Extended Venous Thromboembolism Prophylaxis Research Articles

Safety of postdischarge extended venous thromboembolism prophylaxis after hepatopancreatobiliary surgery

The risk of venous thromboembolism (VTE) after hepatopancreatobiliary (HPB) surgery is high. Extended postdischarge prophylaxis in this patient population has been controversial. This study aimed to examine the safety of postdischarge extended VTE prophylaxis in patients at high risk of VTE events after HPB surgery. Adult patients risk stratified as very high risk of VTE who underwent HPB operations between 2014 and 2020 at a quaternary care center were included. Patients were matched 1:2 extended VTE prophylaxis to the control group (patients who did not receive extended prophylaxis). Analyses compared the proportions of adverse bleeding events between groups. A total of 307 patients were included: 103 in the extended prophylaxis group and 204 in the matched control group. Demographics were similar between groups. More patients in the extended VTE prophylaxis group had a history of VTE (9% vs 3%; P=.045). There was no difference in bleeding events between the extended VTE prophylaxis and the control group (6% vs 2%; P=.091). Of the 6 patients with bleeding events in the VTE prophylaxis group, 5 had gastrointestinal (GI) bleeding, and 1 had hemarthrosis. Of the 4 patients with bleeding events in the control group, 1 had intra-abdominal bleeding, 2 had GI bleeding, and 1 had intra-abdominal and GI bleeding. Patients discharged with extended VTE prophylaxis after HPB surgery did not experience more adverse bleeding events compared with a matched control group. Routine postdischarge extended VTE prophylaxis is safe in patients at high risk of postoperative VTE after HPB surgery.

Real World Data of Extended Venous Thromboembolism Prophylaxis with Low Dose Apixaban Following Cancer Associated Thrombosis

Introduction: Cancer-associated thrombosis (CAT) is a leading cause of morbidity and mortality among patients with malignancies. Direct oral anticoagulants (DOACS) are frequently used to manage CAT. Bleeding risk is higher in cancer patients influencing the risk/benefit balance of treatment. Unlike in other cases of venous thromboembolism (VTE), there are no guidelines for dose reduction and extended prophylaxis after the initial period of full-dose treatment for cancer patients. We aimed to provide efficacy and safety data on patients with CAT that received extended VTE prophylaxis with a reduced dose of apixaban for the prevention of VTE recurrence. Aim: To investigate the clinical outcomes of patients with CAT treated with low-dose apixaban after initial treatment with full-dose anticoagulation. Methods: Data of all cancer patients over the age of 18 years from Sheba medical center that were diagnosed with VTE during the years 2012-2022, and treated with low-dose apixaban were retrieved using the MD Clone platform. All demographic, laboratory, and clinical data were collected from computerized medical files and statistically analyzed. The study was approved by the local IRB committee. Results: One hundred and seventeen patients with CAT, treated by a reduced dose of apixaban after initial full dose treatment for at least 6 months, were followed at our center. Table 1 summarizes the demographic and clinical characteristics of our cohort. At the time of diagnosis with CAT the median age of patients was 72 (IQR 62-78).70.1% were female and 29.9% were male. 54.7% of patients had metastatic disease. After initial treatment with full-dose anticoagulation, patients were switched to low-dose apixaban for a median of 31 months (IQR 21-44 months). Twenty-one patients (18%) had a minor bleed and four patients (3.4%) had a major bleed while treated with low-dose apixaban. During this period 7 patients (6%) had a recurrent VTE. Two-thirds of the patients died. Mortality was attributed to thrombosis in one (0.9%) patient and major bleeding in two patients (1.7%). Conclusions: Low-dose apixaban may be a safe and appropriate option for extended treatment of cancer patients with VTE, with low rates of recurrence and major bleeding.

Persistent underuse of extended venous thromboembolism prophylaxis in patients undergoing major abdominal cancer operations.

