, Crooks CJ, Humes DJ. Risk of Postoperative Venous Thromboembolism After Surgery for Colorectal Malignancy: A Systematic Review and Meta-analysis. Dis Colon Rectum 2021; 64:484-496. [PMID: 33496485 DOI: 10.1097/dcr.0000000000001946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal cancer has the second highest mortality of any malignancy, and venous thromboembolism is a major postoperative complication. OBJECTIVE This study aimed to determine the variation in incidence of venous thromboembolism after colorectal cancer resection. DATA SOURCES Following PRISMA and MOOSE guidelines (PROSPERO, ID: CRD42019148828), Medline and Embase databases were searched from database inception to August 2019 including 3 other registered medical databases. STUDY SELECTION Two blinded reviewers screened studies with a third reviewer adjudicating any discordance. Eligibility criteria: Patients post colorectal cancer resection aged ≥18 years. Exclusion criteria: Patients undergoing completely endoscopic surgery and those without cancer resection. Selected studies were randomized controlled trials and population-based database/registry cohorts. MAIN OUTCOME MEASURES Thirty- and 90-day incidence rates of venous thromboembolism per 1000 person-years following colorectal cancer surgery. RESULTS Of 6441 studies retrieved, 28 met inclusion criteria. Eighteen were available for meta-analysis reporting on 539,390 patients. Pooled 30- and 90-day incidence rates of venous thromboembolism following resection were 195 (95% CI, 148-256, I2 99.1%) and 91 (95% CI, 56-146, I2 99.2%) per 1000 person-years. When separated by United Nations Geoscheme Areas, differences in the incidence of postoperative venous thromboembolism were observed with 30- and 90-day pooled rates per 1000 person-years of 284 (95% CI, 238-339) and 121 (95% CI, 82-179) in the Americas and 71 (95% CI, 60-84) and 57 (95% CI, 47-69) in Europe. LIMITATIONS A high degree of heterogeneity was observed within meta-analyses attributable to large cohorts minimizing within-study variance. CONCLUSION The incidence of venous thromboembolism following colorectal cancer resection is high and remains so more than 1 month after surgery. There is clear disparity between the incidence of venous thromboembolism after colorectal cancer surgery by global region. More robust population studies are required to further investigate these geographical differences to determine valid regional incidence rates of venous thromboembolism following colorectal cancer resection.
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Affiliation(s)
- Christopher A Lewis-Lloyd
- Department of Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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25
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Bellomy ML, Engoren MC, Martin BJ, Shi Y, Shotwell MS, Hughes CG, Freundlich RE. The Attributable Mortality of Postoperative Bleeding Exceeds the Attributable Mortality of Postoperative Venous Thromboembolism. Anesth Analg 2021; 132:82-88. [PMID: 32675637 DOI: 10.1213/ane.0000000000004989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Bleeding and venous thromboembolic disease are considered important sources of postoperative morbidity and mortality. Clinically, treatment of these 2 disorders is often competing. We sought to better understand the relative contributions of bleeding and venous thromboembolic disease to postoperative attributable mortality in a national cohort. METHODS A retrospective analysis of the 2006-2017 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to assess the adjusted odds ratio and attributable mortality for postoperative bleeding and venous thromboembolism, adjusted by year. RESULTS After adjustment for confounding variables, bleeding exhibited a high postoperative attributable mortality in every year studied. Venous thromboembolism appeared to contribute minimal attributable mortality. CONCLUSIONS Bleeding complications are a consistent source of attributable mortality in surgical patients, while the contribution of venous thromboembolic disease appears to be minimal in this analysis. Further studies are warranted to better understand the etiology of this disparity.
