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

Minimally invasive pancreatoduodenectomy is associated with a higher incidence of postoperative venous thromboembolism when compared to the open approach: A systematic review and meta-analysis

BACKGROUND

Despite the increased use of minimally invasive approaches for pancreatoduodenectomy (PD), the association between surgical approach and venous thromboembolism (VTE) risk is still unknown. This study aims to compare VTE rates following open (OPD) and minimally invasive pancreatoduodenectomy (MIPD).

METHOD

MEDLINE, Web of Sciences and EMBASE databases were searched to identify eligible studies. Studies were considered suitable if the incidence of postoperative VTE in open and minimally invasive (laparoscopic or robotic) pancreatic surgery was reported. The review was conducted following the PRISMA guidelines.

RESULTS

Five studies including 12 984 patients met the inclusion criteria and were considered for meta-analysis. A total of 11 060 patients underwent OPD and 1924 MIPD. Overall, patients who underwent OPD had a lower rate of VTE compared to MIPD (3.6 % vs 4.6 %, OR (95 % CI) = 0.66 (0.52-0.85), p < 0.001). Subgroup analysis showed similar results for pulmonary embolism (PE) (1.1 % in OPD vs 1.9 % in MIPD, OR (95 % CI) = 0.54 (0.36-0.80), p 0.002) and deep venous thrombosis (DVT) (1.3 % in OPD vs 3.1 % in MIPD, OR (95 % CI) = 0.48 (0.29-0.79), p 0.004).

CONCLUSION

Patients who undergo minimally invasive pancreatoduodenectomy have a higher incidence of postoperative VTE when compared to open pancreatoduodenectomy.

Biosimilar versus branded enoxaparin to prevent postoperative venous thromboembolism after surgery for digestive tract cancer: Randomized trial

Cancer and/or major surgery are two factors that predispose to post-operative thrombosis. The annual incidence of venous thromboembolic disease (VTED) in cancer patients was estimated at 0.5%-20%. Surgery increases the risk of VTED by 29% in the absence of thromboprophylaxis. Enoxaparin is a low molecular weight heparin that is safe and effective. Branded Enoxaparin and biosimilar Enoxaparin are two enoxaparin treatments. This study aimed to compare Branded Enoxaparin with biosimilar Enoxaparin in patients operated on for digestive cancer regarding the prevention of postoperative thrombosis event, to compare the tolerance of the two treatments and to identify independent predictive factors of thromboembolic incident. A randomized controlled trial conducted in a single-centre, surgical department B of Charles Nicolle Hospital, over a 5-year period from October 12th, 2015, to July 08th, 2020. We included all patients over 18 who had cancer of the digestive tract newly diagnosed, operable and whatever its nature, site, or stage, operated on in emergency or elective surgery. The primary endpoint was any asymptomatic thromboembolic event, demonstrated by systematic US Doppler of the lower limbs on postoperative day 7 to day 10. The sonographer was unaware of the prescribed treatment (Branded Enoxaparin [BE] or biosimilar Enoxaparin [BSE]). Of one hundred sixty-eight enrolled patients, six patients (4.1%) had subclinical venous thrombosis. Among those who had subclinical thrombosis, four patients (5.6%) were in the Branded Enoxaparin group and two patients (2.7%) in the Biosimilar Enoxaparin group without statistically significant difference (p = 0.435). Analysis of the difference in means using Student's t test demonstrated the equivalence of the two treatments. Our study allowed us to conclude that there was no statistically significant difference between Branded Enoxaparin and Biosimilar Enoxaparin regarding the occurrence of thromboembolic accidents postoperatively. BE and BSE are equivalent. Trial registration. Trial registration: The trial was registered on CLINICALTRIALS.GOV under the number NCT02444572.

The Journey Through the Pathogenesis and Treatment of Venous Thromboembolism in Inflammatory Bowel Diseases: A Narrative Review

Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders of the gastrointestinal tract including Crohn's disease and ulcerative colitis, which may result in several extraintestinal complications (∼20-30% of cases), such as increased risk of venous thromboembolism (VTE). The main pathophysiological mechanism of VTE is an inflammation-induced hypercoagulable state, and recent data have shown that endothelial dysregulation due to gut and systemic inflammation may also lead to a prothrombotic state. Several prothrombotic alterations have been described, such as the activation of the coagulation system, platelet abnormalities, and dysregulation of fibrinolysis. Furthermore, the dysregulation of the gut microbiome seems to play a vital role in increasing systemic inflammation and thus inducing a procoagulant state. Our review aims to examine the main correlations between IBD and VTE, the underlying pathophysiology, and current therapeutic options.