Guidelines recommend extended venous thromboembolism (VTE) prophylaxis for high-risk populations undergoing major abdominal cancer operations. Few studies have evaluated extended VTE prophylaxis in the Medicare population who are at higher risk due to age. We performed a retrospective study using a 20% random sample of Medicare claims, 2012-2017. Patients ≥65 years with an abdominal cancer undergoing resection were included. Primary outcome was the proportion of patients receiving new extended VTE prophylaxis prescriptions at discharge. Secondary outcomes included postdischarge VTE and hemorrhagic events. The study included 72 983 patients with a mean age of 75. Overall, 8.9% of patients received extended VTE prophylaxis. This proportion increased (7.2% in 2012, 10.6% in 2017; p < 0.001). Incidence of postdischarge hemorrhagic events was 1.0% in patients receiving extended VTE prophylaxis and 0.8% in those who did not. The incidence of postdischarge VTE events was 5.2% in patients receiving extended VTE prophylaxis and 2.4% in those who did not. Adherence to guideline-recommended extended VTE prophylaxis in high-risk patients undergoing major abdominal cancer operations is low. The higher rate of VTE in the prophylaxis group may suggest we captured some therapeutic anticoagulation, which would mean the actual rate of thromboprophylaxis is lower than reported herein.

463 Adherence to Extended Venous Thromboembolism Prophylaxis for Post Operative Resection of Colorectal Malignancies

Abstract Aim Patients undergoing cancer resection abdominal surgery are at high risk of developing venous thrombo-embolism (VTE) in the post-operative period. To reduce this risk, these patients should be considered for extended pharmacological VTE prophylaxis for 28 days post-surgery as per NICE guidelines (NICE NG89). In our surgical department, we give all colorectal cancer resection patients 5000 units of Deltaparin for 28 days post resection unless it is contraindicated. We aimed to evaluate adherence to this guideline. Method This is a single-centre retrospective audit study. We included 100 colorectal cancer resection cases between 1st October 2021 and 28th February 2022 (n = 100). Retrospective data was collected including the type of procedure, histology and whether post-operative Deltaparin was prescribed for 28 days. All consecutive colorectal cancer resections were included in the study. The data was collected from the patient electronic records, electronic prescribing system and the electronic discharge summaries. Results The most common operation was anterior resection of the rectum (42%) followed by right hemicolectomy (40%). The Adherence to the NICE guidelines for extended VTE prophylaxis was 87%. Conclusions The adherence to the NICE guidelines in our department falls below the national target of 90% adherence. To improve the compliance, we will carry out staff education on appropriate anticoagulation prescribing and also display informative posters in the surgical wards to increase the awareness. We will aim to re-audit the adherence to the guidelines after implementing these measures.

FTP3.13 Patients undergoing major abdominal cancer surgery should receive 28 days of VTE prophylaxis: a single-centre audit of patients treated surgically for colorectal cancer

Abstract Aims The incidence of venous thromboembolism (VTE) following major abdominal cancer surgery is reduced by extended post-operative VTE prophylaxis using low molecular weight heparin, without an associated increase in bleeding risk. The National Institute for Health and Care Excellence (NICE) issued guidance in 2018, recommending 28 days of post-operative VTE prophylaxis for these patients. We audited local compliance for patients undergoing major surgery for colorectal cancer. Methods Clinical records of patients with colorectal cancer were retrieved from a local registry. 104 patients treated surgically between 01/08/2021–24/01/2023 were included in the first audit cycle. Retrospective analysis investigated the nature of operations (elective or emergency) and whether extended VTE prophylaxis was prescribed. Records were examined for documented plans for prophylaxis post-discharge. Data was presented locally and strategies to increase compliance were implemented. Second cycle data is being collected prospectively from 25/01/2023 until the presentation date. Results Of the included patients, 89% underwent elective operations and 11% required emergency surgery. Our first cycle demonstrated 84% compliance with guidance across all patients (88% for elective and 55% for emergency procedures, respectively). An explicitly documented plan for extended prophylaxis was observed for 82% of recipients and 12% of those who did not receive it. Conclusions Compliance to guidance was particularly high for electively treated patients. This should not differ between elective and emergency cases. Documenting post-discharge anticoagulation plans may act as a simple quality improvement measure. We plan to re-audit and present second cycle results following implementation of interventions, including education, posters, and improving electronic discharge processes.