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Affiliation(s)
- Melissa L Bellomy
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Matthew S Shotwell
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Biostatistics
| | - Christopher G Hughes
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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26
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Bafford AC, Cross RK. Risk of Venous Thromboembolism in Patients with Inflammatory Bowel Disease Extends beyond Hospitalization. Inflamm Bowel Dis 2020; 26:1769-1770. [PMID: 31995188 DOI: 10.1093/ibd/izaa003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Andrea C Bafford
- Department of Surgery, Section of Colon and Rectal Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology, University of Maryland School of Medicine, Baltimore, MD, USA
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Schlick CJR, Yuce TK, Yang AD, McGee MF, Bentrem DJ, Bilimoria KY, Merkow RP. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2020; 169:240-247. [PMID: 33077197 DOI: 10.1016/j.surg.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. METHODS Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. RESULTS Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. CONCLUSION Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
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Affiliation(s)
- Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
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Expanding Pharmacotherapy Data Collection, Analysis, and Implementation in ERAS ® Programs-The Methodology of an Exploratory Feasibility Study. Healthcare (Basel) 2020; 8:healthcare8030252. [PMID: 32756346 PMCID: PMC7551795 DOI: 10.3390/healthcare8030252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/25/2020] [Accepted: 07/29/2020] [Indexed: 11/23/2022] Open
Abstract
Surgical organizations dedicated to the improvement of patient outcomes have led to a worldwide paradigm shift in perioperative patient care. Since 2012, the Enhanced Recovery After Surgery (ERAS®) Society has published guidelines pertaining to perioperative care in numerous disciplines including elective colorectal and gynecologic/oncology surgery patients. The ERAS® and ERAS-USA® Societies use standardized methodology for collecting and assessing various surgical parameters in real-time during the operative process. These multi-disciplinary groups have constructed a bundled framework of perioperative care that entails 22 specific components of clinical interventions, which are logged in a central database, allowing a system of audit and feedback. Of these 22 recommendations, nine of them specifically involve the use of medications or pharmacotherapy. This retrospective comparative pharmacotherapy project will address the potential need to (1) collect more specific pharmacotherapy data within the existing ERAS Interactive Audit System® (EIAS) program, (2) understand the relationship between medication regimen and patient outcomes, and (3) minimize variability in pharmacotherapy use in the elective colorectal and gynecologic/oncology surgical cohort. Primary outcomes measures include data related to surgical site infections, venous thromboembolism, and post-operative nausea and vomiting as well as patient satisfaction, the frequency and severity of post-operative complications, length of stay, and hospital re-admission at 7 and 30 days, respectively. The methodology of this collaborative research project is described.
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Pannucci CJ, Fleming KI, Bertolaccini CB, Prazak AM, Huang LC, Pickron TB. Assessment of Anti-Factor Xa Levels of Patients Undergoing Colorectal Surgery Given Once-Daily Enoxaparin Prophylaxis: A Clinical Study Examining Enoxaparin Pharmacokinetics. JAMA Surg 2020; 154:697-704. [PMID: 31116389 DOI: 10.1001/jamasurg.2019.1165] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Between 4% and 12% of patients undergoing colorectal surgery and receiving enoxaparin, 40 mg per day, have a postoperative venous thromboembolism (VTE) event. An improved understanding of why "breakthrough" VTE events occur despite guideline-compliant prophylaxis is an important patient safety question. Objective To determine the proportion of patients undergoing colorectal surgery who received adequate anticoagulation based on peak anti-factor Xa (aFXa) levels while receiving enoxaparin at 40 mg per day. Design, Setting, and Participants This prospective, nonrandomized clinical trial was conducted between February 2017 and July 2018 with 90-day follow-up at a quaternary academic medical center in the Intermountain West and included patients undergoing colorectal surgery who had surgery after receiving general anesthesia, were admitted for at least 3 days, and received enoxaparin, 40 mg once daily. Interventions All patients had aFXa levels measured after receiving enoxaparin 40 mg per day. Patients whose aFXa level was out of range entered the trial's interventional arm where real-time enoxaparin dose adjustment and repeated aFXa measurement were performed. Main Outcomes and Measures Primary outcome: in-range peak aFXa levels (goal range, 0.3-0.5 IU/mL) with enoxaparin, 40 mg per day. Secondary outcomes: (1) in-range trough aFXa levels (goal range, 0.1-0.2 IU/mL) and (2) the proportion of patients with in-range peak aFXa levels from enoxaparin, 40 mg once daily, vs the real-time enoxaparin dose adjustment protocol. Results Over 16 months, 116 patients undergoing colorectal surgery (65 women [56.0%]; 99 white individuals [85.3%], 13 Hispanic or Latino individuals [11.2%], and 4 Pacific Islander individuals [3.5%]; mean [range] age, 52.1 [18-85] years) were enrolled. Among 106 patients (91.4%) whose peak aFXa level was appropriately drawn, 72 (67.9%) received inadequate anticoagulation (aFXa < 0.3 IU/mL) with enoxaparin, 40 mg per day. Weight and peak aFXa levels were inversely correlated (r2 = 0.38). Forty-seven patients (77%) had a trough aFXa level that was not detectable (ie, most patients had no detectable level of anticoagulation for at least 12 hours per day). Real-time enoxaparin dose adjustment was effective. Patients were significantly more likely to achieve an in-range peak aFXa with real-time dose adjustment as opposed to fixed dosing alone (85.4% vs 29.2%, P < .001). Conclusions and Relevance This study supports the finding that most patients undergoing colorectal surgery receive inadequate prophylaxis from enoxaparin, 40 mg once daily. These findings may explain the high rate of "breakthrough" VTE observed in many clinical trials. Trial Registration ClinicalTrials.gov identifier: NCT02704052.