Risk of Postoperative Venous Thromboembolism After Benign Colorectal Surgery: Systematic Review and Meta-analysis

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.

Venous thromboembolism following colectomy for diverticular disease: an English population-based cohort study

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Are IBD Patients Underscored when Determining Postoperative VTE Risk?

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.

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

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.

The Duration and Magnitude of Postdischarge Venous Thromboembolism Following Colectomy

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.

Venous thromboembolism in chronic gastrointestinal disorders

INTRODUCTION

Chronic gastrointestinal disorders (including autoimmune gastritis, celiac disease, inflammatory bowel disease, and diverticular disease) are highly prevalent disorders, that may be associated with unpredictable, life-threatening complications, such as thromboembolic events. Venous thromboembolism (VTE) is one of the major causes of morbidity and mortality worldwide. Several conditions, including cancer, major trauma, surgery, prolonged immobilization, are well-established risk factors for VTE. Over the past decade, chronic inflammation has also been identified as an independent risk factor for VTE due to the prothrombotic effects of inflammatory cytokines and oxidative stress on the coagulation cascade. Other several mechanisms were shown to be associated with a higher incidence of VTE in patients with gastrointestinal disorders.

AREAS COVERED

We critically discuss the latest insights into the mechanisms responsible for thromboembolic manifestations in chronic gastrointestinal disorders, also focusing on the recognition of risk factors and treatment.

EXPERT OPINION

The occurrence of thrombotic complications is underestimated in patients with chronic gastrointestinal disorders. Identifying potential risk factors and concomitant predisposing conditions and to prevent VTE and guide treatment require a multidisciplinary approach, and this is critically important for clinicians, in order to provide the best care for such patients.

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

BACKGROUND

The use of minimally invasive approaches to hepatectomy has increased in recent years, but the risk of postoperative venous thromboembolism (VTE) is undefined. We aimed to compare VTE rates after open hepatectomy and minimally invasive hepatectomy using an administrative dataset.

STUDY DESIGN

Patients with primary or metastatic liver tumors were identified in the National Surgical Quality Improvement Program-targeted hepatectomy database (2016-2018). VTE was compared between patients who underwent open or minimally invasive hepatectomy after a propensity score matching of 1:1 for demographics, comorbidities, and operative factors.

RESULTS

A total of 6935 patients underwent open hepatectomy and 2237 underwent minimally invasive hepatectomy. After matching, there were 1968 patients per group without differences in demographics, comorbidities, or operative variables. Prior to matching, the VTE rate was higher among patients who underwent open hepatectomy (2.8% vs. 1.1%, p < 0.001), and open hepatectomy was independently associated with VTE (OR = 1.90, p = 0.006). The VTE rate remained higher among open hepatectomy compared to minimally invasive hepatectomy after matching (2.4% vs. 1.1%, p = 0.003). Open hepatectomy was associated with a higher VTE rate in patients undergoing minor (1.9 vs. 1.0%, p = 0.028) and major hepatectomy (5.0 vs. 1.9%, p = 0.045).

CONCLUSION

Patients who undergo an open hepatectomy for malignancy have a higher incidence of postoperative VTE compared to minimally invasive hepatectomy for both minor and major hepatectomy.

