Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis

Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade

BACKGROUND

The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution.

METHODS

We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events.

RESULTS

In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022.

CONCLUSIONS

Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery 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.

To Compare the Effectiveness of Low-Molecular-Weight Heparin and Unfractionated Heparin in Reducing Lower Limb Girth in Deep Vein Thrombosis

INTRODUCTION

Treating deep vein thrombosis (DVT) using a once-daily dose of enoxaparin offers greater convenience and the possibility of home-based care for certain patients, as opposed to a continuous infusion of unfractionated heparin (UFH). The study aimed to determine the most cost-effective thromboprophylaxis between low-molecular-weight heparin (LMWH) and UFH for hospitalized patients.

MATERIALS AND METHODS

After obtaining clearance from the institutional ethical committee, the study was conducted in the Department of General Surgery, Sri Devaraj Urs Medical College, over a period of six months. Informed consent was obtained from all 46 patients included in this study. The participants were divided into two groups: group A received LMWH and group B received UFH.

RESULTS

The mean age in group A was 59.8 + 10.6 years and in group B was 54.9 + 12.3 years. There was no significant difference in the girth of the lower limb between the groups during the follow-up period (p > 0.05). In group A, there was a highly significant reduction in lower limb girth from day one to day five (p < 0.0001), day five to day 10 (p < 0.0001), and day one to day 10 (p < 0.0001). In group B, there was no significant reduction from day one to day five (p = 0.06), but there was a significant reduction from day five to day 10 (p = 0.001) and day one to day 10 (p = 0.001).

CONCLUSION

Treatment with LMWH as an anticoagulant significantly reduced the lower extremity girth and thrombus thickness in cases of DVT when compared to UFH.

Clinical guidelines for prevention and treatment of CAT in Japan and other countries

Cancer-associated thrombosis (CAT) is an important prognostic factor for an increasing number of cancer patients. Understanding of CAT among cancer care providers has grown in recent years, and guidelines for the prevention and treatment of CAT have been published in Japan and around the world. In this article, we introduce these major guidelines and discuss differences we identified between the Japanese guidelines and those of other countries, with a focus on problems and issues. Insurance coverage of low-molecular-weight heparin and indications for primary prevention with direct oral anticoagulants in particular require urgent consideration.

Randomized Trial of Sequential Compression Versus Ankle-Calf Movement to Increase Femoral Venous Velocity

Objective In postoperative patients with a high risk of bleeding, sequential compression devices (SCD) and ambulation are effective methods to reduce venous thromboembolic (VTE) risks. High leg venous flow decreases VTE risk. We postulated that ankle flexion and extension (AFE) while in bed increased leg venous flow velocity as well. We wished to compare the effectiveness of SCD versus AFE in increasing leg venous velocity. Methods Thirty-two healthy volunteers were recruited into the study. Each subject had two legs that were randomized into SCD or AFE. After 15 minutes of rest, SCD or AFE was applied, followed by 15 minutes of rest, and then an alternate treatment was given to the second leg. The sequence of leg and methodology was then reversed so the second treatment was applied to the first leg, and the first treatment to the second leg, and measurements were obtained. All treatments were separated by a rest period of 15 minutes. The venous velocity on each leg was measured by Doppler ultrasound at the superficial femoral vein. Venous velocity was measured initially (first cycle peak venous velocity) and during subsequent cycles. The alternate treatments on both legs with both treatments allowed for analysis in a manner where each subject could act as its control. Results Relative to baseline bed rest, SCD increased peak venous flow velocity by 112%, while AFE increased peak venous flow velocity by 161%. AFE resulted in 43% higher venous velocity on average than did SCDs (p<0.05). Conclusions AFE leads to significantly higher venous flow in the femoral veins of healthy subjects.

The usage and outcomes of dextran in the treatment of acute deep venous thrombosis

OBJECTIVES

In this study, we retrospectively compared the outcomes of patients with acute deep vein thrombosis treated with dextran 40 infusion and unfractionated heparin with those of patients treated with unfractionated heparin alone.

METHODS

We evaluated 104 patients with the diagnosis of acute deep vein thrombosis. The pain complaints of the patients at the time of admission and the pain complaints in the calf with dorsiflexion of the foot were evaluated with the visual analogue pain scale, and the calf diameter of affected limbs was measured. Fifty five patients had dextran 40 infusion and unfractionated heparin treatment concomitantly (Group HD), while 49 patients had unfractionated heparin treatment (Group H). Heparin dose was adjusted to obtain 1.5- to 2.5-fold of normal activated partial thromboplastin time in both groups. Oral anticoagulant, warfarin sodium, was administered in the first day and resumed. Unfractionated heparin infusion therapy was resumed until international normalized ratio values of 2-2.5 were obtained. Dextran 40 infusion therapy was administered for 3 days. Calf diameters, current pain, and calf pain at foot dorsiflexion were recorded at 48 h and 72 h. 65 patients were distal, and 39 patients were proximal and popliteal acute DVT. None of the patients had phlegmasia. All were acute DVT.

RESULTS

At 48 and 72 h of therapy, it was determined that the decrease of the calf diameter and the pain were more significant both at 48th and 72nd hours in the Group HD. The calf circumference change, especially at 72 h, was 2.58 ± 0.39 cm in the group receiving heparin + dextran, while it was 1.76 ± 0.56 cm in the group receiving only heparin. (p = 0.000). While there were only 1.24 ± 1.02 people in the group that received dextran at 72 h, leg pain persisted in 3.35 ± 1.11 people in the other group. (p = 0.000). Evaluation was made only with calf vein diameter measurement. When patients with Homan's sign were evaluated for their calf pain at foot dorsiflexion; both groups had decreased pain at 48th and 72nd hours.

