Pre-, intra-, and/or postoperative arterial and venous thromboembolism prophylaxis for breast surgery: Systematic review and meta-analysis

From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery

Thromboembolism is a feared complication in plastic surgery and is linked to higher rates of morbidity and mortality. Despite extensive research, there is a lack of consistency between recommendations and clinical protocols to be implemented pre and post-surgery to reduce the incidence of thromboembolism. A systematic literature review was conducted using Pubmed and Scopus databases to determine the risk factors, screening methods, and existing treatment models for thromboembolism prevention. Articles in non-English languages were excluded. Analysis indicated that predominant risk factors include age (>35), elevated body mass index, coagulation disorders, smoking, estrogen therapies, genetic predisposition, vascular endothelium damage, stasis, and use of general anesthesia in patients with a history of cancer. Implementation of a proper prophylactic protocol is dependent on understanding the interplay between the aforementioned risk factors and the utilization of well-defined, evidence-based guidelines, such as the 2005 Caprini Risk Assessment Model and ultrasound surveillance. The literature review revealed that mechanical prophylaxis is the primary prevention method, followed by thromboprophylaxis for patients with higher Caprini scores. Plastic surgeons often underestimate the present risk stratification tools available for the prophylactic intervention of thromboembolism due to the fear of bleeding or hematoma complications postoperatively. In summary, this literature review emphasizes the importance of plastic surgeons selecting protocols that is inclusive of the patient's risk profile to yield a reduced risk of thromboembolism.

A UK consensus statement on thromboprophylaxis for autologous breast reconstruction ,

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base.

METHODS

Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached.

RESULTS

The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis.

CONCLUSION

To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

BACKGROUND

Abdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection.

METHODS

Retrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery.

RESULTS

A total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7-27) versus 7 (5-11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05-1.93, p = 0.038) and independently predicted its occurrence.

CONCLUSIONS

The risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

Application of evidence-based nursing in prevention of postoperative complications of breast augmentation

OBJECTIVE

To study the application of evidence-based nursing in prosthesis postoperative complications.

METHODS

A total of 78 cases of patients who underwent prosthetic breast augmentation were selected from July 2017 to July 2019. All the patients were divided into control group and study group according to the random number table method. The patients in the control group received routine nursing interventions, and the patients in the study group performed evidence-based nursing interventions based on the control group's care. The mental health, external esthetic effects, and complications of the two groups were observed and compared.

RESULTS

Before the implementation of nursing intervention, there was no significant difference in mental health indicators (SAS, SDS) between the two groups (p > 0.05). After the intervention, the SAS and SDS scores of the two groups were lower than before the intervention, and the study group was lower than the control group, and the difference was statistically significant (p < 0.05); before the implementation of nursing intervention, there was no significant difference in the scores of HADS-A and HADS-D between the two groups (p > 0.05). After the intervention, the scores of HADS-A and HADS-D of the two groups were lower than those before the intervention, and the scores of the study group were lower than those of the control group, and the difference was statistically significant (p < 0.05); 94.9% (37 / 39) was better than 71. 8% (28 / 39) in the control group. The difference was statistically significant (p < 0.05), and the total incidence of postoperative complications in the study group was 5.1% (2 / 39), which was lower than 15.4% (6 / 39) in the control group (p < 0.05).

CONCLUSION

Evidence-based nursing intervention is effective in preventing postoperative complications of silicone breast augmentation prosthesis. It can effectively reduce postoperative complications, improve external esthetic effects, and improve the level of mental health of patients. It is worthy of clinical promotion and application.

Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries

BACKGROUND

Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism.

METHODS

Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted.

RESULTS

A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk.

CONCLUSION

Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.