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Affiliation(s)
- Christopher J Pannucci
- Division of Plastic Surgery, University of Utah, Salt Lake City.,Division of Health Services Research, University of Utah, Salt Lake City
| | - Kory I Fleming
- Division of Plastic Surgery, University of Utah, Salt Lake City
| | | | | | - Lyen C Huang
- Division of General Surgery, University of Utah, Salt Lake City
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Abstract
Venous thromboembolism (VTE) is a leading cause of mortality during the perioperative period, with individuals who have undergone hip and knee arthroplasty at the highest risk for VTE. The American College of Chest Physicians recommends 35 days of postoperative thromboprophylaxis and the use of intermittent pneumatic compression (IPC) therapy for mechanical compression after major orthopedic surgery. However, little research has described adherence to these recommendations during recovery at home. The purpose of this cross-sectional descriptive study was to describe thromboprophylaxis prescription, use, and education among patients discharged home after major orthopedic surgery. We surveyed patients within 2 years of major orthopedic surgery. A total of 388 subjects completed the survey. More than three-quarters of respondents reported a thromboprophylaxis duration <35 days. Most (93.8%) respondents were prescribed a pharmacologic agent, while 55.9% were prescribed mechanical compression therapy. Of the respondents who were prescribed mechanical compression therapy, 13.4% were prescribed IPC. Adherence to mechanical compression therapy was moderate, with 63% of respondents wearing mechanical compression therapy ≥75% of the time. The results of this study suggest a need for increased duration of thromboprophylaxis and increased use of IPC in the outpatient setting. Additional research describing prescribers' perceptions of thromboprophylaxis is also needed.
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Population-Based Analysis of Adherence to Postdischarge Extended Venous Thromboembolism Prophylaxis After Colorectal Resection. Dis Colon Rectum 2020; 63:911-917. [PMID: 32496331 PMCID: PMC7804389 DOI: 10.1097/dcr.0000000000001650] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Prevention of venous thromboembolism after colorectal surgery remains challenging. National guidelines endorse thromboembolism prophylaxis for 4 weeks after colorectal cancer resection. Expert consensus favors extended prophylaxis after IBD surgery. The actual frequency of prescription after resection remains unknown. OBJECTIVE This study aimed to assess prescription of extended, postdischarge venous thromboembolism prophylaxis after resection in Michigan. DESIGN This is a retrospective review of elective colorectal resections within a statewide collaborative receiving postdischarge, extended-duration prophylaxis. SETTING This study was conducted between October 2015 and February 2018 at an academic center. PATIENTS A total of 5722 patients (2171 with colorectal cancer, 266 with IBD, and 3285 with other). MAIN OUTCOME MEASURES We compared the prescription of extended, postdischarge prophylaxis over time, between hospitals and by indication. RESULTS Of 5722 patients, 373 (6.5%) received extended-duration prophylaxis after discharge. Use was similar between patients undergoing surgery for cancer (282/2171, 13.0%) or IBD (31/266, 11.7%, p = 0.54), but was significantly more common for both patients undergoing surgery for cancer or IBD in comparison with patients with other indications (60/3285, 1.8%, p < 0.001). Use increased significantly among patients with cancer (6.8%-16.8%, p < 0.001) and patients with IBD (0%-15.1%, p < 0.05) over the study period. For patients with other diagnoses, use was rare and did not vary significantly (1.5%-2.3%, p = 0.49). Academic centers and large hospitals (>300 beds) were significantly more likely to prescribe extended-duration prophylaxis for all conditions (both p < 0.001), with the majority of prophylaxis concentrated at only a few hospitals. LIMITATIONS This study was limited by the lack of assessment of actual adherence, small number of observed venous thromboembolism events, small sample of patients with IBD, and restriction to the state of Michigan. CONCLUSIONS The use of extended-duration venous thromboembolism prophylaxis after discharge is increasing, but remains uncommon in most hospitals. Efforts to improve adherence may require quality implementation initiatives or targeted payment incentives. See Video Abstract at http://links.lww.com/DCR/B193. ANÁLISIS POBLACIONAL DE LA ADHERENCIA A LA PROFILAXIS ANTI-TROMBÓTICA EXTENDIDA (TEV) EN PACIENTES DE ALTA LUEGO DE UNA RESECCIÓN COLORECTAL.: La prevención del tromboembolismo venoso después de cirugía colorrectal sigue siendo un desafío. Las guías nacionales han aprobado la profilaxia del tromboembolismo durante cuatro semanas luego de una resección