ThTP4.9 Adherence to extended venous thrombo-embolism prophylaxis for post operative resection of colorectal malignancies

Abstract Aim Patients undergoing cancer resection abdominal surgery are at high risk of developing venous thrombo-embolism (VTE) in the post-operative period. To reduce this risk, these patients should be considered for extended pharmacological VTE prophylaxis for 28 days post-surgery as per NICE guidelines (NICE NG89). In our surgical department, we give all colorectal cancer resection patients 5000 units of Deltaparin for 28 days post resection unless it is contraindicated. We aimed to evaluate adherence to this guideline. Method This is a single-centre retrospective audit study. We included 100 colorectal cancer resection cases between 1st October 2021 and 28th February 2022 (n=100). Retrospective data was collected including the type of procedure, histology and whether post-operative Deltaparin was prescribed for 28 days. All consecutive colorectal cancer resections were included in the study. The data was collected from the patient electronic records, electronic prescribing system and the electronic discharge summaries. Results The most common operation was anterior resection of the rectum (42%) followed by right hemicolectomy (40%). The Adherence to the NICE guidelines for extended VTE prophylaxis was 87%. Conclusion The adherence to the NICE guidelines in our department falls below the national target of 90% adherence. To improve the compliance, we will carry out staff education on appropriate anticoagulation prescribing and also display informative posters in the surgical wards to increase the awareness. We will aim to re-audit the adherence to the guidelines after implementing these measures.

Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices.

Venous thromboembolism (VTE) is the most common cause of death following metabolic/bariatric surgery (MBS), with most events occurring after discharge. The available evidence on ideal prophylaxis type, dosage, and duration after discharge is limited. Assess metabolic/bariatric surgeon VTE prophylaxis practices and define existing variability. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. The members of the ASMBS Research Committee developed and administeredaweb-based survey to MBSAQIP medical directors and ASMBS members to examine the differences in clinical practice regarding the administration of VTE prophylaxis after MBS. Overall, 264 metabolic/bariatric surgeons (136 medical directors and 128 ASMBS members) participated in the survey. Both mechanical and chemical VTE prophylaxis was used by 97.1% of the participants, knee-high compression devices by 84.7%, enoxaparin (32.4% 40 mg every 24 hours, 22.7% 40 mg every 12 hours, 24.4% adjusted the dose based on body mass index) by 56.5%, and heparin (46.1% 5000 units every 8 hours, 22.6% 5000 units every 12 hours, 20.9% 5000 units once preoperatively) by 38.1%. Most surgeons (81.6%) administered the first dose preoperatively, while the first postoperative dose was given on the evening of surgery by 44% or the next morning by 42.2%. Extended VTE prophylaxis was prescribed for 2 weeks by 38.7% and 4 weeks by 28.9%. VTE prophylaxis practices vary widely among metabolic/bariatric surgeons. Variability may be related to limited available comparative evidence. Large prospective clinical trials are needed to define optimal practices for VTE risk stratification and prophylaxis in bariatric surgery patients.

Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery

BackgroundClinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined.MethodsThis study retrospectively analyzed a random 10 % sample of the 2009–2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding.ResultsThe study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81–2.96) or bleeding (OR, 0.72, 95 % CI, 0.32–1.61).ConclusionsThe majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.

Outcomes in patients discharged with extended venous thromboembolism prophylaxis after hospitalization with COVID-19.

Venous thromboembolism (VTE) is a known complication of coronavirus disease (COVID-19) in patients requiring hospitalization and intensive care. We examined the association between extended pharmacological VTE prophylaxis and outcomes among patients hospitalized with COVID-19. This was a retrospective cohort study of patients with an index positive SARS-CoV-2 polymerase chain reaction (PCR) test at the time of, or during hospitalization. Patients who were prescribed extended pharmacological VTE prophylaxis were compared against patients who were not. Multivariable logistic regression was used to produce odds ratio (OR) estimates and Cox proportional hazard models for hazard ratios (HR) with 95% CI to examine the association between pharmacological VTE prophylaxis and outcomes of interest. Primary outcomes were 30- and 90-day VTE events. Secondary outcomes included 30- and 90-day mortality, 30-day superficial venous thrombosis (SVT), acute myocardial infarction (MI), acute ischemic stroke, critical limb ischemia, clinically significant bleeding, and inpatient readmissions. A total of 1936 patients were included in the study. Among them, 731 (38%) were discharged on extended pharmacological VTE prophylaxis. No significant difference was found in 30- and 90-day VTE events among groups. Patients discharged on extended VTE prophylaxis showed improved survival at 30 (HR: 0.35; 95% CI: 0.21-0.59) and 90 days (HR: 0.36; 95% CI: 0.23-0.55) and reduced inpatient readmission at 30 days (OR: 0.12; 95% CI: 0.04-0.33) when compared to those without. Patients discharged on extended VTE prophylaxis after hospitalization due to COVID-19 had similar thrombotic events on follow-up. However, use of extended VTE prophylaxis was associated with improved 30- and 90-day survival and reduced risk of 30-day inpatient readmission.