CONCLUSION

In this study, we observed that the use of dextran 40 infusion therapy concomitantly with unfractionated heparin accelerates recovery substantially and decreases patient complaints significantly in early stages. In particular, reduction in leg pain and calf circumference reduction were more adequate in the dextran group. The early decrease in the calf circumference will have clinical consequences such as less heparin intake, earlier return to normal life, and a decrease in the total cost of treatment. Since the antithrombotic and anticoagulant effects of dextran are well known, we think that its use in this treatment as well as venous thromboembolism prophylaxis should be discussed.

Preoperative low-molecular weight heparin chemoprophylaxis in head and neck free flap reconstruction

BACKGROUND

The safety of presurgical thromboprophylaxis using low molecular weight heparin (LMWH) has not been well described in head and neck oncologic surgery with free tissue transfer (HNS-FTT).

METHODS

Retrospective chart review of HNS-FTT patients receiving versus not receiving presurgical subcutaneous enoxaparin (Px-LMWH) was performed. Outcomes included estimated blood loss (EBL), hematoma, flap compromise, DVT or pulmonary embolus (PE). Fisher's exact test and Wilcoxon Rank Sum test were performed to compare groups. Odds ratios and associated 95 % confidence intervals were provided as appropriate.

RESULTS

43 of 128 patients (34 %) received Px-LMWH. There was no significant difference in EBL, hematoma, or flap complications between groups. Patients without Px-LMWH had higher rates of DVT and PE, although the difference did not reach statistical significance (p = 1.00, 0.095, respectively).

CONCLUSION

Presurgical Px-LMWH can be used in major head and neck reconstructive surgery without increased intraoperative blood loss or postoperative complications. Larger studies will need to be done to determine the impact of Px-LMWH on DVT and PE in this patient population.

LEVEL OF EVIDENCE: 3

AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery

BACKGROUND

Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided.

METHODS

Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines.

RESULTS

Levels of evidence and strength of recommendations are presented.

DISCUSSION

While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.

Asymptomatic Venous Thromboembolism After Hepatobiliary-Pancreatic Surgery: Early Detection Using D-dimer and Soluble Fibrin Monomer Complex Levels

AIM

The aim was to investigate the usefulness of a preemptive management strategy that includes monitoring serum D-dimer (DD) and soluble fibrin monomer complex (SFMC) levels for early detection and treatment of venous thromboembolism (VTE) after hepatobiliary-pancreatic (HBP) surgery.

METHODS

Overall, 678 patients who underwent HBP surgery between January 2010 and March 2020 were enrolled. Patients with increased postoperative serum DD or SFMC levels underwent contrast-enhanced computed tomography, and those with VTE received anticoagulant agents. The VTE risk factors were investigated using multivariable analysis. Postoperative changes in DD and SFMC levels were verified, and their ability to identify VTE was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

VTE developed in 83 patients (12.2%), and no symptomatic VTE or death due to VTE was observed. Multivariable analysis identified female sex (odds ratio [OR] 2.26; 95% confidence interval [CI] 1.41-3.60; P < .001) and surgery duration of ≥401 min (OR 2.07; 95% CI 1.27-3.35; P < .001) as independent risk factors for VTE. Maximum serum DD and SFMC levels in patients who developed VTE were significantly higher than those in patients without VTE (DD, 15.1 vs 8.9 μg/mL, P < .001; SFMC, 18.0 vs 10.2 μg/mL, P < .001, respectively). Both DD (n = 678) and the combination of DD and SFMC levels (n = 230) showed a good ability to detect VTE (area under the ROC curve, 0.804 and 0.761, respectively).

CONCLUSION

Our preemptive strategy of monitoring serum DD and SFMC levels enables early detection and treatment intervention of VTE after HBP surgery.

Acute Respiratory Failure

Acute respiratory failure occurs when the lungs fail to oxygenate arterial blood adequately and it is one of the commonest postoperative complications. The preoperative identification of risk factors for postoperative acute respiratory failure allows identification of those patients who may benefit from preoperative optimization and increased postoperative vigilance. Multiple postoperative pulmonary complications are associated with acute hypoxemic respiratory failure and this chapter discusses atelectasis, pulmonary embolism, aspiration, and acute respiratory distress syndrome in detail, as well as providing a unified clinical approach to the acutely hypoxemic perioperative patient.

Analysis of Adherence to Thromboprophylaxis and Incidence of Venous Thromboembolism After Lower Limb Orthopaedic Surgery

Background The economic burden caused by venous thromboembolism (VTE) to the National Health Service (NHS) is approximately £640 million. There is a significant national drive for VTE prophylaxis prescription given the high morbidity and mortality rates associated with VTE following lower limb orthopaedic surgery. The primary objective of this analysis was to examine the adherence to the updated VTE guidelines, NG89, by the National Institute for Health and Care Excellence (NICE) regarding prophylaxis for patients undergoing lower limb orthopaedic surgery, where the weight-bearing status will be reduced postoperatively, in an urban community hospital. Methodology We looked at 586 patients who underwent elective lower limb orthopaedic surgeries over a two year time period. We reviewed their VTE prophylaxis administration. Results were shared with the Hospital Thrombosis Committee department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines as well as complications arising from VTE. Results A total of 586 patients were included in this audit. Compliance with VTE pharmacological prophylaxis was recorded, as well as weight-bearing status advised postoperatively. Compliance with prophylaxis in patients who were non-weight-bearing postoperatively was 54.8%. There were three cases of recorded VTE; however, in all cases, appropriate VTE prophylaxis has been prescribed. Conclusion Increasing hospital-wide awareness and education of VTE and the fatal complications is imperative. All patients should be administered VTE prophylaxis as an inpatient and on discharge if their weight-bearing status is affected following lower limb orthopaedic surgery. Although our compliance rate for prescription of VTE prophylaxis did not achieve the standards set by NICE, all cases of recorded VTE had been correctly prescribed VTE prophylaxis on discharge.