de cáncer colorrectal. El consenso de expertos favorece la profilaxia extendida solamente después de la cirugía por enfermedad inflamatoria intestinal. La frecuencia real de prescripción después de la resección colorrectal sigue siendo desconocida.Evaluar la prescripción de profilaxia prolongada de tromboembolismo venoso después del alta luego de una resección colorrectal en Michigan.Revisión retrospectiva de las resecciones colorrectales electivas seguidas de una profilaxia de larga duración con el apoyo de todo el estado (MI).Este estudio se realizó entre octubre de 2015 y febrero de 2018 en un solo centro académico.Un universo de 5722 pacientes operados (2171 por cáncer colorrectal, 266 por enfermedad inflamatoria intestinal, 3285 por otros diagnósticos).Se comparó la prescripción de profilaxia prolongada después del alta según la duración, los hospitales y la indicación.De 5722 pacientes, 373 (6.5%) recibieron profilaxia de duración prolongada después del alta. El uso fue similar entre pacientes sometidos a cirugía por cáncer (282/2171, 13.0%) o enfermedad inflamatoria intestinal (31/266, 11.7%, p = 0.54), pero fue significativamente más común para ambos en comparación con pacientes con otras indicaciones (60/3285, 1.8%, p < 0.001). El uso aumentó significativamente entre pacientes con cáncer (6.8% a 16.8% (p < 0.001)) y en pacientes con enfermedad inflamatoria intestinal (0% a 15.1%, p < 0.05) durante el período de estudio. Para pacientes con otros diagnósticos, su utilización fue rara y no varió significativamente (1.5% a 2.3%, p = 0.49). Los centros académicos y los grandes hospitales (>300 camas) tenían mayor probabilidad de prescribir la profilaxia de duración extendida en todas las afecciones (ambas p < 0.001), pero la mayoría de las profilaxis se concentraron el algunos pocos grandes hospitales.Este estudio estuvo limitado por la falta de evaluación de actuales adherentes, por el pequeño número de eventos tromboembólicos venosos observados, por la pequeña muestra de pacientes con enfermedad inflamatoria intestinal y debido a ciertas restricciones en el estado de Michigan.El uso de profilaxia para el tromboembolismo venoso de duración prolongada después del alta está en aumento, pero su uso sigue siendo poco frecuente en la mayoría de los hospitales. Los esfuerzos para mejorar la adherencia al tratamiento pueden requerir iniciativas de mejoría en la calidad o incentivos específicos de reembolso. Consulte Video Resumen en http://links.lww.com/DCR/B193. (Traducción-Dr. Xavier Delgadillo).
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McKechnie T, Wang J, Springer JE, Gross PL, Forbes S, Eskicioglu C. Extended thromboprophylaxis following colorectal surgery in patients with inflammatory bowel disease: a comprehensive systematic clinical review. Colorectal Dis 2020; 22:663-678. [PMID: 31490000 DOI: 10.1111/codi.14853] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 08/14/2019] [Indexed: 12/12/2022]
Abstract
AIM Patients with inflammatory bowel disease (IBD) are at increased risk of postoperative venous thromboembolism (VTE) following major abdominal surgery. The pathogenesis is multifactorial and not fully understood. A combination of pathophysiology, patient and surgical risk factors increase the risk of postoperative VTE in these patients. Despite being at increased risk, IBD patients are not regularly prescribed extended pharmacological thromboprophylaxis following colorectal surgery. Currently, there is a paucity of evidence-based guidelines. Thus, the aim of this review is to evaluate the role of extended pharmacological thromboprophylaxis in IBD patients undergoing colorectal surgery. METHOD A search of Ovid Medline, EMBASE and PubMed databases was performed. A qualitative analysis was performed using 10 clinical questions developed by colorectal surgeons and a thrombosis haematologist. The Newcastle-Ottawa Scale was utilized to assess the quality of evidence. RESULTS A total of 1229 studies were identified, 38 of which met the final inclusion criteria (37 retrospective, one case-control). Rates of postoperative VTE ranged between 0.6% and 8.9%. Patient-specific risk factors for postoperative VTE included ulcerative colitis, increased age and obesity. Surgery-specific risk factors for postoperative VTE included open surgery, emergent surgery and ileostomy creation. Patients with IBD were more frequently at increased risk in the included studies for postoperative VTE than patients with colorectal cancer. The risk of bias assessment demonstrated low risk of bias in patient selection and comparability, with variable risk of bias in reported outcomes. CONCLUSION There is a lack of evidence regarding the use of extended pharmacological thromboprophylaxis in patients with IBD following colorectal surgery. As these patients are at heightened risk of postoperative VTE, future study and consideration of the use of extended pharmacological thromboprophylaxis is warranted.