Venous and arterial thromboembolism in patients with inflammatory bowel diseases

The risk of thromboembolism (TE) is increased in patients with inflammatory bowel disease (IBD), mainly due to an increased risk of venous TE (VTE). The risk of arterial TE (ATE) is less pronounced, but an increased risk of cardiovascular diseases needs to be addressed in IBD patients. IBD predisposes to arterial and venous thrombosis through similar prothrombotic mechanisms, including triggering activation of coagulation, in part mediated by impairment of the intestinal barrier and released bacterial components. VTE in IBD has clinical specificities, i.e., an earlier first episode in life, high rates during both active and remission stages, higher recurrence rates, and poor prognosis. The increased likelihood of VTE in IBD patients may be related to surgery, the use of medications such as corticosteroids or tofacitinib, whereas infliximab is antithrombotic. Long-term complications of VTE can include post-thrombotic syndrome and high recurrence rate during post-hospital discharge. A global clot lysis assay may be useful in identifying patients with IBD who are at risk for TE. Many VTEs occur in IBD outpatients; therefore, outpatient prophylaxis in high-risk patients is recommended. It is crucial to continue focusing on prevention and adequate treatment of VTE in patients with IBD.

Systemic Corticosteroids and the Risk of Venous Thromboembolism in Patients with Severe COPD: A Nationwide Study of 30,473 Outpatients

Due to frequent exacerbations, many patients with chronic obstructive pulmonary disease (COPD) are exposed to oral corticosteroids (OCS), which may be thrombogenic. We evaluated the risk of hospitalisation with venous thromboembolism (VTE) and death in patients with acute exacerbation of COPD (AECOPD) treated with long and short OCS regimens. In this nationwide cohort study of 30,473 COPD outpatients treated for AECOPD, we compared the risk of VTE hospitalisation and all-cause mortality within 6 months in OCS dose of >250 mg vs. ≤250 mg. A multivariable Cox proportional hazard regression was used to estimate the risk. The incidence of VTE hospitalisations was 0.23%. A long OCS treatment course was associated with an increased risk of VTE compared to a short course (hazard ratio (HR) 1.69, [95% confidence interval (CI) 1.05 to 2.72], p < 0.031). A higher risk of all-cause mortality was seen in the group of COPD patients treated with a long OCS course (HR 1.71, [95% CI 1.63 to 1.79], p < 0.0001). The risk of reported VTE hospitalisation was higher among AECOPD patients treated with long courses of OCS, but the absolute risk was low, suggesting under-reporting of the condition.

Extended thromboprophylaxis following major abdominal/pelvic cancer-related surgery: A systematic review and meta-analysis of the literature

BACKGROUND

Postoperative venous thromboembolism (VTE) is a significant source of morbidity and mortality in cancer patients undergoing major abdominopelvic surgery. Many guidelines recommend the use of extended duration postoperative low molecular weight heparin (LMWH) thromboprophylaxis, although the evidence for its overall safety and efficacy is unclear.

AIMS

We sought to assess the 30-day postoperative rates of VTE and bleeding complications following major abdominopelvic cancer surgery and to explore the potential risks and benefits of extended duration thromboprophylaxis with LMWH in such setting.

METHODS

A systematic search of the literature was conducted. Observational studies and RCTs of adult patients that underwent abdominopelvic cancer surgery were included. Pooled proportions for the outcome measures and pooled relative risks for the extended duration thromboprophylaxis analyses were generated.

RESULTS

A total of 68 studies (1,631,118 patients) were included in the analysis. The 30-day postoperative rate of VTE was 1.7% (95%CI: 1.5 to 1.9, I² = 98%). The postoperative rate of clinically-relevant bleeding complications was 3.5% (95%CI: 1.6 to 6.1, I² = 99%). Extended duration thromboprophylaxis was associated with a significant reduction in the incidence of clinical VTE (1.0% vs 2.1%; Risk ratio (RR) 0.48, 95%CI: 0.31 to 0.74; I² = 0), without a significant increase in clinically-relevant bleeding (4.0% vs. 4.9%; RR 1.0, 95%CI: 0.66 to 1.5, I² = 0).

CONCLUSIONS

The overall risk of symptomatic VTE within 30 days of surgery was relatively low. Extended LMWH thromboprophylaxis following major abdominopelvic cancer surgery was associated with a reduced incidence of clinical VTE without an increase in clinically-relevant bleeding.

Risk of Postoperative Venous Thromboembolism After Surgery for Colorectal Malignancy: A Systematic Review and Meta-analysis

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.

