Risk factors associated with venous thromboembolism in 49,028 mastectomy patients

Risk of Bleeding Versus Venous Thromboembolism After Surgery for Breast Cancer: A National Surgical Quality Improvement Program Analysis

INTRODUCTION

Patients who undergo surgery for breast cancer are at risk for venous thromboembolism (VTE) and bleeding, which can lead to significant consequences on outcomes. This study examined factors related to VTE and bleeding risk in breast cancer surgery, with and without reconstruction. We also investigated the relationship between operative time and resident involvement on bleeding and VTE risk.

METHODS

Using the ACS-NSQIP database, patients who underwent mastectomy, implant, pedicled, or free flap reconstruction from 2005 to 2021 were identified. Resident involvement was available from 2007 to 2010. We fitted two logistic regressions to model the log odds of bleeding occurrence and VTE as linear functions of procedure type, controlling for age, body mass index, and comorbidities.

RESULTS

Implant reconstruction had significantly reduced 30-d incidence of bleeding, compared to those who underwent transverse rectus abdominus muscle flap (P < 0.001). Free flap was associated with a significant increase in bleeding but not VTE risk (P < 0.001; P = 0.132). Increase in operative time significantly increased the risk of bleeding and VTE (P < 0.001). For surgeries with resident involvement coded, there was no significantly increased risk of bleeding or VTE (P = 0.600; P = 0.766).

CONCLUSIONS

Implant reconstruction remains the procedure with the lowest risk of both bleeding and VTE. Free flap reconstruction did not show a significantly increased risk of VTE, potentially expanding reconstruction options for patients previously excluded from autologous reconstruction. Surgeons should be mindful of operative time, with re-evaluation of risk factors with each additional hour of surgery, irrespective of reconstruction type. Resident involvement in surgeries should continue to be encouraged by faculty.

The Risk of Deep Vein Thrombosis and Optimal Timing of Breast Cancer Surgery After COVID-19 Infection

PURPOSE

The aim of this study was to assess the risk of postoperative deep vein thrombosis (DVT) in breast cancer patients with coronavirus disease 2019 (COVID-19) to determine the optimal timing for surgery in the era of "post COVID-19 pandemic."

METHODS

This prospective study included breast cancer patients who contracted COVID-19 and underwent surgery from December 20th, 2022, to March 20th, 2023 (n = 577). A control group comprised patients who underwent surgery from May 1st, 2019, to October 1st, 2019 (n = 327) and had not contracted COVID-19 prior to surgery. Patients were categorized based on the timing of their surgery relative to their COVID-19 infection. Data were analyzed using logistic regression.

RESULTS

Patients with COVID-19 had a higher incidence of postoperative DVT compared to those without COVID-19 (3.64% vs. 1.21%). Multivariable logistic regression analysis indicated that the timing of surgery was significantly associated with the risk of DVT (odds ratio [OR], 2.795; 95% confidence interval [CI], 0.692-11.278; p = 0.024). Patients who underwent surgery within two weeks of COVID-19 infection experienced the highest DVT rates (OR, 10.556; 95% CI, 1.095-303.313; p = 0.003). However, the incidence decreased to 2.85% when surgery was delayed until two weeks or more after infection. The median follow-up period was 10 months, all patients with DVT after surgery were recovered without serious complications or death. There were no adverse effects on subsequent anti-tumor therapy.

CONCLUSION

Caution is advised when performing breast cancer surgery within two weeks after a COVID-19 infection. Although the risk of DVT remains somewhat elevated even after two weeks, surgery can be considered safe given the urgency of treatment, favorable complication outcomes, and lack of impact on subsequent adjuvant therapy.

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals.

METHODS

This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed.

RESULTS

Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE.

CONCLUSION

The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

Appraising the quality standard of clinical practice guidelines related to central venous catheter-related thrombosis prevention: a systematic review of clinical practice guidelines

OBJECTIVE

To evaluate the quality and analyse the content of clinical practice guidelines regarding central venous catheter-related thrombosis (CRT) to provide evidence for formulating an evidence-based practice protocol and a risk assessment scale to prevent it.

DESIGN

Scoring and analysis of the guidelines using the AGREE II and AGREE REX scales.

DATA SOURCES

Pubmed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and the Chinese Biomedical Literature, and the relevant websites of the guideline, were searched from 1 January 2017 to 26 March 2022.

ELIGIBILITY CRITERIA

Guidelines covering CRT treatment, prevention, or management were included from 1 January 2017 to 26 March 2022.

DATA EXTRACTION AND SYNTHESIS

Three independent reviewers systematically trained in using the AGREE II and AGREE REX scales were selected to evaluate these guidelines.

RESULTS

Nine guidelines were included, and the quality grade results showed that three were at A-level and six were at B-level. The included guidelines mainly recommended the prevention measure of central venous CRT from three aspects: risk screening, prevention strategies, and knowledge training, with a total of 22 suggestions being recommended.

CONCLUSION

The overall quality of the guidelines is high, but there are few preventive measures for central venous CRT involved in the guidelines. All preventive measures have yet to be systematically integrated and evaluated, and no risk assessment scale dedicated to this field has been recommended. Therefore, developing an evidence-based practice protocol and a risk assessment scale to prevent it is urgent.

Venous thromboembolism incidence in postoperative breast cancer patients

BACKGROUND

Venous Thromboembolism (VTE) is an important cause of morbidity in cancer patients. Breast cancer patients undergoing surgical treatment are at an increased risk of VTE. The aim of this study was to determine the frequency of VTE in patients who underwent surgery for the treatment of breast cancer and to identify the related risk factors.

METHODS

A historical cohort of patients at the São Paulo State Cancer Institute (ICESP) underwent surgery for breast cancer. The inclusion criteria covered patients with invasive breast cancer or ductal carcinoma in situ who had breast surgery anytime from January 2016 to December 2018.