Rate of venous thromboembolism on an enhanced recovery program after gynecologic surgery

Venous thromboembolism is a life-threatening complication of surgery. An Enhanced Recovery After Surgery program is a multimodal care pathway that facilitates faster recovery from surgery. The rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery program is unknown. This study aimed to evaluate the rate of venous thromboembolism within 30 days of gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center. Data were collected prospectively on Enhanced Recovery After Surgery pathway gynecologic patients undergoing open surgery (November 3, 2014, to March 31, 2021) and minimally invasive surgery (February 1, 2017, to March 31, 2021). Care was delivered at a tertiary cancer care center located in a large urban area. Patients undergoing emergency surgery or multispecialty surgeries were excluded. Patients undergoing open surgery were to receive heparin prophylaxis before surgery, sequential compression devices during surgery and admission, and low-molecular-weight heparin prophylaxis during admission. If diagnosed with malignancy, patients were to receive extended venous thromboembolism prophylaxis for 28 days after surgery. For minimally invasive surgery, patients received only sequential compression devices during surgery and no heparin prophylaxis before or after surgery. Venous thromboembolism events were included if detected on imaging obtained for symptoms or other indications. Descriptive statistics and bivariate statistical analyses were performed. Of 3329 patients, 1519 (45.6%) underwent laparotomy, 1452 (43.6%) underwent laparoscopy, and 358 (10.8%) underwent robotic surgery. The incidence rates of venous thromboembolism were 0.6% (n=21; 95% confidence interval, 0.4%-0.9%) overall, 1.1% (n=16, 95% confidence interval, 0.6%-1.7%) in the open approach, and 0.3% (n=5; 95% confidence interval, 0.3%-0.6%) in the minimally invasive approach (P=.02). The incidence rates of venous thromboembolism among the 1999 patients with malignancy were 0.9% (n=18; 95% confidence interval, 0.5%-1.4%) overall, 1.4% (n=15; 95% confidence interval, 0.7%-2.2%) in the open approach, and 0.3% (n=3; 95% confidence interval, 0.1%-0.9%) in the minimally invasive approach. The incidence rates of venous thromboembolism among the 1165 patients with benign disease were 0.3% (n=3; 95% confidence interval, 0.1%-0.7%) overall, 0.3% (n=1; 95% confidence interval, 0.0%-1.7%) in the open approach, and 0.2% (n=2; 95% confidence interval, 0.0%-0.9%) in the minimally invasive approach. The rate of venous thromboembolism among patients undergoing laparotomy and minimally invasive surgery on an Enhanced Recovery After Surgery pathway was ≤1%. This study established a benchmark for the rate of venous thromboembolism after gynecologic surgery on an Enhanced Recovery After Surgery pathway performed at a cancer center.

Postoperative Venous Thromboembolism in Colon and Rectal Cancer: Do Tumor Location and Operation Matter?

Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals.

Safety of post discharge extended VTE prophylaxis after hepatopancreatobiliary surgery

Background: Patients undergoing hepatopancreaticobiliary (HPB) operations for malignancy are at high risk for venous thromboembolism (VTE) following surgery. Due to potential risk of bleeding, differing recommendations have been proposed for the use of extended VTE prophylaxis after hospital discharge in this patient population. This study aims to examine the safety of routine post-discharge extended VTE prophylaxis in patients at high risk for VTE events following HPB surgery.

Venous thromboembolism prophylaxis following colorectal surgery: a survey of American Society of Colon and Rectal Surgery (ASCRS) member surgeons.

