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Mou D, Falconer E, Majumdar M, Delgado T, Fay K, Hall CE, Smach C, Ashraf S, Levett S, Lin E, Davis S, Patel A, Stetler J, Serrot F, Srinivasan J, Oyefule O, Diller M, Hechenbleikner E. Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center. Surg Obes Relat Dis 2024; 20:72-79. [PMID: 37684191 DOI: 10.1016/j.soard.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/30/2023] [Accepted: 08/05/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized. OBJECTIVES To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles. SETTING Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital. METHODS We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology. RESULTS A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed. CONCLUSIONS Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.
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Affiliation(s)
- Danny Mou
- Department of Surgery, Emory University, Atlanta, Georgia.
| | | | | | - Tori Delgado
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Katherine Fay
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Carrie E Hall
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Carla Smach
- Department of Surgery, Emory University, Atlanta, Georgia; Emory University School of Nursing, Atlanta, Georgia
| | - Shanza Ashraf
- Department of Surgery, Emory University, Atlanta, Georgia; Emory University Office of Quality, Atlanta, Georgia
| | - Sydnee Levett
- Department of Surgery, Emory University, Atlanta, Georgia; University of Miami, Miami, Florida
| | - Edward Lin
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Scott Davis
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ankit Patel
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Jamil Stetler
- Department of Surgery, Emory University, Atlanta, Georgia
| | | | | | | | - Maggie Diller
- Department of Surgery, Emory University, Atlanta, Georgia
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Zhang Z, Zhen K, Li W, Qin X, Qu J, Shi Y, Xu R, Xu Y, Shen D, Du J, Cai C, Zhai Z, Wang C. Validation of the IMPROVE bleeding risk assessment model in surgical patients: Results from the DissolVE-2 Study. Thromb Res 2023; 223:69-77. [PMID: 36708692 DOI: 10.1016/j.thromres.2023.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION IMPROVE Bleeding Risk Score (BRS) is known to be validated and widely accepted in medical patients. However, its relevance in surgical patients has so far not been explored. External validation of the IMPROVE BRS on bleeding in surgical patients can hopefully improve clinical practice (for surgical patients). METHODS Data from 6986 surgical patients were collected from the DissolVE-2 cohort. The Kaplan-Meier method was used to assess the incidences of major bleeding and any bleeding among surgical patients within 14 days of admission. A cut-off value of BRS ≥7 indicated a higher risk of bleeding. Risk factors associated with major and any bleeding were analysed by the Cox regression method. Model discrimination was evaluated by area under the receiver operator characteristic curves (AUC). Calibration curves and Hosmer-Lemeshow χ2 statistics were used to measure the difference between predicted and observed bleeding risks. RESULTS A total of 6399 surgical patients were included in the final validation cohort. The cumulative incidence rate of any bleeding was 3.9 % (95 % confidence interval [CI], 3.4-4.5), of which the incidence rate of major bleeding was 1.2 % (95 % CI, 0.9-1.6). Among patients with a BRS of ≥7, 16.3 % reported any bleeding, and 26.3 % reported major bleeding. The IMPROVE BRS had a better discriminative power (AUC = 0.69) and excellent goodness of fit (Hosmer-Lemeshow test, P = 0.208) for the prediction of major bleeding events as compared with any bleeding (AUC = 0.55; Hosmer-Lemeshow test, P = 0.004). The calibration plot suggested a more accurate prediction for major bleeding events. Moreover, the IMPROVE BRS had a higher AUC value of 0.83 and better goodness of fit (P = 0.2616) for major bleeding in patients undergoing abdominal surgery than other surgery types. CONCLUSION The IMPROVE BRS is a simple and practical technique that can help in predicting the risk of major bleeding in surgical patients, improving functional and safety outcomes of hospitalized patients with surgery.