RESULTS

Of the 1672 patients included in the study, 15 had a confirmed diagnosis of VTE (0.9%), and 3 of these had deep vein thrombosis (0.2%), and 12, had pulmonary thromboembolism (0.7%). Clinical and tumoral characteristics did not differ between the groups. The incidence of VTE was higher in patients who had undergone skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.032). Immediate reconstruction, particularly with abdominal-based flaps (4.7%), increased VTE events (p = 0.033). Median surgical time was higher in patients with VTE episodes (p = 0.027), and total hospital length of stay increased in days (6 days vs. 2 days, p = 0.001). Neoadjuvant chemotherapy and postoperative prophylaxis with Low Molecular Weight Heparin (LMWH) were associated with lower VTE rates (0.2% vs. 1.2%, p = 0.048 and 0.7% vs. 2.7%, p = 0.039; respectively) in these patients.

CONCLUSIONS

The incidence of VTE events in breast cancer patients who underwent surgery was 0.9%. Immediate reconstruction (especially with abdominal-based flaps), skin-sparing/nipple-sparing mastectomies, and longer surgeries were associated with increased risk. The LMWH postoperative prophylaxis reduced this risk.

Prolonged Venous Thromboembolism Prophylaxis May Not Be Necessary for DIEP Flap Breast Reconstruction: A Tertiary Center's 10-Year Experience

BACKGROUND

 Based on the 2005 Caprini Risk Assessment Model for venous thromboembolism, the American Society of Plastic Surgeons prevention guidelines would result in prolonged chemoprophylaxis (1 week or more) for the majority of patients undergoing deep inferior epigastric perforator flap breast reconstruction. We aim to assess the necessity of prolonged prophylaxis by describing our institutional experience in thromboembolism prevention and evaluating the incidence of symptomatic VTE in our patient cohort.

METHODS

 Women who underwent DIEP flap reconstruction from August 2011 to March 2020 at a tertiary care center were included. Charts were retrospectively reviewed for patient characteristics, VTE prophylaxis regimens, and development of deep vein thrombosis and pulmonary embolism within 60 days of surgery. Caprini scores were calculated for all patients.

RESULTS

 Out of the 249 patients included in the study, 245 patients received chemoprophylaxis only during hospitalization, while four patients additionally received anticoagulant for at least 2 weeks after discharge for prophylactic or therapeutic indications. The cohort's average Caprini score was 6.0, with 72.7% of scores between 3 and 6 and 26.5% at 7 or higher. One patient (0.4%), who scored a 7 and received prophylaxis only while hospitalized, developed deep vein thrombosis. There were no cases of pulmonary embolism. There was no significant difference in VTE rate between patients who received chemoprophylaxis consistent with ASPS guidelines and those who did not (p = 1.000).

CONCLUSION

 Despite our limited chemoprophylaxis use in DIEP flap patients, our VTE incidence is low. This current work suggests that the blanket application of prolonged prophylaxis is not warranted, and it further serves as impetus to re-evaluate the 2005 Caprini RAM in this patient population.

Incidence and Risk Factors for Venous Thromboembolism in Female Patients Undergoing Breast Surgery

Albeit it does not have the highest venous thromboembolism (VTE) incidence compared to other neoplasms, breast cancer contributes to many VTE events because it is the most diagnosed tumor in women. We aim to analyze the occurrence and timing of VTE during the follow-up of patients who underwent breast surgery, the possible correlated factors, and the overall survival. This retrospective study included all female patients diagnosed with mammary pathology and surgically treated in our clinic between January 2002 and January 2012. Of 5039 women who underwent breast surgery, 1056 were found to have no evidence of malignancy, whereas 3983 were diagnosed with breast cancer. VTE rate resulted significantly higher in patients with invasive breast cancer than in women with benign breast disease or carcinoma in situ. Invasive cancers other than lobular or ductal were associated with a higher VTE rate. In addition, chronic hypertension, high BMI, cancer type, and evidence of metastasis turned out to be the most significant risk factors for VTE in women who underwent breast surgery. Moreover, VTE occurrence significantly impacted survival in invasive breast cancer patients. Compared to women with benign mammary pathology, VTE prevalence in women with breast cancer is significantly higher. The knowledge about the risk factors of VTE could be helpful as prognostic information, but also to eventually target preventive treatment strategies for VTE, as far as the co-existence of invasive breast cancer and VTE has a significantly negative impact on survival.

Perioperative Risk Factors for Prolonged Blood Loss and Drainage Fluid Secretion after Breast Reconstruction

Background: Surgical breast reconstruction is an integral part of cancer treatment but must not compromise oncological safety. Patient-dependent risk factors (smoking, BMI, etc.) are said to influence perioperative outcomes and have often been investigated. Here, we analyzed independent perioperative risk factors for increased postoperative blood loss or drainage fluid volume loss and their possible impact. Methods: Patients undergoing breast reconstructions after breast cancer with either tissue expanders, definitive breast implants, or autologous breast reconstruction were analyzed. The collected data on patients’ characteristics, blood, and drainage fluid loss were correlated and statistically investigated. Results: Traditional patient-dependent risk factors did not influence blood loss or drainage volumes. On the contrary, patients with preoperative anemia had significantly higher drainage outputs compared to non-anemic patients (U = 2448.5; p = 0.0012). The administration of low molecular weight heparin showed a tendency of increased drainage output. Similar correlations could be seen in prolonged procedure time, all of which contributed to prolonged hospital stay (τb = 0.371; p < 0.00001). Conclusion: Preoperative anemia is one of the most critical factors influencing postoperative drainage fluid output. Previously assumed patient-dependent risk factors did not affect drainage output. Preoperative anemia must be monitored, and if possible, treated preoperatively to reduce postoperative morbidity.

Public awareness on cancer associated thrombosis (CAT) among the Greek population. First findings from the ROADMAP-CAT Awareness study

Background  Cancer-associated thrombosis (CAT) is the second cause of mortality after cancer itself. CAT is underestimated as a health challenge among oncologists, whereas the levels of awareness among patients and the public have not been systematically assessed and followed in the European Union countries.

Aim  The Prospective Risk Assessment and Management of Patient with CAT (ROADMAP-CAT) Awareness study is an investigator-initiated, descriptive and nonexperimental study with a cross-sectional design and it explores CAT risk awareness among cancer patients and the general public in Greece to provide an impetus for health policy interventions and a benchmark against which impact of any future interventions may be assessed.