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Affiliation(s)
- T McKechnie
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J E Springer
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - P L Gross
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - S Forbes
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - C Eskicioglu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Li YD, Li HD, Zhang SX. Effect of thromboprophylaxis on the incidence of venous thromboembolism in surgical patients with colorectal cancer: a meta-analysis. INT ANGIOL 2020; 39:353-360. [PMID: 32286764 DOI: 10.23736/s0392-9590.20.04321-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION This study evaluates the role of thromboprophylaxis in venous thromboembolism (VTE) incidence in colorectal cancer (CRC) surgical patients. EVIDENCE ACQUISITION Literature search was conducted in electronic databases and studies (randomized controlled trials, or prospective/retrospective cohorts) were selected if they reported the incidence of VTE in CRC patients who underwent any type of open or laparoscopic surgery. Random-effects meta-analyses were performed to obtain pooled incidence estimates; or odds ratios (OR) of incidence between prophylaxis and no-prophylaxis groups; or between VTE and non-VTE patients to identify risk factors. EVIDENCE SYNTHESIS Twenty-four studies (804,003 patients) were included. Prophylaxis was performed mainly with low molecular weight heparins. Odds of VTE were significantly lower in prophylactic than in non-prophylactic patients (OR 0.42 [95% CI: 0.28, 0.63]; P<0.00001). Incidence of radiological and symptomatic VTE in patients with prophylaxis was 9.7% [95% CI: 8.6, 10.8] and 1.3% [95% CI: 0.7, 2.0] respectively. Odds of bleeding were higher in patients with prophylaxis (OR: 3.37 [95% CI: 1.05, 10.8]; P=0.04). Incidence of bleeding in patients with and without prophylaxis was 4.3% [95% CI: 3.2, 5.4] and 1.2% [95% CI: 0.02, 2.4] respectively. Operative time, anesthesia duration, and hospital stay were longer in patients with VTE. Obesity, disseminated cancer, chemotherapy, steroid use, emergency case status, advanced stage cancer, hypoalbuminemia, postoperative infection/sepsis, and history of VTE are identified as important risk factors for VTE incidence. CONCLUSIONS Thromboprophylaxis reduces the incidence of VTE in CRC surgical patients but may increase the chances of bleeding. Several risk factors can influence VTE incidence.
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Affiliation(s)
- Yu-Dong Li
- Department of Proctology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Hai-Dong Li
- Department of Andrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shu-Xin Zhang
- Department of Proctology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China -
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Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events. WORLD JOURNAL OF PEDIATRIC SURGERY 2020; 3:e000084. [DOI: 10.1136/wjps-2019-000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
BackgroundAlthough less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery.MethodsUsing data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated.ResultsOf 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16–18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001).ConclusionIn a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.