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Affiliation(s)
- Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Centre of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.; National Centre for Respiratory Medicine, Beijing, China.; National Clinical Research Centre for Respiratory Diseases, Beijing, China
| | - Kaiyuan Zhen
- Department of Pulmonary and Critical Care Medicine, Centre of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.; National Centre for Respiratory Medicine, Beijing, China.; National Clinical Research Centre for Respiratory Diseases, Beijing, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Sichuan, China
| | - Xinyu Qin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jieming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.; Department of Respiratory Medicine; Huadong Hospital affiliated to Fudan University, Shanghai, China
| | - Yuankai Shi
- Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Ruihua Xu
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong, China
| | - Yuming Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dan Shen
- Sanofi China, 17-19 Floor, Jing'an Kerry Centre Tower 3, Jing'an District, Shanghai, China
| | - Jingjing Du
- Sanofi China, 17-19 Floor, Jing'an Kerry Centre Tower 3, Jing'an District, Shanghai, China
| | - Changbin Cai
- Sanofi China, 17-19 Floor, Jing'an Kerry Centre Tower 3, Jing'an District, Shanghai, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Centre of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.; National Centre for Respiratory Medicine, Beijing, China.; National Clinical Research Centre for Respiratory Diseases, Beijing, China..
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Centre of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.; Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.; WHO Collaboration Center for Tobacco Cessation and Respiratory Diseases Prevention, Beijing, China.; National Centre for Respiratory Medicine, Beijing, China.; National Clinical Research Centre for Respiratory Diseases, Beijing, China
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El Ansari W, El-Ansari K. Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base. Ann Med Surg (Lond) 2020; 59:264-273. [PMID: 33133579 PMCID: PMC7588328 DOI: 10.1016/j.amsu.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/09/2020] [Accepted: 08/09/2020] [Indexed: 11/01/2022] Open
Abstract
Background Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality. Methods This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions. Results VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies. Conclusion VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.
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Affiliation(s)
- Walid El Ansari
- Department of Surgery, Hamad General Hospital, 3050, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar.,Schools of Health and Education, University of Skovde, Skövde, Sweden
| | - Kareem El-Ansari
- Volunteer, Hamad General Hospital, Hamad Medical Corporation, 3050, Doha, Qatar
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Alenazi NA, Ahmad KS, Essa MS, Alrushdan MS, Al-Shoaibi AM. Porto-mesenteric vein thrombosis following laparoscopic sleeve gastrectomy for morbid obesity: Case series and literature review. Int J Surg Case Rep 2019; 63:59-64. [PMID: 31563666 PMCID: PMC6796684 DOI: 10.1016/j.ijscr.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/24/2019] [Accepted: 09/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Portal vein thrombosis is a rare and a potentially lethal complication of Laparoscopic sleeve gastrectomy. In this series, we describe the presentation, treatment, and outcome of 5 cases of PMVT post-laparoscopic sleeve gastrectomy (LSG) treated successfully at our hospital. CASE REPORT Five patients presented to our emergency department with diffuse abdominal pain associated with anorexia, nausea and vomiting after laparoscopic sleeve gastrectomy (LSG). Computed tomography (CT) scan showed evidence of portal, mesenteric and splenic vein thrombosis and small bowel ischemia in three patients. Two patients were treated only with anticoagulant and the other three patients were treated with surgery in the form of diagnostic laparoscopy converted to laparotomy with Small bowel resection. CONCLUSION Portal and mesenteric venous thrombosis after laparoscopic sleeve gastrectomy is an unusual complication but it has life threatening consequences if it is not diagnosed early and treated adequately. The patients with porto-mesenteric venous thrombosis (PMVT) usually present themselves with vague abdominal symptoms. As so, the physicians should have high index of suspicion to recommend computed tomography (CT) abdomen to confirm diagnosis and start adequate treatment.
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Affiliation(s)
- Naif A Alenazi
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia.