Methods  A total of 1,003 participants aged above 18 years were contacted by phone after random selection from the national telephone catalogue. Participation was voluntary and completely anonymous, and a structured questionnaire was used to elicit responses. Data were analyzed using IBM SPSS version 25.

Results  Among respondents, almost one-third (32.3%) reported CAT awareness, while only one in five (21.7%) were aware of the signs and symptoms of venous thromboembolism (VTE). Among patients with a personal history of cancer or of VTE, 47 and 58%, respectively, were aware of CAT risk. Of those aware of the association, 35.2% identified their treating physician as the main source of information. The level of awareness did not significantly differ by responders' demographics.

Conclusion  The ROADMAP-CAT Awareness study revealed very low levels of awareness on CAT and VTE risk both among the general public and cancer patients in Greece. Awareness of the signs and symptoms of VTE was also particularly low. Treating physicians are not actively engaging in educating their patients about CAT. Public awareness of the increased risk of VTE among cancer patients is critical to prevent and diagnose the disease early. It is imperative that a structured campaign supports medical professionals to take the time to increase awareness and educate their patients on this matter if to improve morbidity and mortality of cancer patients.

Significant difference between coagulation parameters and clinicopathological characteristics in breast cancer

The purpose of this research is to investigate the correlation between coagulation parameters and survival on patients with breast cancer. A total of 244 patients with breast cancer and 84 patients with metastatic advanced breast cancer admitted to the Second Affiliated Hospital of Chongqing Medical University from January 2017 to February 2019 were selected as the research objects. Their age, tumor size, status of estrogen receptor and progesterone receptor status, status of Her-2 receptor and lymph node were evaluated. Additional 99 cases of benign breast tumors were selected as the control group. All patients were newly diagnosed. PTA, PT ratio, PT, APTT, APTT ratio, TT, TT ratio, PT-INR, FIB, and FDP were detected on all patients. There were significant differences in APTT, APTT ratio, FIB, TT, TT ratio, and FDP between breast cancer and benign tumor control group (P < 0.05). The changes of FIB were correlated with age (P = 0.007), PR status (P = 0.017), and Her-2 status (P = 0.008). The older the age, the higher the FIB level. The FIB level of Er negative state is higher than that of positive state, and the FIB level of PR negative state is also higher than that of positive state. Survival analysis showed that PR negative status, the elevated level of APTT, APTT ratio, TT increased, and TT ratio were the indicators affecting 3-year DFS of patients (P < 0.05). Multivariate COX regression analysis showed that APTT and TT were independent prognostic factors affecting 3 years DFS (P < 0.05). Blood hypercoagulable state in patients with breast cancer, abnormal coagulation system plays an important role in the progress of breast cancer.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Independent Predictors of Venous Thromboembolism in Patients Undergoing Reconstructive Breast Cancer Surgery

INTRODUCTION

Breast cancer is a hypercoagulable state and predisposes patients to venous thromboembolism (VTE). We sought to determine independent risk factors for VTE post-surgical treatment for breast cancer using a national risk adjusted database.

METHODS

Participant Use Data Files in the National Surgical Quality Improvement Program database from 2012 to 2016 were studied. Female patients with invasive and in situ breast cancer that underwent either mastectomy with immediate breast reconstruction, autologous or implant-based, or lumpectomy were identified with current procedural terminology and International Classification of Diseases-9 codes. Venous thromboembolism was defined as occurrence of deep vein thrombosis or pulmonary embolism. Non-VTE and VTE groups were compared and statistical differences were addressed through propensity score weighting. The balance of the model was checked with comparing standardized differences before and after weighting. Multivariate logistic regression was used to determine independent predictors of VTE.

RESULTS

A total of 137 449 procedures were identified. After applying exclusion criteria, 40 986 lumpectomies and 35 909 mastectomies remained for the analysis (n = 76 895). Venous thromboembolism was found in 172/76 895 patients (0.2%). In the weighted data set, mastectomy, BMI> 35 and length of stay >3 days were predictors of VTE. The greatest odds ratio (OR) was observed with mastectomy with immediate autologous breast reconstruction (OR = 8.792, P < .001; 95% CI: 3.618-21.367).

CONCLUSION

Autologous breast reconstruction was associated with highest risk of VTE. Hospital LOS >3 days, BMI >35, and general anesthesia also increase odds of developing VTE. These variables are predisposing factors that need to be considered in patients undergoing surgical treatment for breast cancer.

Overview of risk assessment models for venous thromboembolism in ambulatory patients with cancer

A B S T R A C T Important progress has been made in the development of risk assessment models (RAM) for the identification of outpatients on anticancer treatment at risk of venous thromboembolism (VTE). Since the breakthrough publication of the original Khorana risk score (KRS) more than 10 years ago, a new generation of KRS-based scores have been developed, including the Vienna Cancer and Thrombosis Study, PROTECHT, CONKO, ONCOTEV, TicOnco and the CATS/MICA score. Among these the CATS/MICA score showed that a simplified score composed of only two calibrated predictors, the type of cancer and the D-dimer levels, offers a user-friendly tool for the evaluation of cancer-associated thrombosis (CAT) risk. The COMPASS-CAT score is the first that introduced a more synthetic approach of risk evaluation by combining cancer-related predictors with patient comorbidity in a score which is designed for the types of cancer frequently seen in the community (i.e. breast, lung colon or ovarian cancers) and has been externally validated in independent studies. The Throly score is registered as part of the same group as it has a similar structure to the COMPASS-CAT score and is applicable in patients with lymphoma. The incorporation of specific biomarkers of hypercoagulability to the RAM for CAT offers the possibility to perform a precision medicine approach in the prevention of CAT. The improvement of RAM for CAT with artificial intelligence methodologies and deep learning techniques is the challenge in the near future.

Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: A case series

BACKGROUND

Venous thromboembolism (VTE) is a potentially devastating complication following abdominally based microsurgical breast reconstruction, with a reported incidence of 0.08-4%. The authors aim to describe disease presentation and clinical course following VTE diagnosis in patients within their practice.