Liver Injury Among Japanese Patients Treated Using Prophylactic Enoxaparin After Colorectal Surgery

BACKGROUND

Enoxaparin, a low molecular weight heparin, has been used to prevent thrombotic events during major surgery without increasing the rate of hemorrhage. On the other hand, it was reported to cause liver injury, but the details of liver injury induced by prophylactic enoxaparin after abdominal surgery remain unclear.

AIMS

This study aimed to clarify the relationship between prophylactic enoxaparin and liver injury after colorectal surgery, and characterize the injury profile.

METHODS

We retrospectively reviewed 732 Japanese patients who underwent elective resection of the colorectum, and compared their clinicopathological background, details of surgery, postoperative complications, including liver injury, and the type of liver injury according to prophylactic use of enoxaparin. Univariate and multivariate analyses were performed to identify risk factors for liver injury during the postoperative period.

RESULTS

The rate of liver injury was 8.9% for patients treated by prophylactic enoxaparin and 1.4% for those who did not receive enoxaparin after colorectal surgery (p < 0.0001). The median onset of liver injury among patients receiving enoxaparin was seven days, and the majority demonstrated the hepatocellular pattern. Enoxaparin was one of the independent risk factors for postoperative liver injury by multivariate analysis (odds ratio: 7.63, p < 0.0001).

CONCLUSIONS

Prophylactic use of enoxaparin markedly increased the rate of postoperative liver injury in patients who underwent colorectal surgery. Our study confirmed that close monitoring of liver function parameters is essential for patients receiving enoxaparin during the postoperative period.

Severe alpha-1-antitrypsin deficiency increases the risk of venous thromboembolism

BACKGROUND

Severe alpha-1-antitrypsin deficiency (AATD), phenotype PiZZ, is associated with increased risk of liver disease and chronic obstructive pulmonary disease (COPD), but the risk of venous thromboembolism (VTE) is unknown. Our aim was to evaluate the risk of VTE in individuals with severe AATD compared with control subjects from the general population.

METHODS

Individuals with severe AATD (n = 1577) were recruited from the Swedish national AATD register. Control subjects (n = 5969) were selected from the OLIN (Obstructive Lung Disease in Northern Sweden) studies, that include a random general population sample. Longitudinal data on VTE and diagnoses were obtained from the Swedish National Patient Registry. Associations were analyzed using multivariable Cox regression.

RESULTS

At inclusion, 46% of the AATD individuals and 53% of the controls were never-smokers. COPD was present in 46% of the AATD individuals compared with 4% of the controls. During a median follow-up of 18 years, 116 (7%) of the AATD individuals and 89 (1%) of the control subjects developed VTE, unadjusted hazard ratio 6.5 (95% confidence interval 4.9-8.6). Risk factors for incident VTE were male gender, age, COPD, cancer, and liver disease. Adjusting for these factors, the AATD individuals had a significantly higher risk of incident VTE, adjusted hazard ratio 4.2 (95% confidence interval 2.9-6.2) as compared with the controls.

CONCLUSION

Subjects with severe AATD have considerably increased risk of developing VTE compared with the general population, even after accounting for risk factors. This calls for optimized risk factor management and clinical follow-up of this patient group.

High prevalence of pulmonary embolism prior to cancer therapies in patients with ovarian and endometrial cancers detected by contrast-enhanced CT using D-dimer as an index

OBJECTIVE

We aimed to evaluate the prevalence of pulmonary embolism (PE) before cancer therapies in patients with ovarian and endometrial cancers with enhanced computed tomography (CT) using D-dimer (DD), and determine the optimal cut-off level of DD.

METHODS

Since 2009, we have performed preoperative venous thromboembolism (VTE) screening of patients with ovarian and endometrial cancer. For patients with DD levels of more than 1.0 μg/ml, enhanced CT images were obtained from the pulmonary apex to the foot to detect PE and deep venous thrombosis (DVT) simultaneously.

RESULTS

Among patients with ovarian cancer, 84 of 413 (20.3%) had VTEs (DVT alone, n = 31 [7.5%]; PE with or without DVT, n = 53 [12.8%]; PE alone, n = 12 [2.9%]). Among patients with endometrial cancer, 50 of 455 (11.0%) had VTEs (DVT alone, n = 19 [4.2%]; PE with or without DVT, n = 31 [6.8%], PE alone, n = 14 [3.1%]). The optimal cut-off level of DD was estimated to be ≥1.5 and ≥1.2 μg/ml in ovarian and endometrial cancers, respectively.

CONCLUSION

Our study revealed a high prevalence of PE before cancer therapies in patients with ovarian and endometrial cancers by enhanced CT using DD.