Prevalence and Effect of Genetic Risk of Thromboembolic Disease in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The largest cause of mortality in patients with inflammatory bowel disease (IBD) remains thromboembolic disease (TED). Recent reports have demonstrated that both monogenic and polygenic factors contribute to TED and 10% of healthy subjects are genetically at high risk for TED. Our aim was to utilize whole-exome sequencing and genome-wide genotyping to determine the proportion of IBD patients genetically at risk for TED and investigate the effect of genetic risk of TED in IBD.

METHODS

The TED polygenic risk score was calculated from genome-wide genotyping. Thrombophilia pathogenic variants were extracted from whole-exome sequencing. In total, 792 IBD patients had both whole-exome sequencing and genotyping data. We defined patients at genetically high risk for TED if they had a high TED polygenic risk score or carried at least 1 thrombophilia pathogenic variant.

RESULTS

We identified 122 of 792 IBD patients (15.4%) as genetically high risk for TED. Among 715 of 792 subjects whose documented TED status were available, 63 of the 715 patients (8.8%) had TED events. Genetic TED risk was significantly associated with increased TED event (odds ratio, 2.5; P = .0036). In addition, we confirmed an additive effect of monogenic and polygenic risk on TED (P = .0048). Patients with high TED genetic risk more frequently had thrombosis at multiple sites (78% vs 42%, odds ratio, 3.96; P = .048).

CONCLUSIONS

Genetic risk (both poly- and monogenic) was significantly associated with TED history. Our results suggest that genetic traits identify approximately 1 in 7 patients with IBD who will experience 2.5-fold or greater risk for TED.

Patient's compliance is a contributor to failure of extended antithrombotic prophylaxis in colorectal surgery: prospective cohort study

BACKGROUND

Venous thromboembolic events (VTE) continue to be a major source of morbidity following colorectal surgery. Selective extended VTE prophylaxis for high-risk patients is recommended; however, provider compliance is low. The purpose of this study is to evaluate whether the "global" extended use of enoxaparin in all colorectal patients is feasible and safe.

METHODS

This is a prospective study conducted at a tertiary care center. All Patients undergoing elective colorectal procedures from November 1, 2017 to October 31, 2018 were discharged on 30 days of enoxaparin. Safety of use and patient compliance were examined.

RESULTS

Total of 270 patients received extended prophylaxis during the study period (100% of intended patients) with five VTE recorded (1.85%). There was no significant difference in rates of VTE or complications when compared to years of selective prophylaxis (1.26% for 2016, 2.32% for 2017). Only 64% of patients reported full compliance.

CONCLUSION

Global use of extended enoxaparin prophylaxis is safe, but does not decrease rates of VTE when compared to selective use. Patient's non-adherence is likely a significant contributing factor.

Timing and characteristics of venous thromboembolism after noncancer surgery

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality postoperatively. The use of pharmacologic prophylaxis is effective in reducing the incidence of VTE. However, the prophylaxis is often discontinued at hospital discharge, especially for those with benign disease. The implications of this practice are not known. We assessed the data from a large, ongoing registry regarding the time course of VTE and outcomes after noncancer surgery.

METHODS

We analyzed the RIETE (Computerized Registry on Venous Thromboembolism) registry, which includes data from consecutive patients with symptomatic confirmed VTE. In the present study, we focused on general surgical patients who had developed symptomatic postoperative VTE in the first 8 weeks after noncancer surgery. The main objective was to assess the interval between surgery and the occurrence of VTE. Additional variables included the clinical presentation associated with the event, the use of thrombosis prophylaxis, and unfavorable outcomes.

RESULTS

The data from 3296 patients were analyzed. The median time from surgery to the detection of VTE was 16 days (interquartile range, 8-30 days). Of the VTE events, 77% were detected after the first postoperative week and 27% after 4 weeks. Overall, 43.9% of the patients with VTE had received pharmacologic prophylaxis after surgery for a median of 8 days (interquartile range, 5-14 days), and three quarters of the VTE events were detected after pharmacologic prophylaxis had been discontinued. Overall, 54% of the patients with VTE had presented with pulmonary embolism. For 15% of the patients, the clinical outcome was unfavorable, including 4% who had died within 90 days.

CONCLUSIONS

The risk of VTE after noncancer general surgery remains high for ≤2 months. More than one half of the patients had presented with symptomatic PE as the VTE event, and 15% had had unfavorable outcomes. Only 44% of these patients had received pharmacologic prophylaxis for around 1 week.