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Do Patients With Inflammatory Bowel Disease Have a Higher Postoperative Risk of Venous Thromboembolism or Do They Undergo More High-risk Operations? Ann Surg 2020; 271:325-331. [DOI: 10.1097/sla.0000000000003017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Prospective Study of Doppler Ultrasound Surveillance for Deep Venous Thromboses in 1000 Plastic Surgery Outpatients. Plast Reconstr Surg 2020; 145:85-96. [DOI: 10.1097/prs.0000000000006343] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nemeth B, Lijfering WM, Nelissen RGHH, Schipper IB, Rosendaal FR, le Cessie S, Cannegieter SC. Risk and Risk Factors Associated With Recurrent Venous Thromboembolism Following Surgery in Patients With History of Venous Thromboembolism. JAMA Netw Open 2019; 2:e193690. [PMID: 31074822 PMCID: PMC6512304 DOI: 10.1001/jamanetworkopen.2019.3690] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The size of the risk of recurrent venous thromboembolism (VTE) after surgery in patients with a history of VTE is not well known. OBJECTIVES To estimate the risk of and to identify the factors associated with recurrent VTE in patients undergoing surgery who have a history of VTE. DESIGN, SETTING, AND PARTICIPANTS This population-based, follow-up cohort study includes patients with VTE who participated in the Multiple Environment and Genetic Assessment (MEGA) study. Original data were collected from March 1999 to April 2010. Data analysis began in June 1999 and ended in April 2010. EXPOSURES Surgery following a first VTE. MAIN OUTCOMES AND MEASUREMENTS Kaplan-Meier analyses were used to estimate cumulative incidences of recurrent VTE. Cox regression with a time-dependent covariate (surgery) was used to calculate the hazard ratio (HR) for developing recurrent VTE after surgery compared with no surgery. RESULTS Overall, 3741 patients (mean [SD] age, 48.4 [12.8] years; 2020 [54.0%] women) with a history of VTE were included in the analysis, amounting to 18 899 person-years, with a median (interquartile range) follow-up of 5.7 (3.0-7.2) years. Of the 3741 patients, 580 (15.5%) underwent surgery and 601 (16.1%) developed a recurrent thrombotic event. The 1-month cumulative incidence of recurrent VTE for all surgery types was 2.1% (95% CI, 1.2%-3.6%), which increased to 3.3% (95% CI, 2.1%-5.1%) at 3 months and 4.6% (95% CI, 3.1%-6.6%) at 6 months. At 6 months, risk of recurrent VTE ranged from 2.3% to 9.3%, depending on surgery type. In addition to surgery type, factor V Leiden mutation (HR, 3.4; 95% CI, 1.6-7.4) and male sex (HR, 2.7; 95% CI, 1.3-5.8) were associated with increased risk of recurrent VTE. CONCLUSIONS AND RELEVANCE Surgery was associated with an increased risk of recurrent VTE in patients with a history of VTE; risk remained high for up to 6 months after the procedure. This study suggests that high-risk individuals may be identified based on surgery type, sex, and the presence of factor V Leiden mutation. These findings stress the need for revision of the current thromboprophylactic approach to prevent recurrence in these patients.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M. Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob G. H. H. Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Inger B. Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Medical Statistics, Department of Biomedical Datascience, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Matsuoka Y, Morimatsu H. Incidence Rates of Postoperative Pulmonary Embolisms in Symptomatic and Asymptomatic Patients, Detected by Diagnostic Images ― A Single-Center Retrospective Study ―. Circ J 2019; 83:432-440. [DOI: 10.1253/circj.cj-18-0729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshikazu Matsuoka
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Emoto S, Nozawa H, Kawai K, Hata K, Tanaka T, Shuno Y, Nishikawa T, Sasaki K, Kaneko M, Hiyoshi M, Murono K, Ishihara S. Venous thromboembolism in colorectal surgery: Incidence, risk factors, and prophylaxis. Asian J Surg 2019; 42:863-873. [PMID: 30683604 DOI: 10.1016/j.asjsur.2018.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023] Open
Abstract
Colorectal surgery is associated with a high risk of perioperative venous thromboembolism (VTE), and this risk is especially high following colorectal cancer resection and surgery for inflammatory bowel disease. Previous analyses of large databases have reported the incidence of postoperative VTE in this population to be approximately 1.1%-2.5%. Therefore, to minimize this risk, patients should be offered appropriate prophylaxis, which may involve a combination of mechanical and pharmacologic prophylaxis with low-dose unfractionated heparin or low molecular weight heparin as recommended by several guidelines. Prior to initiation of treatment, appropriate risk stratification should be performed according to the patients' basic and disease-related as well as procedure-related risk factors, and post-operative factors. Furthermore, a risk-benefit calculation that takes into account patients' VTE and bleeding risk should be performed prior to starting pharmacologic prophylaxis and to help determine the duration of treatment.