An update on the efficacy and safety of novel anticoagulants for cancer associated thrombosis

Introduction: Cancer-associated thrombosis (CAT) refers to the most common thromboembolic complication of cancer which is venous thromboembolism (VTE). CAT primary prophylaxis, treatment, and secondary prevention are challenging for the complexity of cancer patients, who exhibit hypercoagulability with concomitant-heightened bleeding risk.Areas covered: In this review, the author examines the role of low molecular weight heparins (LMWH), which have been the standard of care for CAT treatment for many years. Direct oral anticoagulants (DOACS) have practical advantages over subcutaneous LMWH, especially for long-term therapy. The author then discusses the results of two RCTs which separately compared the direct oral factor Xa inhibitors, apixaban or rivaroxaban, with placebo for CAT prophylaxis in ambulatory high-risk cancer patients and found that DOACS reduced VTE but increased bleeding. Finally, the author discusses four RCTS separately comparing an oral direct factor Xa inhibitor (edoxaban, rivaroxaban, or apixaban) with LMWH for CAT treatment. DOACS showed non-inferior efficacy, although rivaroxaban and edoxaban showed higher bleeding rates, especially in gastrointestinal cancers.Expert opinion: DOACS have a convenient route of administration and do not require laboratory monitoring, although choice of anticoagulants for CAT depends on factors such as tumor type, bleeding risk, concomitant drugs, and comorbidities.

[Treatment recommendations in cardio-oncology: where are we?]

This article provides an overview of current prevention and treatment options for typical cardiovascular side effects of oncological therapies as well as cardiovascular complications of malignant disease. Focus is put on the prevention and treatment of heart failure under potentially cardiotoxic cancer therapies. In addition, current options for the treatment of common venous thromboembolism in cancer patients will be discussed.

Low-molecular weight vs. unfractionated heparin for prevention of venous thromboembolism in general surgery: a meta-analysis

To assess the association between low-molecular weight heparin (LMWH) and unfractionated heparin (UFH) in the prevention of venous thromboembolism (VTE) among participants undergoing general surgery. LMWH and UFH are the standard of practice in the prevention of VTE in surgery. However, in the context of general surgery, studies comparing the effectiveness of these treatments are limited. A systematic search was conducted to find studies which examined the comparative effectiveness between LMWH and UFH in the prophylaxis of VTE in the context of general surgery. The number of events of VTE in groups receiving LMWH or UFH was the primary outcome of interest, and was used to calculate odds-ratios. Amongst 33,068 participants pooled from twelve studies, the rate of VTE was 1.3% in those treated with LMWH, and 3.1% in those treated with UFH. Although there was a wide difference in rates due to clinical heterogeneity, there was no statistically significant difference between treatment effects [OR 0.77; 95% CI 0.58-1.03; p value = 0.0783; I²= 62.3%; 12 studies]. In terms of the sensitivity analysis, sources overly contributing to heterogeneity were removed. The random-effects model continued to show insignificance between LMWH and UFH in the prevention of VTE in participants undergoing general surgery [OR 0.86; 95% CI 0.69-1.08; p value = 0.2005; I²= 0%; 9 studies]. Results show an equal effectiveness in the prevention of VTE between participants undergoing general surgery in those allocated to receive LMWH to those allocated to receive UFH.

Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer

In the general population, the incidence of thromboembolic events is 117 cases/100,000 inhabitants/year, while in cancer patient incidence, it is four-fold higher, especially in patients who receive chemotherapy and who are affected by pancreatic, lung or gastric cancer. At the basis of venous thromboembolism (VTE) there is the so-called Virchow triad, but tumor cells can activate coagulation pathway by various direct and indirect mechanisms, and chemotherapy can contribute to VTE onset. For these reasons, several studies were conducted in order to assess efficacy and safety of the use of anticoagulant therapy in cancer patients, both in prophylaxis setting and in therapy setting. With this review, we aim to record principal findings and current guidelines about thromboprophylaxis in cancer patients, with particular attention to subjects with additional risk factors such as patients receiving chemotherapy or undergoing surgery, hospitalized patients for acute medical intercurrent event and patients with central venous catheters. Nonetheless we added a brief insight about acute and maintenance therapy of manifested venous thromboembolism in cancer patients.

Intermittent pneumatic compression versus additional prophylaxis with enoxaparin for prevention of venous thromboembolism after laparoscopic surgery for gastric and colorectal malignancies: multicentre randomized clinical trial

Background

The role of antithrombotic chemoprophylaxis in prevention of venous thromboembolism (VTE) in laparoscopic surgery for gastric and colorectal malignancies is unknown. This study compared the addition of enoxaparin following intermittent pneumatic compression (IPC) with IPC alone in patients undergoing laparoscopic surgery for gastrointestinal malignancy.

Methods

In this multicentre RCT, eligible patients were older than 40 years and had a WHO performance status of 0 or 1. Exclusion criteria were prescription of antiplatelet or anticoagulant drugs and history of VTE. Patients were allocated to IPC or to ICP with enoxaparin in a 1 : 1 ratio. Stratification factors included sex, location of cancer, age 61 years and over, and institution. Enoxaparin was administered on days 1–7 after surgery. Primary outcome was VTE, evaluated by multidetector CT on day 7.

Results

Of 448 patients randomized, 208 in the IPC group and 182 in the IPC with enoxaparin group were evaluated. VTE occurred in ten patients (4·8 per cent) in the IPC group and six (3·3 per cent) in the IPC with enoxaparin group (P = 0·453). Proximal deep vein thrombosis and/or pulmonary embolism occurred in seven patients (3·4 per cent) in the IPC group and one patient (0·5 per cent) in the IPC with enoxaparin group (P = 0·050). All VTE events were asymptomatic and non‐fatal. Bleeding occurred in 11 of 202 patients in the IPC with enoxaparin group, and one patient needed a transfusion. All bleeding events were managed by discontinuation of the drug.

Conclusion

IPC with enoxaparin after laparoscopic surgery for gastric and colorectal malignancies did not reduce the rate of VTE. Registration number: UMIN000011667 ( https://www.umin.ac.jp/).