Postoperative venous thromboembolism (VTE) is associated with significant morbidity. Evidence from other surgical specialties demonstrate inadequate use of extended VTE prophylaxis following cancer surgery. While guidelines recommend extended VTE prophylaxis for patients undergoing surgery for colorectal cancer (CRC), it is unknown to what extent colon and rectal surgeons adhere to these recommendations. An 18-question online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS). The survey was designed to capture knowledge, attitudes, and practices regarding ASCRS VTE prevention guidelines. Questions were also designed to elucidate barriers to adopting these guidelines. The survey was distributed to 2,316 ASCRS-member surgeons and there were 201 complete responses (8.7% response rate). Most respondents (136/201, 68%) reported that they were familiar with ASCRS VTE prevention guidelines and used them to guide their practice. Extended VTE prophylaxis was reported to be routinely prescribed by the majority of surgeons following CRC resection (109/201, 54%), with an additional 27% reporting selective prescribing (55/201). The most frequently reported reasons for not prescribing extended VTE chemoprophylaxis following CRC resection included patient compliance and insurance/copay issues. Most ASCRS-member surgeon respondents reported that they are familiar with ASCRS VTE prevention guidelines, though only 54% surgeons reported routinely prescribing extended VTE prophylaxis following CRC surgery. Patient compliance and insurance issues were identified as the most common barriers. Targeted interventions at the surgeon, patient, and payer level are required to increase the use of extended VTE prophylaxis following CRC resection.

Does Synchronous Liver Intervention Increase Risk of Venous Thromboembolism in Patients with Metastatic Small-Bowel and Pancreatic Neuroendocrine Tumors?

INTRODUCTION: Previous literature suggests a higher incidence of venous thromboembolism (VTE) in patients with pancreatic neuroendocrine tumor (PNET) but no other gastrointestinal NET. In this study, we analyze the incidence of VTE in patients with metastatic small-bowel neuroendocrine tumors (SBNETs) and PNET undergoing synchronous liver procedures to determine whether these patients require extended VTE prophylaxis. METHODS: The American College of Surgeons NSQIP database was queried from 2008 to 2019 for patients undergoing operation for SBNET, PNET, benign small bowel, and pancreatic pathology. Patients with SBNET and PNET were stratified by additional operative procedures for liver metastasis (LM). The rate of 30-day postoperative VTE (pulmonary embolism [PE] and/or deep vein thrombosis [DVT]) was compared. Pearson’s chi-square and ANOVA tests were used for analysis. RESULTS: A total of 89,054 patients met inclusion criteria (63,396 benign small bowel, 3,073 SBNET, including 918 with LM, 18,724 benign pancreas, 3,861 PNET including 949 with LM). There was no statistically significant difference in the rate of VTE in patients with small-bowel disease with or without LM. Patients in the PNET with LM group had a significantly higher rate of PE but not DVT than those undergoing pancreatic operation for benign pathology (2.4% vs 1.1%; p < 0.001). Total operation time (odds ratio [OR] 1.002; p = 0.002), length of hospital stay (OR 1.027; p < 0.001), and preoperative dialysis (OR 3.779; p = 0.004) were independently associated with VTE. However, synchronous liver intervention was not an independent factor associated with VTE or PE in patients with PNET (Table 1). Table 1. - Rates of DVT and PE in Patients with PNETs and SBNETs Undergoing Synchronous Liver Procedures Group Total Rate of DVT Rate of PE Benign small-bowel procedures 63,396 987 (1.6%) 398 (0.6%) Procedures for SBNETs 2,155 26 (1.2%) 11 (0.5%) SBNETs with synchronous liver procedures 918 12 (1.3%) 9 (1.0%) Benign pancreas procedures 18,724 400 (2.1%) 203 (1.1%) Procedures for PNETs 2,912 59 (2.0%) 44 (1.5%) PNETs with synchronous liver procedures 949 18 (1.9%) 23 (2.4%) CONCLUSION: Synchronous liver intervention does not increase the risk of VTE in patients with metastatic SBNET or PNET.

Risk factors for venous thromboembolism (VTE) after adrenalectomy for adrenal cortical neoplasms.

Incidence of venous thromboembolism (VTE) after adrenalectomy for adrenal cortical carcinoma (ACC) is unknown. Herein, we aim to identify the relative incidence and risk factors of VTE after adrenalectomy for ACC. The American College of Surgeons National Surgical Quality Improvement Programdatabase was queried to identify patients who underwent adrenalectomy for ACC, Cushing syndrome (CS), and benign adrenal cortical syndromes (BACS). Univariable and multivariable analyses were used to determine clinical characteristics, 30-day postoperative VTE occurrences, and associated risk factors. Khorana oncologic risk score (KRS) for VTE was calculated and compared between groups. A total of 5896 patients were analyzed: 576 ACC, 371 CS, and 4949 BACS. Postoperative VTE occurred 0.9%, with the highest rate occurring in ACC (2.6% ACC vs. 1.6% CS vs. 0.7% BACS, p < 0.001). Forty percent of VTEs in theACC cohort were diagnosed postdischarge. ACC patients with KRS ≥ 2 had a 9.6% incidence of VTE (p = 0.007). Multivariable analysis identified increased age (p = 0.03), presence of adrenal cancer (p = 0.01), and KRS ≥ 2 (p = 0.005) as risk factors for VTE after adrenalectomy. Postoperative VTE after adrenalectomy occurs most frequently for ACC. ACC patients with increased age and/or Khorana score ≥2 should be considered for extended VTE prophylaxis.