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Affiliation(s)
- Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Yasutaka Shuno
- Department of Surgical Oncology, The University of Tokyo, Japan
| | | | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Masaya Hiyoshi
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Japan
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Simianu VV, Kumar AS. Surgical Care and Outcomes Assessment Program (SCOAP): A Nuanced, Flexible Platform for Colorectal Surgical Research. Clin Colon Rectal Surg 2019; 32:25-32. [PMID: 30647543 DOI: 10.1055/s-0038-1673351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The Surgical Care and Outcomes Assessment Program (SCOAP) is a surgeon-led quality improvement (QI) initiative developed in Washington State to track and reduce variability in surgical care. It has developed into a collaboration of over two-thirds of the hospitals in the state, who share data and receive regular benchmarking reports. Data are abstracted at each site by trained abstractors. While there has some overlap with other national QI databases, the data captured by SCOAP has clinical nuances that make it pragmatic for studying surgical care. We review the unique properties of SCOAP and offer some examples of its novel applications.
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Affiliation(s)
- Vlad V Simianu
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
| | - Anjali S Kumar
- Elson S. Floyd College of Medicine, Washington State University, Everett, Spokane, Tri-Cities, and Vancouver, Washington
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Alhassan N, Trepanier M, Sabapathy C, Chaudhury P, Liberman AS, Charlebois P, Stein BL, Lee L. Risk factors for post-discharge venous thromboembolism in patients undergoing colorectal resection: a NSQIP analysis. Tech Coloproctol 2018; 22:955-964. [PMID: 30569263 DOI: 10.1007/s10151-018-1909-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/12/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- N Alhassan
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - M Trepanier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - C Sabapathy
- Division of Hematology and Oncology, Department of Pediatrics, McGill University Health Centre, Montreal, Canada
| | - P Chaudhury
- Department of Surgery, McGill University Health Centre, McGill University Health Centre, Montreal, Canada
| | - A S Liberman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Department of Surgery, McGill University Health Centre, McGill University Health Centre, Montreal, Canada
| | - P Charlebois
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Department of Surgery, McGill University Health Centre, McGill University Health Centre, Montreal, Canada
| | - B L Stein
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Department of Surgery, McGill University Health Centre, McGill University Health Centre, Montreal, Canada
| | - L Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada. .,Department of Surgery, McGill University Health Centre, McGill University Health Centre, Montreal, Canada.
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Li M, Guo Q, Hu W. Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis. Thromb Res 2018; 173:48-56. [PMID: 30471508 DOI: 10.1016/j.thromres.2018.11.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/06/2018] [Accepted: 11/14/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery. METHODS We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE. RESULTS Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1-2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9-18.2) and lung cancer (8.1%, 95% CI 3.7-12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40-0.53; I2 = 93.8%), radiation (OR 1.29, 95% CI 1.03-1.62; I2 = 34.6%), transfusion (OR 1.96, 95% CI 1.48-2.59; I2 = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07-1.16; I2 = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07-30.56; I2 = 92.0%). CONCLUSIONS The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.
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Affiliation(s)
- Mao Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qiang Guo
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Weiming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
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Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery. Dis Colon Rectum 2018; 61:1306-1315. [PMID: 30239396 DOI: 10.1097/dcr.0000000000001213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy. OBJECTIVE This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications. DESIGN AND SETTING This is a retrospective cross-sectional study conducted at a single quaternary referral center. PATIENTS Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included. MAIN OUTCOME MEASURES The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism. RESULTS One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38-3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67-5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37-6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47-4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04-4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11-49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications. LIMITATIONS This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period. CONCLUSIONS One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. "High-risk" patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these "high-risk" patients. See Video Abstract at http://links.lww.com/DCR/A747.