METHODS

A retrospective chart review identified patients who underwent microsurgical breast reconstruction from January 2007 through December 2018. Patients with VTE diagnosed within 90 days of surgery were included. Demographics, co-morbidities, signs and symptoms, and characteristics of oncologic, surgical, and post-operative care were analyzed.

RESULTS

Seven hundred one patients underwent microsurgical breast reconstruction. Eleven patients with pulmonary embolism (PE) and four with deep vein thrombosis (DVT) were identified, resulting in VTE incidence of 2.1% (0.57% DVT, 1.6% PE). Patients were on average 51 years old and had an average body mass index (BMI) of 31.7 kg/m2. Two had a history of VTE, and none had a known hypercoagulable disorder. Using the 2005 Caprini model, all were high risk and seven were highest risk. Among those with PE, the most common symptom was shortness of breath, and the most common signs were desaturation or supplemental oxygen requirements. VTE was diagnosed on average 14.2 days post-operatively (range 2-52 days).

CONCLUSION

VTE is an infrequent complication following abdominally based microsurgical breast reconstruction. We recommend a high index of suspicion in women reporting shortness of breath or having desaturation, especially in those with high BMI, high Caprini scores, post-operative complications, or early return to the operating room.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Risk factors for venous thromboembolism and evaluation of the modified Caprini score in patients undergoing lung resection

Background

There is a high incidence of venous thromboembolism (VTE) after lung resection, so it is necessary to identify the risk factors for VTE in these patients. It is also important to evaluate whether the modified Caprini score can accurately assess the risk of VTE in patients after lung resection.

Methods

This retrospective study included 437 patients undergoing lung resection between July 2016 and December 2017. All patients underwent lower extremities ultrasound before and after operation to determine the presence of the newly diagnosed VTE.

Results

Forty-seven (10.8%) of the 437 patients were diagnosed with VTE after lung surgery. Multivariate logistic regression analysis showed that age (OR, 2.04; 95% CI, 1.40-2.99), duration of operation (OR, 1.51; 95% CI, 1.08-2.12), lymphocyte count (OR, 0.28; 95% CI, 0.11-0.69), and D-dimer concentration (OR, 1.55; 95% CI, 1.22-1.97) were significantly associated with VTE in lung resection patients. The cut-off values for lymphocyte count and D-dimer concentration determined using receiver operating characteristic (ROC) curve were 1.15×10⁹/L and 1.37 µg/mL respectively. The modified Caprini score divided the patients into three groups: low risk (0-4 points), moderate risk (5-8 points) and high risk (≥9 points), and the incidence of VTE was 12.3% (37/300), 7.5% (10/133) and 0% (0/4), respectively (P>0.05).

Conclusions

In this study, we identified four independent factors for VTE after lung resection patients: age, duration of operation, lymphocyte count, and D-dimer. According to the modified Caprini score, there were fewer patients in the high-risk group, and the incidence of VTE not increased with the increase of risk. Better evaluation of operation time and D-dimer may help the modified Caprini score to better assess VTE risk in these patients.

External Validation of a Venous Thromboembolic Risk Score for Cancer Outpatients with Solid Tumors: The COMPASS-CAT Venous Thromboembolism Risk Assessment Model

BACKGROUND

Current risk assessment models (RAMs) for prediction of venous thromboembolism (VTE) risk in the outpatient cancer population have shown poor predictive value in many of the most common cancers. The Comparison of Methods for Thromboembolic Risk Assessment with Clinical Perceptions and AwareneSS in Real Life Patients-Cancer Associated Thrombosis (COMPASS-CAT) RAM was derived in this patient population and predicted patients at high risk for VTE even after initiation of chemotherapy. We sought to externally validate this RAM.

MATERIALS AND METHODS

Patients aged ≥18 years who presented to a tertiary care center between January 1, 2014, and December 31, 2016, with invasive breast, ovarian, lung, or colorectal cancers were included. The COMPASS-CAT RAM was applied using our health system's tumor registry and variables that were identified by International Statistical Classification of Diseases and Related Health Problems-9 and -10 codes of the electronic health record and independent chart review. The primary endpoint at 6-month study follow-up was documented VTE.

RESULTS

A total of 3,814 patients were included. Documented VTE at 6-month follow-up occurred in 5.85% of patients. Patients stratified into low/intermediate- and high-risk groups had VTE rates of 2.27% and 6.31%, respectively. The sensitivity, specificity, and negative and positive predictive value of the RAM were 95%, 12%, 97.73%, and 6.31%, respectively. Diagnostic accuracy via receiver operating characteristic curve was calculated at 0.62 of the area under the curve.

CONCLUSION

In this large retrospective external validation study of the COMPASS-CAT RAM for VTE in patients with cancer undergoing active treatment, model discrimination was moderate and calibration was poor. The model had good negative predictive value. Further prospective validation studies-especially within 6 months of cancer diagnosis-are needed before the model can be implemented into routine clinical practice for primary thromboprophylaxis of high-VTE-risk patients with cancer with solid tumors.

IMPLICATIONS FOR PRACTICE

This study provides further guidance for researchers and clinicians in determining clinical and laboratory risk factors associated with development of venous thromboembolism among the ambulatory population of patients being treated for lung, breast, colorectal, or ovarian cancer. It validates the COMPASS-CAT risk model that was developed in this cancer population and suggests that further prospective validation of the model, with more focus on patients within 6 months of their index cancer diagnosis, would likely enhance the accuracy and usefulness of this model as a clinical prediction tool.

Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis

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.

Implementation of a Venous Thromboembolism Prophylaxis Protocol Using the Caprini Risk Assessment Model in Patients Undergoing Mastectomy

BACKGROUND

Guidelines for venous thromboembolism (VTE) prophylaxis are not well-established for breast surgery patients. An individualized VTE prophylaxis protocol using the Caprini score was adopted at our institution for patients undergoing mastectomy ± implant-based reconstruction. In this study, we report our experience during the first year of implementation.

METHODS

In August 2016, we adopted a VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction. We used the Caprini score, a validated risk assessment tool for VTE, to determine each patient's perioperative prophylaxis regimen. Detailed chart review was performed to record patient and treatment details, the Caprini score, pharmacologic VTE prophylaxis administration, and 30-day incidence of VTE and bleeding complications. We performed univariate analysis to identify factors associated with protocol compliance.