The Duration and Magnitude of Postdischarge Venous Thromboembolism Following Colectomy.

Objective:To assess the impact of current guidelines by reporting weekly postoperative postdischarge venous thromboembolism (VTE) rates.Summary Background Data:Disparity exists between the postoperative thromboprophylaxis duration colectomy patients receive based on surgical indication, where malignant resections routinely receive 28 days extended thromboprophylaxis into the postdischarge period and benign resections do not.Methods:English national cohort study of colectomy patients between 2010 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type and surgical indication, absolute incidence rates (IRs) per 1000 person-years and adjusted incidence rate ratios (aIRRs) for postdischarge VTE were calculated for the first 4 weeks following resection and postdischarge VTE IRs for each postoperative week to 12 weeks postoperative.Results:Of 104,744 patients, 663 (0.63%) developed postdischarge VTE within 12 weeks after colectomy. Postdischarge VTE IRs per 1000 person-years for the first 4 weeks postoperative were low following elective resections [benign: 20.66, 95% confidence interval (CI): 13.73–31.08; malignant: 28.95, 95% CI: 23.09–36.31] and higher following emergency resections (benign: 47.31, 95% CI: 34.43–65.02; malignant: 107.18, 95% CI: 78.62–146.12). Compared with elective malignant resections, there was no difference in postdischarge VTE risk within 4 weeks following elective benign colectomy (aIRR=0.92, 95% CI: 0.56–1.50). However, postdischarge VTE risks within 4 weeks following emergency resections were significantly greater for benign (aIRR=1.89, 95% CI: 1.22–2.94) and malignant (aIRR=3.13, 95% CI: 2.06–4.76) indications compared with elective malignant colectomy.Conclusions:Postdischarge VTE risk within 4 weeks of colectomy is ∼2-fold greater following emergency benign compared with elective malignant resections, suggesting emergency benign colectomy patients may benefit from extended VTE prophylaxis.

Assessing the use of Extended Venous Thromboembolism Prophylaxis on the Rates of Venous Thromboembolism and Postpancreatectomy Hemorrhage Following Pancreatectomy for Malignancy.

To compare rates of venous thromboembolism (VTE) and postpancreatectomy hemorrhage (PPH) in patients with pancreatic or periampullary malignancy preimplementation and postimplementation of routine extended VTE prophylaxis. Guidelines recommend up to 28 days of VTE prophylaxis following major abdominal cancer operations. There is a paucity of data examining rates of VTE and PPH in patients who receive extended VTE prophylaxis following pancreatectomy. Single-institution analysis of patients who underwent pancreatectomy for malignancy (2004-2021). VTE and PPH rates within 90 days of discharge were compared based on receipt of extended VTE prophylaxis with enoxaparin. A total of 478 patients were included. Twenty-two (4.6%) patients developed a postoperative VTE, 12 (2.5%) of which occurred postdischarge. Twenty-five (5.2%) patients experienced PPH, 13 (2.7%) of which occurred postdischarge. There was no associated difference in the development of postdischarge VTE between patients who received extended VTE prophylaxis and those who did not (2.3% vs 2.8%, P =0.99). There was no associated difference in the rate of postdischarge PPH between patients who received extended VTE prophylaxis and those who did not (3.4% vs 1.9%, P =0.43). In the subset of patients on antiplatelet agents, the addition of enoxaparin did not appear to be associated with higher VTE (3.9 vs. 0%, P =0.31) or PPH (3.0 vs. 4.5%, P =0.64) rates. Extended VTE prophylaxis following pancreatectomy for malignancy was not associated with differences in postdischarge VTE and PPH rates. These data suggest extended VTE prophylaxis is safe but may not be necessary for all patients following pancreatectomy.

Extended Anticoagulation after Radical Cystectomy Using Direct Acting Oral Anticoagulants: A Single-Institutional Experience.