Does preoperative pharmacologic prophylaxis reduce the rate of venous thromboembolism in pancreatectomy patients?

BACKGROUND

Whether the risk of venous thromboembolism (VTE) may be reduced by preoperative administration of prophylactic heparin is unknown. We hypothesized that timing of heparin administration does not significantly alter the incidence of VTE in pancreatic surgery.

METHODS

An analysis was conducted using data from Massachusetts General Hospital's National Surgical Quality Improvement Program from 2012 to 2017. All patients admitted for elective pancreatic resection were included. The primary outcome was development of VTE. Multivariable regression was performed, adjusting for patient demographics and various clinical factors.

RESULTS

In total, 1448 patients were analyzed, of whom 1062 received preoperative heparin (73.3%). Overall, 36 (2.5%) patients developed VTE. On unadjusted analysis, there was no statistically significant difference between patients who received preoperative heparin compared with those who did not (2.6% vs. 1.3%, respectively; p = 0.079). On adjusted analysis, there was an association with increased VTE rates among patients who received preoperative heparin (OR 2.93, 95% CI 1.10-7.81; p = 0.031).

CONCLUSION

There was an association between preoperative heparin administration and increased incidence of VTE on adjusted analysis, possibly reflecting appropriate surgical judgment in patient selection for prophylaxis. These data question the inclusion of preoperative VTE pharmacologic prophylaxis as a reliable quality indicator.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery

BACKGROUND

In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis.

METHODS

Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control.

RESULTS

In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009).

CONCLUSION

In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

Venous Thromboembolism Incidence and Prophylaxis Use After Gastrectomy Among Korean Patients With Gastric Adenocarcinoma: The PROTECTOR Randomized Clinical Trial

Importance

The guidelines by the National Comprehensive Cancer Network and the American Society for Clinical Oncology recommend the routine use of thromboprophylaxis for patients with gastric adenocarcinoma. However, many physicians in Asian countries use venous thromboembolism (VTE) prophylaxis much less often because of the perceived lower VTE incidence in this population.

Objectives

To evaluate the incidence of postgastrectomy VTE in Korean patients with gastric adenocarcinoma, and to identify the complications and evaluate the efficacy and safety of VTE prevention methods.

Design, Setting, and Participants

The Optimal Prophylactic Method for Venous Thromboembolism After Gastrectomy in Korean Patients (PROTECTOR) randomized clinical trial was conducted between August 1, 2011, and March 31, 2015. Patients with histologically confirmed gastric adenocarcinoma presenting to a single center (Seoul St Mary's Hospital in Seoul, South Korea) were enrolled. Patients were randomized to either an intermittent pneumatic compression (IPC)-only group or an IPC+low-molecular-weight (LMW) heparin sodium group. The data were analyzed on intention-to-treat and per protocol bases. Data analysis was performed from April 1, 2016, to October 30, 2017.

Main Outcomes and Measures

Venous thromboembolism incidence was the primary outcome. Postoperative complications, particularly those associated with VTE prophylaxis methods, were the secondary end point.

Results

Of the 682 patients enrolled and randomized, 447 (65.5%) were male and 245 (34.5%) were female, with a mean (SD) age of 57.67 (12.94) years. Among the 666 patients included in the analysis, the overall incidence of VTE was 2.1%. The incidence of VTE was statistically significantly higher in the IPC-only group compared with the IPC+LMW heparin group (3.6%; 95% CI, 2.05%-6.14% vs 0.6%; 95% CI, 0.17%-2.18%; P = .008). Among the 14 patients (2.1%) with VTE, 13 were asymptomatic and received a deep vein thrombosis diagnosis, whereas 1 patient received a symptomatic pulmonary thromboembolism diagnosis. The overall incidence of bleeding complications was 5.1%. The incidence of bleeding complications was significantly higher in the IPC+LMW heparin group compared with the IPC-only group (9.1% vs 1.2%; P < .001). No cases of VTE-associated mortality were noted.

Conclusions and Relevance

Use of IPC alone is inferior to the use of IPC+LMW heparin in preventing postoperative VTE. Because LMW heparin is associated with a high bleeding risk, further study is needed to stratify the patients at high risk for perioperative development of VTE.

Trial Registration

ClinicalTrials.gov Identifier: NCT01448746.

Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options

The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.

Frequency and risk factors for venous thromboembolism after gastroenterological surgery based on the Japanese National Clinical Database (516 217 cases)

AIM

To investigate the frequency and risk factors of perioperative, symptomatic venous thromboembolism (VTE) after gastroenterological surgery.

METHODS

We assessed the frequency of and risk factors for VTE after eight gastroenterological procedures (total 516 217 cases including, gastrectomy, total gastrectomy, hepatectomy, esophagectomy, right hemicolectomy, low anterior resection, pancreaticoduodenectomy, and acute pan-peritonitis surgery) based on data from the National Clinical Database. Data collected between 2011 and 2013 (382 124 cases) were used as a test set, and data from 2014 (134 093 cases) were used as a validation set.

RESULTS

The frequency of deep vein thrombosis (DVT) was 0.3% (382 124 cases), and the incidence of pulmonary embolism (PE) was 0.2% (382 124 cases) ranging from 0.1% to 0.7% for DVT and from 0.1% and 0.3% for PE among eight surgeries, respectively. Analyses using pre-and intra-operative factors identified the top three risk factors for VTE as esophagectomy, pancreaticoduodenectomy, and hepatectomy. Using pre-, intra-, and postoperative factors, the second through fourth risk factors were sepsis, prolonged ventilation >48 hours and readmission within 30 days. The highest risks factor for PE using pre-, intra-, and postoperative factors were any cardiac events. Unplanned intubation was the fourth risk factor.