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Extended Venous Thromboembolism Prophylaxis After Elective Surgery for IBD Patients: Nomogram-Based Risk Assessment and Prediction from Nationwide Cohort. Dis Colon Rectum 2018; 61:1170-1179. [PMID: 30192325 DOI: 10.1097/dcr.0000000000001189] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Identification of risk factors for postoperative venous thromboembolism is an important step to reduce the morbidity associated with this potentially preventable complication after elective surgery for patients with IBD. OBJECTIVE This study aimed to determine the risk factors for 30-day venous thromboembolism after abdominal surgery for patients with venous thromboembolism, identify potential indications for extended thromboprophylaxis, and develop a nomogram for prediction of risk. DESIGN This is a retrospective cohort study from a prospectively collected database. SETTING The American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 was used for data analysis. PATIENTS All patients with IBD undergoing elective abdominopelvic bowel surgery were included. MAIN OUTCOME MEASURES The primary outcomes were the incidence of in-hospital and postdischarge venous thromboembolism within 30 days of the index abdominopelvic surgery. RESULTS A total of 24,182 patients met the inclusion criteria. Thirty-day total and postdischarge rates of venous thromboembolism were 2.5% (n = 614) and 1% (n =252). Forty-one percent (252/614) of venous thromboembolism events occurred after hospital discharge. Univariate analysis assessed 37 variables for association with study outcomes. On multivariate logistic regression analysis, older age, steroid use, bleeding disorders, open surgery, hypertension, longer operative time, and preoperative hospitalization were associated with venous thromboembolism before discharge and also postoperative transfusion, steroid use, pelvic and enterocutaneous fistula surgery, and longer operative time were associated with venous thromboembolism after discharge. A nomogram was constructed for each outcome, translating multivariate model parameter estimates into a visual scoring system where the estimated probability of venous thromboembolism can be calculated. LIMITATIONS This study was limited by its retrospective nature and the limitations inherent to a database. CONCLUSION Given the higher risk of venous thromboembolism in patients with IBD after elective abdominopelvic surgery compared with other indications, an accurate prediction of venous thromboembolism before and after discharge using the proposed nomogram can facilitate decision making for individualized extended thromboprophylaxis in the preoperative setting as a screening tool. See Video Abstract at http://links.lww.com/DCR/A711.
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Ulrych J, Kvasnicka T, Fryba V, Komarc M, Malikova I, Brzezkova R, Kvasnicka Jr J, Krska Z, Briza J, Kvasnicka J. The impact of hereditary thrombophilia on the incidence of postoperative venous thromboembolism in colorectal cancer patients: a prospective cohort study. Eur Surg 2018. [DOI: 10.1007/s10353-018-0534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Saunders R, Comerota AJ, Ozols A, Torrejon Torres R, Ho KM. Intermittent pneumatic compression is a cost-effective method of orthopedic postsurgical venous thromboembolism prophylaxis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:231-241. [PMID: 29719413 PMCID: PMC5922246 DOI: 10.2147/ceor.s157306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a major complication after lower-limb arthroplasty that increases costs and reduces patient’s quality of life. Using anticoagulants for 10–35 days following arthroplasty is the standard prophylaxis, but its cost-effectiveness after accounting for bleeding complications remains unproven. Methods A comprehensive, clinical model of VTE was created using the incidences, clinical effects (including bleeding), and costs of VTE and prophylaxis from randomized controlled trials, meta-analyses, and large observational studies. Over 50 years, the total health care costs and clinical impact of three prophylaxis strategies, that are as follows, were compared: low-molecular-weight heparin (LMWH) alone, intermittent pneumatic compression (IPC), and IPC with LMWH (IPC+LMWH). The cost per VTE event that was avoided and cost per quality-adjusted life year (QALY) gained in both the US and Australian health care settings were calculated. Results For every 2,000 patients, the expected number of VTE and major bleeding events with LMWH were 151 and 6 in the USA and 160 and 46 in Australia, resulting in a mean of 11.3 and 9.1 QALYs per patient, respectively. IPC reduced the expected VTE events by 11 and 8 in the USA and Australia, respectively, compared to using LMWH alone. IPC reduced major bleeding events compared to LMWH, preventing 1 event in the US and 7 in Australia. IPC+LMWH only reduced VTE events. Neither intervention substantially impacted QALYs but both increased QALYs versus LMWH. IPC was cost-effective followed by IPC+LMWH. Conclusion IPC and IPC+LMWH are cost-effective versus LMWH after lower-limb arthroplasty in the USA and Australia. The choice between IPC and IPC+LMWH depends on expected bleeding risks.
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Affiliation(s)
| | | | | | | | - Kwok Ming Ho
- Royal Perth Hospital and School of Population Health, University of Western Australia, Perth, WA, Australia
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To What Extent Does Posthospital Discharge Chemoprophylaxis Prevent Venous Thromboembolism After Bariatric Surgery? Ann Surg 2018; 267:727-733. [PMID: 28475558 DOI: 10.1097/sla.0000000000002285] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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49
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Which Patients Require Extended Thromboprophylaxis After Colectomy? Modeling Risk and Assessing Indications for Post-discharge Pharmacoprophylaxis. World J Surg 2018; 42:2242-2251. [DOI: 10.1007/s00268-017-4447-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fleming F, Gaertner W, Ternent CA, Finlayson E, Herzig D, Paquette IM, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum 2018; 61:14-20. [PMID: 29219916 DOI: 10.1097/dcr.0000000000000982] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Fergal Fleming
- Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons
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