RESULTS

Overall, 522 patients met the inclusion criteria. Median age was 51 years, 486 (93.1%) patients had malignancy, 234 (44.8%) underwent bilateral mastectomy, and 350 (67.0%) underwent reconstruction. Caprini scores ranged from 2 to 11, with 431 (82.6%) patients having a score from 5 to 7. Overall protocol compliance was 60.5%, and was associated with bilateral mastectomy (p = 0.02), reconstruction (p = 0.03), and longer procedures (p < 0.001). The rate of VTE was 0.2% (95% confidence interval [CI] 0.03-1.1%), rate of reoperation for hematoma was 2.7% (95% CI 1.6-4.5%), and rate of blood transfusion was 0.4% (95% CI 0.1-1.4%).

CONCLUSIONS

The implementation of an individualized VTE prophylaxis protocol for patients undergoing mastectomy ± implant-based reconstruction is safe and feasible. Despite a high-risk cohort, the incidence of VTE was very low and bleeding complications were consistent with reported rates for breast surgery. Continued evaluation of this strategy is warranted.

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

METHODS

A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

RESULTS

High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

CONCLUSION

Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A Predictive Score for Thrombosis Associated with Breast, Colorectal, Lung, or Ovarian Cancer: The Prospective COMPASS-Cancer-Associated Thrombosis Study

The COMPASS‐CAT study was undertaken in outpatients with breast, colon, lung, or ovarian cancer. The aim of the study was to identify the most relevat risk factors for symptomatic thromboembolism and to develop a risk assessment model applicable to patients after the initiation of anticancer treatment.

Background.

The stratification of outpatients on chemotherapy for breast, colorectal, lung, and ovarian cancers at risk of venous thromboembolism (VTE) remains an unmet clinical need. The derivation of a risk assessment model (RAM) for VTE in these patients was the aim of the study “Prospective Comparison of Methods for thromboembolic risk assessment with clinical Perceptions and AwareneSS in real life patients–Cancer Associated Thrombosis” (COMPASS–CAT).

Patients and Methods.

The derivation cohort consisted of 1,023 outpatients. Patients on low molecular weight heparin (LMWH) thromboprophylaxis were excluded. Documented symptomatic VTE was the endpoint of the study.

Results.

Patients had breast (61%), colorectal (17%), lung (13%), or ovarian cancer (8.6%) at localized (30%) or advanced stage (70%). In 64% of patients, cancer was diagnosed within the last 6 months prior to inclusion. Most of them were on chemotherapy when assessed. Symptomatic VTE occurred in 8.5% of patients. The COMPASS–CAT RAM includes the following variables: (a) anthracycline or anti‐hormonal therapy, (b) time since cancer diagnosis, (c) central venous catheter, (d) stage of cancer, (e) presence of cardiovascular risk factors, (f) recent hospitalization for acute medical illness, (g) personal history of VTE, and (h) platelet count. At 6 months, patients stratified at low/intermediate and high‐risk groups had VTE rates of 1.7% and 13.3%, respectively. The area under the curve of receiver operating characteristics analysis was 0.85. The sensitivity and specificity of the RAM were 88% and 52%, respectively. The negative and positive predictive values of the RAM were 98% and 13%, respectively.

Conclusion.

The COMPASS–CAT RAM includes reliable and easily collected VTE risk predictors and, in contrast to the Khorana score, it is applicable after the initiation of anticancer treatment in patients with common solid tumors. Its robustness for stratification of patients at high and low/intermediate VTE risk needs to be externally validated.

Implications for Practice.

The Prospective Comparison of Methods for thromboembolic risk assessment with clinical Perceptions and AwareneSS in real life patients–Cancer Associated Thrombosis (COMPASS–CAT) study provides a new risk assessment model (RAM) for venous thromboembolism (VTE) applicable in outpatients with breast, colorectal, lung or ovarian cancer. The COMPASS–CAT RAM is robust, applicable during chemotherapy and determines the need for VTE prévention by including reliable and easily collected VTE predictors associated with cancer status, its treatment as well as with patients' characteristics and comorbidities. An independent external validation of the RAM is indicated before its use in clinical practice.

Coagulation Changes following Combined Ablative and Reconstructive Breast Surgery

BACKGROUND

This study assessed hemostatic function in cancer patients at high risk for venous thromboembolism.

METHODS

Thirty-eight female patients (age, 53 ± 9 years) undergoing immediate postmastectomy reconstruction were prospectively studied with informed consent. Blood was sampled preoperatively, on postoperative day 1, and at 1 week follow-up. Rotational thromboelastography clotting time, α-angle (clot kinetics), clot formation time, and maximum clot firmness were studied with three different activating agents: intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D. Thromboprophylaxis was unfractionated heparin plus sequential compression devices if not contraindicated. Hypercoagulability was defined by one or more parameters outside the reference range.

RESULTS

Preoperatively, 29 percent of patients were hypercoagulable, increasing to 67 percent by week 1 (p = 0.017). Clotting time, clot formation time, and α-angle remained relatively constant over time, but maximum clot formation increased in intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (all p < 0.05). Body mass index was 28 ± 5 kg/m, 23 percent received preoperative chemotherapy, and 15 percent had a history of tobacco use, but there was no association between these risk factors and hypercoagulability.

CONCLUSIONS

Despite perioperative thromboprophylaxis, two-thirds of patients undergoing combined tumor resection and reconstructive surgery for breast cancer were hypercoagulable 1 week after surgery. Hypercoagulability was associated with increased clot strength mediated by changes in platelet and fibrin function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Causal Therapy of Breast Cancer Irrelevant of Age, Tumor Stage and ER-Status: Stimulation of Estrogen Signaling Coupled With Breast Conserving Surgery

Abstract: Background

Results of long-term studies justify that the rate of breast cancer recurrence and tumor-related mortality remains quite unpredictable, regardless of the use of any current therapeutic measures.

Objective

Since the application of standard therapies, such as surgery, radiation, chemotherapy and antiestrogen administration does not work as might be expected; our therapeutic practice requires thorough rethinking.