CONCLUSION

The risk for DVT and PE differed for each surgical procedure. VTE and PE risk factors changed after considering postoperative factors. It may be necessary to reconsider the prophylaxis depending on whether the complication occurs after surgery, particularly breathing and cardiac complications.

Efficacy and safety of anticoagulant prophylaxis for prevention of postoperative venous thromboembolism in Japanese patients undergoing laparoscopic colorectal cancer surgery

AIM

To investigate the efficacy and safety of anticoagulant prophylaxis to prevent postoperative venous thromboembolism (VTE) during laparoscopic colorectal cancer (CRC) surgery, which is unknown in Japanese patients.

METHODS

We conducted this randomized controlled trial at nine institutions in Japan from 2011 to 2015. It included 302 eligible patients aged 20 years or older who underwent elective laparoscopic surgery for CRC. Patients were randomly assigned to an intermittent pneumatic compression (IPC) therapy group or to an IPC + anticoagulation therapy group. Anticoagulation therapy comprised fondaparinux or enoxaparin for postoperative VTE prophylaxis. Postoperative VTE was diagnosed based on enhanced multi-detector helical computed tomography. The primary endpoint was VTE incidence, including asymptomatic cases, the secondary endpoint was incidence of major bleeding, and we conducted an intention-to-treat analysis. This study is registered in UMINCTR (UMIN000008435).

RESULTS

Postoperative VTE incidence was 5.10% with IPC therapy (n = 157) and 2.76% with IPC + anticoagulant therapy (n = 145; P = .293). We identified no symptomatic VTE cases. The major bleeding rates were 1.27% with IPC alone and 1.38% with the combination (P = .936). The overall bleeding rates were 7.69% for enoxaparin and 13.6% for fondaparinux (P = .500), and there were no bleeding-related deaths.

CONCLUSION

Anticoagulant prophylaxis did not reduce the incidence of VTE and the incidence of major bleeding was comparable between the two groups. Usefulness of perioperative anticoagulation was not demonstrated in this study. Pharmacological prophylaxis must be restricted in Japanese patients with higher risk of VTE.

Performance of Risk Assessment Models for Peripartum Thromboprophylaxis

Objective:

There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period.

Study Design:

This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant.

Results:

A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini.

Conclusion:

The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.

Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients

Essentials The risk of venous thromboembolism (VTE) after lumbar spine surgery (LBS) is not precisely known. More than 320 000 patients who underwent LBS in France between 2009 and 2014 were followed-up. The overall risk of VTE after LBS is less than 1% but modulated by patient and procedural factors. Surgical device implantation, anterior approach and complex surgery increase the risk of VTE. SUMMARY: Background Postoperative venous thromboembolism (VTE) is a severe complication, the risk of which after lumbar spine surgery (LBS) is not precisely known. Objective To estimate the incidence of VTE after LBS, and to identify individual and surgical risk factors. Methods All patients aged >18 years who underwent LBS in France between 2009 and 2014 were identified. Among 477 024 patients screened, exclusions concerned recent VTE or surgery, and multiple surgeries during the same hospital stay. Results In 323 737 patients (mean age 52.9 years, 51.4% male), we observed 2911 events (0.91%) after a median time of 12 days (Q1-Q3: 5-72 days). The multivariate adjusted Cox model showed increased risks associated with age (4% per year of age; 95% confidence interval [CI] 3.8-4.3), obesity (hazard ratio [HR] 1.32, 95% CI 1.18-1.46), active cancer (HR 1.65, 95% CI 1.5-1.82), previous thromboembolism (HR 5.41, 95% CI 4.74-6.17), severe paralysis (HR 1.47, 95% CI 1.17-1.84), renal disease (HR 1.28, 95% CI 1.04-1.6), psychiatric disease (HR 1.21, 95% CI 1.1-1.32), use of antidepressants (HR 1.13, 95% CI 1.03-1.24), use of contraceptives (HR 1.56, 95% CI 1.19-2.03), extended surgery for scoliosis (HR 3.61, 95% CI 2.96-4.4), implantation of pedicular screws with a 'dose-effect' association, and an anterior approach (HR 1.97, 95% CI 1.6-2.43) or a combined approach (HR 2.03, 95% CI 1.44-2.84). Conclusions The overall VTE risk after LBS is moderate (< 1%) but is widely modulated by several easily identifiable risk factors. The surgical community should be aware of this heterogeneity, adapt prevention according to patients and to the procedure, and use drug prophylaxis in the event of a high risk being present.

An Unusual Case of Deep Vein Thrombosis After Orthognathic Surgery: A Case Report and Review of the Literature

Deep vein thrombosis (DVT) is caused primarily by obstruction of blood flow in the deep veins in the lower limbs. It is a form of thrombophlebitis and can be a major cause of morbidity and mortality in hospitalized patients. This report describes an unusual case of DVT in a 21-year-old woman with Class III malocclusion who underwent bimaxillary orthognathic surgery (bilateral sagittal split osteotomy and Le Fort I osteotomy) under general anesthesia. She developed DVT unexpectedly 1 week after surgery, with episodes of sweating and chills in addition to lower limb edema, tenderness, and rigidity. D-dimer laboratory testing and venous Doppler sonography were performed and the DVT diagnosis was confirmed; therefore, the patient was admitted to the intensive care unit for anticoagulant and supportive therapy. Although the incidence rate of thromboembolism in hospitalized patients undergoing oral and maxillofacial surgery is low, it is not an operation without risk of DVT. This complication can cause fatal acute pulmonary thromboembolism and death. This case study illustrates that pharmacologic treatment of menorrhagia with mefenamic acid combined with intraoperative use of tranexamic acid for control of blood loss might put the patient at increased risk of DVT. Hence, maxillofacial surgeons should assess all their patients preoperatively for thromboembolism risk; if they suspect any risk factors in the patient, prompt diagnostic tests and management should be ordered.