The incidence of venous thromboembolism in children following colorectal resection for inflammatory bowel disease: A multi-center study

BACKGROUND/PURPOSE

Children with inflammatory bowel disease (IBD) have increased risk for venous thromboembolism (VTE). We sought to determine incidence and risk factors for postoperative VTE in a multicenter cohort of pediatric patients undergoing colorectal resection for IBD.

METHODS

Retrospective review of children ≤18 years who underwent colorectal resection for IBD from 2010 to 2016 was performed at four children's hospitals. Primary outcome was VTE that occurred between surgery and last follow-up. Factors associated with VTE were determined using univariable and multivariable analyses.

RESULTS

Two hundred seventy-six patients were included with median age 15 years [13,17]. Forty-two children (15%) received perioperative VTE chemoprophylaxis, and 88 (32%) received mechanical prophylaxis. DVT occurred in 12 patients (4.3%) at a median of 14 days postoperatively [8,147]. Most were portomesenteric (n = 9, 75%) with the remaining catheter-associated DVTs in extremities (n = 3, 25%). There was no association with chemoprophylaxis (p > 0.99). On Cox regression, emergent procedure [HR 18.8, 95%CI: 3.18-111], perioperative plasma transfusion [HR 25.1, 95%CI: 2.4-259], and postoperative infectious complication [HR 10.5, 95%CI: 2.63-41.8] remained predictive of DVT.

CONCLUSION

Less than 5% of pediatric IBD patients developed postoperative VTE. Chemoprophylaxis was not protective but rarely used. Patients with risk factors identified in this study should be monitored or given prophylaxis for VTE.

LEVEL OF EVIDENCE

Treatment Study, Level III.

A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery

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.

Inflammatory Bowel Disease Therapy and Venous Thromboembolism

Purpose of review

To explore the relationship between IBD (inflammatory bowel diseases) therapy and VTE (venous thromboembolism) risk, as well as the safety, barriers, and utility of VTE prophylaxis.

Recent findings

In 2019, the Food and Drug Administration (FDA) issued a black box warning concerning the use of tofacitinib among ulcerative colitis (UC) patients with a post hoc analysis revealing that all patients had additional risk factors for VTE. Additionally, although IBD patients experiencing a disease flare often present with hematochezia, these patients are less likely to receive VTE prophylaxis, despite data showing that pharmacologic prophylaxis has not been associated with clinically significant signs of bleeding.

Summary

Among IBD patients, corticosteroid use has been associated with an increased risk of VTE, whereas anti-TNF therapy does not appear to increase this risk. High-dose tofacitinib has also been shown to increase the likelihood of VTE in patients with additional risk factors. In order to prevent future VTE events, pharmacologic thromboprophylaxis should be emphasized, particularly in hospitalized IBD patients, with recent data suggesting that a select population at risk may benefit from continued prophylaxis.

Venous thromboembolism in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are at an increased risk for venous thromboembolism (VTE). VTE events carry significant morbidity and mortality, and have been associated with worse outcomes in patients with IBD. Studies have suggested that the hypercoagulable nature of the disease stems from a complex interplay of systems that include the coagulation cascade, natural coagulation inhibitors, fibrinolytic system, endothelium, immune system, and platelets. Additionally, clinical factors that increase the likelihood of a VTE event among IBD patients include older age (though some studies suggest younger patients have a higher relative risk of VTE, the incidence in this population is much lower as compared to the older IBD patient population), pregnancy, active disease, more extensive disease, hospitalization, the use of certain medications such as corticosteroids or tofacitinb, and IBD-related surgeries. Despite the increased risk of VTE among IBD patients and the safety of pharmacologic prophylaxis, adherence rates among hospitalized IBD patients appear to be low. Furthermore, recent data suggests that there is a population of high risk IBD patients who may benefit from post-discharge prophylaxis. This review will provide an overview of patient specific factors that affect VTE risk, elucidate reasons for lack of VTE prophylaxis among hospitalized IBD patients, and focus on recent data describing those at highest risk for recurrent VTE post-hospital discharge.