Method

Published long-term therapeutic results on breast cancer cases were analyzed in correlation with stage at diagnosis, ER-status of tumors and patients’ age. The effectiveness of current therapeutic measures was also compared by estimating the rate of tumor-free survival, breast cancer recurrence and breast cancer-specific mortality.

Results

Diagnosis and treatment of breast cancer at an early stage cannot improve the rate of tumor-free survival. Poor differentiation of tumors, ER-negativity in particular, defines poor prognosis even after applying aggressive therapies. In patients treated with in situ breast cancer, the recurrence-rate of invasive tumor increased directly with ageing irrespective of tumor size or ER-status at diagnosis. Women who underwent lumpectomy without adjuvant radiation or chemotherapy exhibited significantly better overall and breast cancer specific survival rates than those receiving mastectomy, regardless of stage and ER-status of tumors. Antiestrogen treatment exhibited unforeseeable effectiveness even on targeted ER-positive tumors. Recent patents propose the detection of ESR1-gene amplification or restoration of ER-alpha expression for prediction of effective antiestrogen treatment, suggesting a crucial inhibitory role of estrogen-signaling against tumor-growth.

Conclusion

Estradiol-induced upregulation of estrogen signaling coupled with sparing of the estrogen-rich mammary fatpad are the most effective strategies against breast cancer.

Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients

Background

Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties.

Objectives

This study analyzed the risk factors for VTE in cosmetic surgical procedures.

Methods

A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.

Results

A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%).

Conclusions

The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Risk factors associated with venous thromboembolism in patients undergoing spine surgery

OBJECTIVE

Patients undergoing spinal surgery are at risk for developing venous thromboembolism (VTE). The authors sought to identify risk factors for VTE in these patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database for the years 2006–2010 was reviewed for patients who had undergone spinal surgery according to their primary Current Procedural Terminology code(s). Clinical factors were analyzed to identify associations with VTE.

RESULTS

Patients who underwent spinal surgery (n = 22,434) were identified. The rate of VTE in the cohort was 1.1% (pulmonary embolism 0.4%; deep vein thrombosis 0.8%). Multivariate binary logistic regression analysis revealed 13 factors associated with VTE. Preoperative factors included dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race. Operative factors included surgery duration > 4 hours, emergency presentation, and American Society of Anesthesiologists Class III–V, whereas postoperative sepsis was the only significant postoperative factor. A risk score was developed based on the number of factors present in each patient. Patients with a score of ≥ 7 had a 100-fold increased risk of developing VTE over patients with a score of 0. The receiver-operating-characteristic curve of the risk score generated an area under the curve of 0.756 (95% CI 0.726–0.787).

CONCLUSIONS

A risk score based on race, preoperative comorbidities, and operative characteristics of patients undergoing spinal surgery predicts the postoperative VTE rate. Many of these risks can be identified before surgery. Future protocols should focus on VTE prevention in patients who are predisposed to it.

Morbidity After Inguinal Lymph Node Dissections: It Is Time for a Change

BACKGROUND

Inguinal lymph node dissection (ILND) for stage 3 melanoma is accompanied by high wound complication rates. During the past decades, several changes in perioperative care have been instituted to decrease the incidence of these complications. This study aimed to evaluate the effect of these different care protocols on wound complications after ILND.

METHODS

A retrospective analysis of prospectively collected data was performed with 240 patients who underwent an ILND in the University Medical Center Groningen between 1989 and 2014. Four groups with different treatment protocols were analyzed: A (≥10 days of bed rest with a Bohler Braun splint), B (10 days of bed rest without a splint), C (5 days of bed rest), and D (1 day of bed rest). The effect of early mobilization, abolishment of the Bohler Braun splint and postural restrictions, and the introduction of prophylactic antibiotics were analyzed.

RESULTS

One or more wound complications occurred in 51.2 % of the patients including wound infection (29.8 %), seroma (21.5 %), wound necrosis (13.6 %), and hematoma (5 %). In consecutive periods, respectively 44.4, 60.3, 44.9 and 55.2 % of the patients experienced wound complications. None of the instituted changes in protocols led to a decrease in wound complications.

CONCLUSION

Changes in perioperative care protocols did not affect the rate of wound complications. Perhaps a change in the surgical procedure itself can lead to the necessary reduction of wound complications after ILND.

The Use of Surgical Care Improvement Projects in Prevention of Venous Thromboembolism

Venous thromboembolism (VTE) is a potentially mortal complication in patients undergoing surgery. Deep venous thrombosis and pulmonary embolism can be seen up to 40 % of patients who have no or inappropriate VTE prophylaxis during perioperative period.In addition to the preoperative and intraoperative preventive measures, the standardization of postoperative care and follow-up are essential to reduce VTE risk. Modern healthcare prioritizes patient's safety and aims to reduce postoperative morbidity by using standardized protocols. Use of quality improvement projects with well-organized surgical care has an important role to prevent VTE during hospital stay. Present surgical care improvement projects have provided us the opportunity to identify patients who are vulnerable to VTE. Description and introduction of the quality standards for VTE prevention in the educational materials, meetings and at the medical schools will increase the VTE awareness among the health care providers. You are going to find the characteristics of the major surgical quality improvement projects and their relations with VTE in the chapter.

Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings.

METHODS

In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504.

FINDINGS

Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46).

INTERPRETATION

Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients.

FUNDING

National Natural Science Foundation.

Pre-treatment mean platelet volume associates with worse clinicopathologic features and prognosis of patients with invasive breast cancer

BACKGROUND

Mean platelet volume (MPV) is one of the four platelet parameters (platelet count, MPV, platelet distribution width and plateletcrit), which indicates the activation of platelet. We aim to investigate the associations between pre-treatment MPV levels and clinical hematology parameters, pathology parameters and prognosis of patients with invasive breast cancer (IBC).

METHODS

Medical records of 340 breast tumor patients (170 IBC vs. 170 breast benign tumor) were retrospectively reviewed. Patients in two groups were matched for age, body mass index, smoking status and complications. To analyze: differences in pre-treatment MPV levels between IBC group and breast benign tumor group; differences between pre- and postoperative MPV levels in IBC patients; correlations between pre-treatment MPV and clinical hematology parameters, clinicopathologic parameters and prognosis in IBC patients.