In vitro evaluation of the effect of haemodilution with dextran 40 on coagulation profile as measured by thromboelastometry and multiple electrode aggregometry

We evaluated the effects of haemodilution with either dextran 40 or 0.9% normal saline on coagulation in vitro using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) and multiple electrode aggregometry (Multiplate® Platelet Function Analyser, Dynabyte, Munich, Germany). Venous blood samples obtained from 20 healthy volunteers were diluted in vitro with dextran 40 or normal saline by 5%, 10% and 15%. Fibrinogen concentration, ROTEM-EXTEM® (screening test for the extrinsic coagulation pathway), FIBTEM® (an EXTEM-based assay of the fibrin component of clot) parameters including coagulation time, clot formation time, alpha angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each level of haemodilution. Dextran 40 at 15% haemodilution significantly prolonged coagulation time, clot formation time and significantly decreased the alpha angle and maximal clot firmness (EXTEM amplitude at five minutes [A5] and ten minutes [A10]) compared with normal saline. The FIBTEM assay (maximal clot firmness and FIBTEM A5 and A10) showed a marked decrease in maximal clot firmness at all dilutions suggesting impaired fibrinogen activity and a risk of bleeding. Multiple electrode aggregometry did not demonstrate any platelet dysfunction. Haemodilution with dextran 40 causes significant impairment in clot formation and strength compared to saline haemodilution and undiluted blood. At the levels of in vitro haemodilution designed to reflect the clinical use of dextran infusions, no significant fibrinolysis or platelet inhibition was observed.

Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective

Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective.

SUMMARY

Background The incidence of venous thromboembolism (VTE) after liver surgery remains high. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis after liver surgery for the prevention of VTE. Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included thromboembolic deterrent hoses and sequential compression devices. Once hemostasis had been ensured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the duration of hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued to receive anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) minor/minimally invasive approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1%, and 10.5%, respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and on POD 1 for 84 (67.7%) patients. During 90 days of follow-up, no postoperative symptomatic deep vein thrombosis or pulmonary embolic events were diagnosed. Standard-protocol computed tomography scans of the chest, abdomen and pelvis that were obtained for 112 (90.3%) study patients showed no pulmonary emboli, or other thoracic, splanchnic or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.

Venous thromboembolic events in lymphoma patients: Actual relationships between epidemiology, mechanisms, clinical profile and treatment

Venous thromboembolic events (VTE) are an underestimated health problem in patients with lymphoma. Many factors contribute to the pathogenesis of thromboembolism and the interplay between various mechanisms that provoke VTE is still poorly understood. The identification of parameters that are associated with an increased risk of VTE in lymphoma patients led to the creation of several risk-assessment models. The models that evaluate potential VTE risk in lymphoma patients in particular are quite limited, and have to be validated in larger study populations. Furthermore, the VTE prophylaxis in lymphoma patients is largely underused, despite the incidence of VTE. The lack of adequate guidelines for the prophylaxis and treatment of VTE in lymphoma patients, together with a cautious approach due to an increased risk of bleeding, demands great efforts to ensure the implementation of current knowledge in order to reduce the incidence and complications of VTE in lymphoma patients.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol.

METHODS

The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.

RESULTS

Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.

CONCLUSIONS

A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

Venous thromboembolism following colorectal resection

AIM

The study investigated the rate of significant venous thromboembolism (VTE) following colorectal resection during the index admission and over 1 year following discharge. It identifies risk factors associated with VTE and considers the length of VTE prophylaxis required.

METHOD

All adult patients who underwent colorectal resections in England between April 2007 and March 2008 were identified using Hospital Episode Statistics data. They were studied during the index admission and followed for a year to identify any patients who were readmitted as an emergency with a diagnosis of deep venous thrombosis or pulmonary embolism.

RESULTS

In all, 35 997 patients underwent colorectal resection during the period of study. The VTE rate was 2.3%. Two hundred and one (0.56%) patients developed VTE during the index admission and 571 (1.72%) were readmitted with VTE. Following discharge from the index admission, the risk of VTE in patients with cancer remained elevated for 6 months compared with 2 months in patients with benign disease. Age, postoperative stay, cancer, emergency admission and emergency surgery for patients with inflammatory bowel disease (IBD) were all independent risk factors associated with an increased risk of VTE. Patients with ischaemic heart disease and those having elective minimal access surgery appear to have lower levels of VTE.

CONCLUSION

This study adds to the benefits of minimal access surgery and demonstrates an additional risk to patients undergoing emergency surgery for IBD. The majority of VTE cases occur following discharge from the index admission. Therefore, surgery for cancer, emergency surgery for IBD and those with an extended hospital stay may benefit from extended VTE prophylaxis. This study demonstrates that a stratified approach may be required to reduce the incidence of VTE.

Deep vein thrombosis related to environment (Review)

The first-time venous thromboembolism (VTE) is less frequent than other thrombotic events, however, both the pulmonary embolism (PE) and the deep vein thrombosis (DVT) show a frequent morbidity. Many factors play as risk situations in determining VTE, and the air exposure to the fine and ultrafine particulate matter (PM) as PM10, PM2.5, PM0.1 is considered. Epidemiological studies have supported this association although both the effective burden of the association and the mechanisms are to date unclear. The PM concentrations and the exposure time are notable as emerging factors. Interestingly, the seasonal climate variations resulted as effective risk factor for appearance of VTE or DVT. There is a need to ameliorate the environment by reducing the air pollution at global scale.