Extended prophylactic anticoagulation therapy with enoxaparin 40 mg daily is effective in reducing the incidence of venous thromboembolism (VTE) after radical cystectomy. In an effort to improve compliance, we modified our extended anticoagulation options to direct oral anticoagulants (DOAs; eg apixaban 2.5 mg twice daily or rivaroxaban 10 mg daily). This study assesses our experience with extended VTE prophylaxis using DOAs. This is a retrospective review that included all patients who underwent radical cystectomy at our institution between January 2007 and June 2021. Multivariable logistic regression models were constructed to test the hypothesis that use of extended DOAs is similar to enoxaparin in terms of VTE events and risk of gastrointestinal bleeding. In 657 patients, the median age was 71 years. Of the 101 patients who received extended VTE prophylaxis, 46 (45.5%) patients received rivaroxaban/apixaban. At 90 days of followup, 40 patients (7.2%) who did not receive extended prophylaxis on discharge developed a VTE compared to 2 patients (3.6%) in the enoxaparin group and 0 patients in the DOA group (p=0.11). Seven patients (1.3%) who did not receive extended anticoagulation developed gastrointestinal bleeding compared to 0 patients in the enoxaparin group and 1 (2.2%) in the DOA group (p=0.60). On multivariable analysis, both enoxaparin and DOAs were associated with similar reductions in the risk of developing VTE compared to controls (enoxaparin: OR 0.33, p=0.09 and DOAs: OR 0.19, p=0.15). These preliminary data suggest that oral apixaban and rivaroxaban are acceptable alternatives to enoxaparin with similar safety and efficacy profiles.

A151 RISK FACTORS FOR VENOUS THROMBOEMBOLISM AFTER HOSPITAL DISCHARGE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

BackgroundInflammatory bowel disease (IBD) is a chronic inflammatory condition which is independently associated with venous thromboembolism (VTE). Although the absolute risk of VTE is greatest during hospitalization, the risk remains elevated in the early post-discharge period. The risk factors for VTE during this vulnerable period remain unknown.AimsWe performed a systematic review and meta-analysis to determine risk factors for VTE in the post discharge period among adult patients with IBD.MethodsWe performed a systematic search of Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials from inception through April 29, 2021 for publications that reported risk factors for VTE during the post-discharge period among patients with IBD. Study eligibility was assessed independently in duplicate without age or language restriction. We defined the post-discharge period as within 6 months of discharge. Pooled summary estimates of adjusted hazard/odds ratios, when available, were calculated for individual risk factors using random effects model with 95% confidence intervals. The analysis was performed when a minimum of three studies were available for a given risk factor. Heterogeneity was assessed using I2 statistic. Study quality was assessed using an adapted version of the National Institute of Health criteria.ResultsWe identified 10 studies from a total of 4339 abstracts that met our inclusion criteria: 8 population-based studies, 1 multicenter observational study and 1 single center observational study. Risk factors for post-discharge VTE were assessed at 6 weeks in 1 study, 1 month in 5 studies, 3 months in 2 studies, and 6 months in 2 studies. The variables assessed in our meta-analysis are reported in Table 1. Exposure to corticosteroid (odds ratio [OR], 1.77; 95% CI, 1.53–2.06) but not biologics (OR, 1.21; 95% CI 0.80–1.82) was associated with an increased risk of VTE. Furthermore, greater length of stay (OR 1.49; 95% CI, 1.01–2.20), ulcerative colitis (OR 1.41; 95% CI, 1.19–1.66), history of malignancy (OR 1.35; 95% CI, 1.12–1.62), and surgery during admission (OR 1.26; 95% CI, 1.12–1.42) but not female sex (OR 0.98; 95% CI, 0.88–1.10) or surgery type (OR 1.09; 95% CI, 0.75–1.57) were associated with increased risk of VTE after discharge. Overall, the study quality was rated as fair.ConclusionsIn our meta-analysis, which consisted of moderate quality of evidence, we identified multiple risk factors associated with VTE in the post-discharge period. This work will help inform which factors should be considered for developing point of care clinical predictive models to help guide when extended VTE prophylaxis is required. Funding AgenciesNone

Application of the Caprini Risk Assessment Model to Select Patients for Extended Thromboembolism Prophylaxis After Sleeve Gastrectomy

BackgroundThe Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications. Materials and MethodsWe conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients’ Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG. ResultsSix hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m2 (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis. ConclusionThe Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population.