RESULTS

As we analyzed, pre-treatment MPV levels of IBC patients were significantly higher than the controls (8.65 ± 0.98 vs 8.34 ± 0.78, P = 0.002), and preoperative MPV levels were significantly higher than the postoperative in IBC patients (8.65 ± 0.98 vs 8.44 ± 0.91, P = 0.042). In IBC group, pre-treatment MPV level associated, significantly, with clinical hematology parameters (platelet, fibrinogen, albumin, fasting blood glucose, P = 0.003, 0.042, 0.032, 0.046, respectively) and with clinicopathological parameters (distant metastasis, primary tumor size, tumor node metastasis stages, P = 0.039, 0.002, 0.001, respectively). Furthermore, univariate and multivariate survival analysis demonstrated that MPV was significant prognostic factor (P = 0.035, HR 1.86, 95 % confidence interval 1.06-3.25).

CONCLUSION

High pre-treatment MPV level in IBC patients was a potential predictive factor and significant independent prognostic factor.

Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy

OBJECT

Patients undergoing craniotomy are at risk for developing venous thromboembolism (VTE). The safety of anticoagulation in these patients is not clear. The authors sought to identify risk factors predictive of VTE in patients undergoing craniotomy.

METHODS

The authors reviewed a national surgical quality database, the American College of Surgeons National Surgical Quality Improvement Program. Craniotomy patients were identified by current procedural terminology code. Clinical factors were analyzed to identify associations with VTE.

RESULTS

Four thousand eight hundred forty-four adult patients who underwent craniotomy were identified. The rate of VTE in the cohort was 3.5%, including pulmonary embolism in 1.4% and deep venous thrombosis in 2.6%. A number of factors were found to be statistically significant in multivariate binary logistic regression analysis, including craniotomy for tumor, transfer from acute care hospital, age ≥ 60 years, dependent functional status, tumor involving the CNS, sepsis, emergency surgery, surgery time ≥ 4 hours, postoperative urinary tract infection, postoperative pneumonia, on ventilator ≥ 48 hours postoperatively, and return to the operating room. Patients were assigned a score based on how many of these factors they had (minimum score 0, maximum score 12). Increasing score was predictive of increased VTE incidence, as well as risk of mortality, and time from surgery to discharge.

CONCLUSIONS

Patients undergoing craniotomy are at low risk of developing VTE, but this risk is increased by preoperative medical comorbidities and postoperative complications. The presence of more of these clinical factors is associated with progressively increased VTE risk; patients possessing a VTE Risk Score of ≥ 5 had a greater than 20-fold increased risk of VTE compared with patients with a VTE score of 0.

Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction

BACKGROUND

Older breast cancer patients undergo postmastectomy breast reconstruction infrequently, in part because of a perception of increased surgical risk. This study sought to investigate the effects of age on perioperative complications after postmastectomy breast reconstruction.

METHODS

The American College of Surgeons National Surgery Quality Improvement Program Participant Use Files from 2005 to 2012 were used to identify women with breast cancer who underwent unilateral mastectomy alone or with immediate reconstruction. Thirty-day complication rates were compared between younger (<65 years) and older (≥65 years) women after implant-based reconstruction, autologous reconstruction, or mastectomy alone. Linear and logistic regression models were used to control for differences in comorbidities and age.

RESULTS

A total of 40,769 patients were studied, of whom 15,093 (37 percent) were aged 65 years or older. Breast reconstruction was performed in 39.5 percent of younger and 10.7 percent of older women. The attributable risks of breast reconstruction, manifested by longer hospital stays (p < 0.001), more frequent complications (p < 0.001), and more reoperations (p < 0.001), were similar in older and younger women. There were no differences in the adjusted complication rates between older and younger patients undergoing implant-based reconstruction. However, older women undergoing autologous reconstruction were more likely to suffer venous thromboembolism (OR, 3.67; p = 0.02).

CONCLUSIONS

The perioperative risks attributable to breast reconstruction are similar in older and younger women. Older patients should be counseled that their age does not confer an increased risk of complications after implant-based breast reconstruction. However, age is an independent risk factor for venous thromboembolism after autologous reconstruction. Special attention should be paid to venous thromboembolism prophylaxis in this group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Peripherally Inserted Central Catheter-Related Vein Thrombosis in Breast Cancer Patients

Purpose

To identify clinical incidence, risk factors and treatment of peripherally inserted central venous catheters (PICCs)-related upper extremity venous thrombosis (UEVT) in breast cancer patients undergoing chemotherapy.

Methods

We performed a retrospective cohort study of breast cancer patients with PICC insertion undergoing chemotherapy. PICC-related UEVT was diagnosed by ultrasound. Patient-, catheter- and insertion-related factors were analyzed in univariable and multivariable logistic regression to identify significant independent risk factors for PICC-related UEVT. The incidence and treatment of PICC-related UEVT were also analyzed.

Results

A total of 568 breast cancer patients with PICC undergoing chemotherapy were included, for a total of 54,769 catheter days; 8 patients (1.4%) developed PICC-related UEVT. The median time of developing UEVT was 11 days (range of 3 to 79 days). In multivariable analysis, metastasis (p = 0.002) and malposition (p = 0.013) were shown to be significant risk factors for PICC-related UEVT. All patients were treated with low-molecular-weight heparin (LMWH) and followed until PICCs were removed. None of the patients developed pulmonary embolus.

Conclusions

Metastasis and malposition were significant risk factors for PICC-related UEVT in breast cancer patients. With early diagnosis and standardized anticoagulant treatment, a better clinical outcome could be achieved. Further prospective and large sample studies are needed.

Economic impact of bleeding complications after mastectomy

BACKGROUND

We sought to determine the incidence of postmastectomy bleeding, identify bleeding predictors, and evaluate the economic impact.

METHODS

Using the 2011 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, hospital discharges for a primary diagnosis of breast cancer were extracted using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 85.34-85.48 for mastectomy and diagnosis codes 174.0-174.9 for breast cancer. Discharges with postoperative bleeding were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 998.11 and 998.12. Discharges with male gender or a history of coagulation disorders were excluded. Bleeding complication rates and reoperation rates were assessed. Predictors and the impact of bleeding on length of stay and hospital costs were determined using regression analysis and projected to the national level.