The Efficacy of Dextran-40 as a Venous Thromboembolism Prophylaxis Strategy in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.

Safety and Effectiveness of Enoxaparin as Venous Thromboembolism Prophylaxis after Gastric Cancer Surgery in Japanese Patients

Routine prophylaxis for venous thromboembolism (VTE) has been recommended after surgery not only in the West but also in Asia recently. The primary objective of this study was to investigate the safety and effectiveness of enoxaparin as a prophylaxis in patients undergoing distal, proximal, or total gastrectomy (TG) for gastric cancers. A total of 565 patients who underwent gastrectomy for gastric cancer were reviewed retrospectively. About 256 patients received postoperative prophylaxis with enoxaparin (2000 international unit twice daily for at least six days) and compression stockings; these patients were assigned to the enoxaparin group. About 257 patients comprised a historical control group, who used only compression stockings as a thromboprophylaxis. All patients underwent the same rehabilitation programs during the perioperative period. None of the patients developed symptomatic venous thromboembolism in either the enoxaparin group or the control group. The complication rate of bleeding was not significantly different between the two groups. Only one patient who used three antiplatelet agents concomitantly with enoxaparin required reoperation for anastomotic site bleeding. The usage of enoxaparin for venous thromboembolism prophylaxis is safe for Japanese patients after gastrectomy. But, cautious application is still needed especially when used concomitantly with other antiplatelet agents.

Thromboprophylaxis adherence to the ninth edition of American college of chest physicians antithrombotic guidelines in a tertiary care centre: a cross-sectional study

RATIONALE

Venous thromboembolic disease is a source of significant morbidity in hospitalized patients. The American College of Chest Physicians published the ninth edition of antithrombotic therapy and prevention guidelines (AT9) in 2012, addressing thromboprophylaxis in hospitalized patients. A notable difference from previous guidelines was utilization of risk assessment models for thrombosis and bleeding to classify patients into risk categories.

AIM

This study's objective was to evaluate thromboprophylaxis adherence to AT9 guidelines in a population of patients at the Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke.

METHOD

A cross-sectional study at the Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke was performed between June and December 2012. Patients' risk factors for thrombosis and bleeding, and thromboprophylaxis use were documented. The Padua and Caprini models were used to determine thrombotic risk, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score was used for bleeding risk.

RESULTS

A total of 290 patients were included for analysis. Overall, 200 patients (70%) received some form of thromboprophylaxis. However, according to AT9 guidelines, only 162 patients (55.9%) received recommended prophylaxis, 91 (31.4%) had overuse of prophylaxis and 37 (12.7%) had underuse of prophylaxis. Appropriate prophylaxis use was higher in surgical (61.8%) than in medical (46.7%) patients.

CONCLUSIONS

There was a high rate of inappropriate thromboembolic prophylaxis in our centre according to AT9 guidelines, mostly from overuse of prophylaxis. Utilization of risk assessment models in AT9 guidelines adds to the complexity of physician's decisions to prescribe thromboprophylaxis and needs further validation.

Prevention of venous thromboembolism in gynecologic oncology surgery

Gynecologic oncology patients are at a high-risk of postoperative venous thromboembolism and these events are a source of major morbidity and mortality. Given the availability of prophylaxis regimens, a structured comprehensive plan for prophylaxis is necessary to care for this population. There are many prophylaxis strategies and pharmacologic agents available to the practicing gynecologic oncologist. Current venous thromboembolism prophylaxis strategies include mechanical prophylaxis, preoperative pharmacologic prophylaxis, postoperative pharmacologic prophylaxis and extended duration pharmacologic prophylaxis that the patient continues at home after hospital discharge. In this review, we will summarize the available pharmacologic prophylaxis agents and discuss currently used prophylaxis strategies. When available, evidence from the gynecologic oncology patient population will be highlighted.

Legal issues related to postoperative pulmonary thromboembolism in Korea

PURPOSE

Currently, development of pulmonary thromboembolism (PTE) after surgery is frequently being followed by legal action in Korea, as consequences may be fatal. In the current study, we assessed possible countermeasures that medical teams can take when faced with conflicting opinions on responsibility for PTE.

METHODS

A retrospective analysis of claims handled by the Supreme Court and subordinate courts, from 1999 to 2015, was performed. We analyzed the type of procedure, associated complications, and critical legal points from the recorded judgments along with any liability limitations on surgeons.

RESULTS

After reviewing cases between 1999 and 2015, a total of 18 cases were analyzed. There were no cases in which the surgeon was held accountable between 1999 and 2002. From 2003, there were instances of the surgeon being held accountable, with a peak of cases in 2013. Legal standards applied in judicial decision-making related to appropriate use of preventive measures, operation characteristics, doctor's reaction towards symptom occurrence, obligation of postoperative medical care, and duty of explanation.

CONCLUSION

The courts in Korea have changed their position from one of denying doctors' liability to one of enforcing responsibility for PTE. Surgeons are therefore being held responsible with greater frequency, depending on the details of the case. Lessons can be learnt from precedents that can be incorporated into medical education and training programs with the aim of reducing both major PTE complication rates and litigation costs.

Efficacy of Dextran Solutions in Vascular Surgery

The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A MEDLINE search using “dextran,” “vascular surgery,” and “antiplatelet therapy” as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in “difficult” infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or “difficult” infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.