The incidence of venous thromboembolism after curative colon cancer surgery within an enhanced recovery after surgery programme

AIM

Based on three randomised controlled trials performed more than a decade ago, several national guidelines recommend prolonged venous thromboprophylaxis for 28 days following elective surgery for colon cancer. None of these studies were conducted within enhanced recovery after surgery setting. Newer studies indicate that prolonged prophylaxis might not be necessary with enhanced recovery after surgery. We aimed to provide further evidence to this unresolved discussion.

METHOD

Retrospective study of patients undergoing elective surgery for colon cancer stage I-III with enhanced recovery after surgery in the Capital Region of Denmark from 2014 to 2017. Patients were excluded if discharged on postoperative day 28 or later, dying before discharge, undergoing concomitant rectum resection, or discharged with vitamin K antagonists, direct-oral anticoagulants, or low molecular weight heparin treatment. All patients received only low-dose low molecular weight heparin as prophylaxis during their admission. The primary endpoint was symptomatic lower limb deep venous thrombosis or pulmonary embolism diagnosed within 60 days postoperatively.

RESULTS

Out of the included population of 1806 patients, only three experienced a symptomatic venous thromboembolic event; none was fatal. Two had pulmonary embolism associated with pneumonia, while one patient was diagnosed with lower limb deep venous thrombosis at postoperative day 15 after an uncomplicated course with first discharge at postoperative day 2.

CONCLUSION

The risk of symptomatic venous thromboembolism after elective surgery for colon cancer with enhanced recovery after surgery seems negligible even without prolonged prophylaxis. The current guidelines need to be reconsidered.

A survey of preoperative diagnosis and management of complicated appendicitis

INTRODUCTION

Complicated appendicitis is a severe condition, requiring early diagnosis and intervention to prevent complications. We aimed to investigate how resident surgeons distinguish and manage complicated appendicitis and their perspectives on preoperative diagnostic markers.

METHODS

The electronic survey was face validated. It contained questions about demographics, resident surgeons' considerations on the preoperative diagnosis of complicated appendicitis, and views on the need for and relevance of preoperative diagnostic markers. It was sent to all resident surgeons in the Eastern part of Denmark.

RESULTS

Seven hospitals and their 92 resident surgeons received the survey, and 90% responded. Most resident surgeons used symptoms and signs of pain to diagnose suspected complicated appendicitis. Half of the surgeons used computed tomographies, and 95% used routine blood tests. Most surgeons (83%) would change the management of patients with preoperatively diagnosed complicated appendicitis in comparison to uncomplicated appendicitis. However, only 17% felt the need for a preoperative diagnostic marker.

CONCLUSIONS

Resident surgeons in Eastern Denmark use non-specific diagnostic techniques to distinguish complicated from uncomplicated appendicitis and would change treatment if appendicitis was diagnosed preoperatively. However, despite limited interest, our results suggest a need for new diagnostic markers to differentiate between the severity of appendicitis, thus enhancing education and training in managing such cases.

FUNDING

None.

TRIAL REGISTRATION

None.

Visceral obesity is a predictor of surgical site occurrence and hernia recurrence after open abdominal wall reconstruction

PURPOSE

High body mass index (BMI) increases the risk of postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR). However, BMI does not provide specific information on the mass and distribution of adipose tissue. We hypothesized that visceral fat volume (VFV) was a better predictor than BMI for recurrence after AWR.

METHODS

We included all patients undergoing AWR at our institution from November 2010 to December 2016. Data were collected from a prospective database and all patients were summoned for follow-up. VFV was calculated from preoperative CT. The primary and secondary outcomes were hernia recurrence and 30-day postoperative surgical site occurrences (SSO), respectively.

RESULTS

We included a total of 154 patients. At follow-up, 42 (27.3%) patients had developed recurrence. The recurrence rate was significantly higher in patients with a VFV higher than the mean compared to a VFV lower than the mean, P = 0.004. After multivariable Cox-regression, VFV remained significantly predictive of recurrence (HR 1.09 per 0.5 L increase of VFV, P = 0.018). In contrary, BMI was not associated with hernia recurrence. There was no significant difference in the rate of SSO between patients with a VFV above and below the mean. A multivariable logistic regression model showed that VFV was significantly associated with development of SSO (OR 1.12 per 0.5 L increase, P = 0.009).

CONCLUSION

VFV was significantly associated with recurrence and SSOs after AWR. This study suggests VFV as a risk assessment tool for patients undergoing AWR.

Should simultaneous stoma closure and incisional hernia repair be avoided?

PURPOSE

Patients scheduled for stoma closure may also have an incisional hernia. Studies have reported acceptable outcomes after contaminated ventral hernia repair, but whether stoma closure and incisional hernia repair should be performed as a combined procedure is unknown. This study examined combined stoma closure and incisional hernia repair compared with incisional hernia repair only.

METHODS

This was a nationwide propensity-score matched study. Patients who underwent elective incisional hernia repair from 2007-2017 were identified in the Danish Hernia Database. All patients who underwent concurrent stoma closure were matched 1:3 with patients who underwent incisional hernia repair only. The primary outcome was reoperation for hernia recurrence, whereas secondary outcomes included anastomotic leakage, length of hospital stay, and 30-day reoperation and readmission rates.

RESULTS

In total, 516 patients were included. The risk of reoperation for recurrence was increased after concurrent stoma closure compared with incisional hernia repair only (hazard ratio 1.69, 95% confidence interval 1.01-2.82, p = 0.044). Seven (5.4%) patients who underwent incisional hernia repair concurrent to stoma closure were reoperated for anastomotic leakage. Length of hospital stay and reoperation rates within 30 days were increased after concurrent stoma closure compared with incisional hernia repair only (median 8 versus 3 days, p < 0.001 and 29.5% versus 18.6%, p = 0.013), whereas there was no difference in 30-day readmission rates (p = 0.251).

CONCLUSIONS

Stoma closure and incisional hernia repair should be performed as a dual-stage procedure to decrease the risk of hernia recurrence.

Enhanced recovery after abdominal wall reconstruction reduces length of postoperative stay: An observational cohort study

BACKGROUND

Enhanced recovery after surgery has been shown to lead to improved postoperative outcomes after several surgical procedures. However, only a few studies have examined the application of enhanced recovery after surgery after abdominal wall reconstruction. The aim of the current observational cohort study was to evaluate the outcomes of enhanced recovery after surgery after abdominal wall reconstruction in a large cohort.

METHOD

This was a retrospective cohort study comparing patients undergoing abdominal wall reconstruction in a standard care pathway (control group) with patients undergoing abdominal wall reconstruction in an enhanced recovery after surgery pathway. Registered outcomes included 30-day postoperative complications, length of stay, and readmission rate.

RESULTS

A total of 190 patients undergoing abdominal wall reconstruction for large incisional hernias were included in the study, of which 96 were treated according to standard protocol, and 94 underwent enhanced recovery after surgery pathway. Length of stay was significantly reduced after the introduction of enhanced recovery after surgery (median 4, interquartile range 3-6 days vs. control 5, 4-7 days, P < .001). There was no difference between the cohorts in the incidence of postoperative complications requiring operative intervention (enhanced recovery after surgery 10.6% vs control 10.4%, P = 1.0) or the rate of readmissions (enhanced recovery after surgery 16.0% vs control 12.5%, P = .635).

CONCLUSION

Enhanced recovery after surgery is feasible after abdominal wall reconstruction, leading to reduced length of stay without increasing the rate of complications or readmissions. Enhanced recovery should be implemented as standard in centers performing abdominal wall reconstruction.