| | - Khaled S Ahmad
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Mohamed S Essa
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia; Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mahir S Alrushdan
- Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
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Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients: A Systematic Review of Clinical Studies. Clin Drug Investig 2018; 38:673-693. [DOI: 10.1007/s40261-018-0662-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Gaborit B, Moulin PA, Bege T, Boullu S, Vincentelli C, Emungania O, Morange PE, Berdah S, Salem JE, Dutour A, Frere C. Lean body weight is the best scale for venous thromboprophylaxis algorithm in severely obese patients undergoing bariatric surgery. Pharmacol Res 2018; 131:211-217. [PMID: 29452290 DOI: 10.1016/j.phrs.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/15/2018] [Accepted: 02/09/2018] [Indexed: 10/18/2022]
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AlSabah SA, AlRuwaished M, Almazeedi S, Al Haddad E, Chouillard E. Portomesenteric Vein Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Case Series and Literature Review. Obes Surg 2018; 27:2360-2369. [PMID: 28281234 DOI: 10.1007/s11695-017-2637-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is today one of the leading procedures in bariatric surgery, and portomesenteric vein thrombosis (PMVT) has been reported as one of its rare complications. The purpose of this study is to determine the prevalence, clinical presentation, and outcomes of PMVT in patients undergoing LSG. METHODS A retrospective study of a database of all post-LSG patients was conducted on the patients who developed PMVT post-LSG from July 2011 to March 2016, at Amiri Hospital, Kuwait. RESULTS A total of 2280 patients underwent LSG during the study period. Nine (0.39%) patients were diagnosed with PMVT post-LSG. Diagnosis was confirmed by CT scan for eight patients, and one had urgent laparotomy. The median age was 34 years (20-50), and there were 7 women and 2 men. Median preoperative body mass index (BMI) was 42 kg/m2 (37.5-74.6), and median operative time was 80 min (60-150). The median post-operative anticoagulation duration was 4 days (2-22). The median onset of diagnosis after the surgery was 28 days (18-453), and two patients had a positive thrombophilia study. All patients were treated medically except one patient who underwent urgent laparotomy for small bowel necrosis and eventually had small bowel transplant. CONCLUSIONS PMVT post-LSG is a rare but possibly dangerous complication. It should be suspected with patients presenting with unresolving abdominal pain. Treatment is mainly conservative and surgical intervention might be needed for small bowel necrosis. Extended anticoagulation prophylaxis is a hypothesis for patients after LSG, and may play a role in preventing PMVT.
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Affiliation(s)
- S Alman AlSabah
- Department of Surgery, Amiri Hospital, Kuwait Ministry of Health, Kuwait City, Kuwait.
| | - Mohammed AlRuwaished
- Department of Surgery, Amiri Hospital, Kuwait Ministry of Health, Kuwait City, Kuwait
| | - Sulaiman Almazeedi
- Department of Surgery, Amiri Hospital, Kuwait Ministry of Health, Kuwait City, Kuwait
| | - Eliana Al Haddad
- Department of Surgery, Amiri Hospital, Kuwait Ministry of Health, Kuwait City, Kuwait
| | - Elie Chouillard
- Department of General and Minimally Invasive Surgery, Paris Poissy Medical Center, Paris, France
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Moulin PA, Dutour A, Ancel P, Morange PE, Bege T, Ziegler O, Berdah S, Frère C, Gaborit B. Perioperative thromboprophylaxis in severely obese patients undergoing bariatric surgery: insights from a French national survey. Surg Obes Relat Dis 2017; 13:320-326. [PMID: 27720420 DOI: 10.1016/j.soard.2016.08.497] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/13/2016] [Accepted: 08/28/2016] [Indexed: 01/19/2023]
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Mukherjee S, Alhamdani A, Sufi P, Parmar C. Reply to "Bleeding in Sleeve Gastrectomy-A Simple and Cost-Effective Solution". Obes Surg 2016; 27:814-815. [PMID: 28035525 DOI: 10.1007/s11695-016-2507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Samrat Mukherjee
- Department of Bariatric Surgery, The Whittington Hospital, Magdala Avenue, London, N19 5NF, UK
| | - Ali Alhamdani
- Department of Bariatric Surgery, The Whittington Hospital, Magdala Avenue, London, N19 5NF, UK
| | - Pratik Sufi
- Department of Bariatric Surgery, The Whittington Hospital, Magdala Avenue, London, N19 5NF, UK
| | - Chetan Parmar
- Department of Bariatric Surgery, The Whittington Hospital, Magdala Avenue, London, N19 5NF, UK.
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Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity. Surg Clin North Am 2016; 96:743-62. [DOI: 10.1016/j.suc.2016.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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