RESULTS

A total of 7907 discharges met inclusion criteria; 201 had bleeding complications (2.54%), with 42 cases requiring reoperation. On univariate analysis, the presence of congestive heart failure (CHF), obesity, diabetes, chronic pulmonary disease, and the absence of concomitant reconstruction were associated with increased bleeding events. On multivariate analysis, only the presence of CHF remained as a significant predictor of bleeding complications (odds ratio [95% confidence interval], 2.45, [1.25-4.92], P = 0.009). On average, bleeding complications extended the length of stay by 1.3 d (P < 0.0001) while increasing hospital costs by $5495 per admission (P < 0.0001). Projected to a national level, bleeding complications accounted for an additional 1254 d of hospital care at a cost exceeding $5.3 million.

CONCLUSIONS

Postmastectomy bleeding complications had an incidence of 2.54%, with CHF the only independent predictor identified. Such bleeding events, although infrequent, are associated with substantial economic costs.

Impact of breast cancer stage, time from diagnosis and chemotherapy on plasma and cellular biomarkers of hypercoagulability

Background

In breast cancer patients routine thromboprophylaxis is not recommended but individualized risk assessment is encouraged. The incorporation of hypercoagulability biomarkers could increase the sensitivity of risk assessment models (RAM) to identify patients at VTE risk. To this aim we investigated the impact of cancer-related characteristics on hypercoagulability biomarkers.

Methods

Thrombin generation (TG) assessed with the Thrombogramme-Thrombinoscope®, levels of platelet derived microparticles (Pd-MP) assessed with flow cytometry, procoagulant phospholid dependent clotting time (PPL-ct) measured with a clotting assay and D-Dimers (were assessed in a cohort of 62 women with breast cancer and in 30 age matched healthy women.

Results

Patients showed significantly higher TG, Pd-MP, D-Dimers levels and shortened PPL-ct compared to the controls. The PPL-ct was inversely correlated with the levels of Pd-MP, which were increased in 97% of patients. TG and D-Dimers were increased in 76% and 59% of patients respectively. In any stage of the disease TG was significantly increased as compared to the controls. There was no significant difference of TG in patients with local, regional of metastatic stage. There was no significant difference in Pd-MP or Pd-MP/PS⁺ between the subgroups of patients with local or regional stage of cancer. Patients with metastatic disease had significantly higher levels of Pd-MP and Pd-MP/PS⁺ compared to those with regional stage. The D-Dimers increased in patients with metastatic stage. In patients on chemotherapy with less than 6 months since diagnosis TG was significantly higher compared to those on chemotherapy who diagnosed in interval > 6 months. Patients with metastatic disease had significantly higher levels of Pd-MP and D-Dimers compared to those with non-metastatic disease.

Conclusion

In breast cancer patients the stage, the time elapsed since the diagnosis and the administration of chemotherapy are determinants of cellular and plasma hypercoagulability. The levels and the procoagulant activity of Pd-MP are interconnected with the biological activity and the overall burden of cancer. TG reflects the procoagulant properties of both breast cancer and chemotherapy in the initial period of cancer diagnosis. Thus the weighted incorporation of the biomarkers of cellular and plasma hypercoagulabilty in RAM for VTE might improve their predictive value.

Venous Thromboembolism following Elective Aesthetic Plastic Surgery: A Longitudinal Prospective Study in 1254 Patients

Background. Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Healthy patients submitted to elective aesthetic plastic surgeries (EAPS) have risk factors to develop VTE not well established yet. The objective of this study was to examine the incidence and risk factors for VTE in these patients. Methods. Longitudinal, prospective (minimum follow-up of 3 months), observational study. Comprehensive information on patient characteristics and surgeries performed was obtained. Preoperative, intraoperative, and postoperative risk factors were analyzed for their association with VTE. Results. A total of 1254 patients were included in the study. Postoperative VTE occurred in 17 (1,35%) of patients. VTE was more frequent in patients more than 40 years old (82.3%). Smoking, patients with 2 or 3 pregnancies, and hormone replacement therapy, and oral contraceptives use presents higher levels of VTE. In this study we have not found any correlation between liposuction, augmentation mammoplasty, mastopexy, and rhinoplasty as an isolated risk factor for VTE. Conclusions. The incidence of VTE in patients undergoing EAPS was 1.35%. Patients with more than 40 years of age, tobacco users, patients with 2 or more pregnancies, and hormone replacement therapy or oral contraceptives use presents higher levels of VTE.

Venous thromboembolism in reconstructive pelvic surgery

OBJECTIVE

We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS).

STUDY DESIGN

Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables.

RESULTS

In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037).

CONCLUSION

The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database

BACKGROUND

There are numerous factors that may contribute to microvascular free flap failure. Although technical issues are dominant factors, patient and clinical characteristics are also contributory. The aim of this study was to investigate non-technical variables associated with microsurgical free flap failure using a multi-institutional dataset.

METHODS

Utilizing the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database, we identified all patients who underwent microvascular free tissue transfer from 2005 through 2009. Univariate analysis was performed to determine the association of flap failure with the following factors: age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes, smoking, alcohol, American Society of Anesthesiologists classification, year of operation, operative time, number of flaps, and type of reconstruction. Factors with a significance of P < 0.2 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors.

RESULTS

A total of 639 patients underwent microsurgical free flap reconstruction with 778 flaps over the 4-year study period; 139 patients had two free flaps during the same operation. The overall incidence of flap failure was 4.4% (34/778) (95% confidence interval [CI]: 3.0%, 6.2%). Operative time was identified as an independent risk factor for free flap failure. After adjusting for other factors, those whose operative time was equal to or greater than the 75th percentile (625.5 min) were twice as likely to experience flap failure (AOR 2.09; 95% CI: 1.01-4.31; P = 0.045). None of the other risk factors studied were significant contributors.

CONCLUSIONS

In this series, the overall flap loss rate of was 4.4%. Operative time was a significant independent risk factor for flap failure.