Postoperative Pulmonary Embolism Research Articles

Racial Disparities in the Incidence of Pulmonary Embolism after Colectomy

Disparities in the incidence of pulmonary embolism (PE) based on racial and socioeconomic factors remain ill-defined. The present study evaluated the impact of race and hospital characteristics on rates of PE for all adult colectomy patients in the 2005 to 2014 Nationwide Inpatient Sample. Hospitals were designated as high-burden hospitals (HBHs) or low-burden hospitals of underinsured payers. Chi-squared tests of trend and multivariable regression adjusting for patient and hospital characteristics were performed. Of the 2,737,977 adult patients who underwent colectomy in the study period, 79 per cent were White, 10 per cent Black, and 7 per cent Hispanic. The annual rate of PE increased from 0.6 per cent in 2005 to 0.95 per cent in 2014 (P < 0.0001). Black patients had significantly higher incidence of PE than Whites (1.5% vs 0.9%, P < 0.001) and Hispanics (1.5% vs 0.8%, P < 0.001). Colectomy at HBHs was also associated with significantly higher rates of PE (1% vs 0.86%, P < 0.001). After adjusting for baseline differences, colectomy at HBHs (odds ratio 1.14, 95% confidence interval 1.02-1.27, P = 0.02) and Black race (odds ratio 1.4, 95% confidence interval 1.26-1.66, P < 0.001) were independent predictors of PE. In this national study of colectomy patients, Black patients experienced a disproportionate burden of postoperative PE. Further investigation into the causes and prevention of PE in vulnerable populations may identify targets for surgical quality improvement.

Evaluation of Lateral Temporal Bone Resection in Locally Advanced Tumours of the Parotid Gland.

This study evaluated the effects of lateral temporal bone resection (LTBR) on local tumour control in patients with locally advanced parotid gland tumours. The medical records of seven patients treated with radical parotidectomy combined with LTBR for locally advanced primary parotid tumour at the Otolaryngology Department of Dokuz Eylul University between January 1995 and December 2016 were retrospectively evaluated. Demographic variables, tumour characteristics, treatment properties, postoperative complications, follow-up durations and local, regional and distant recurrences were analysed. Before referral to our clinic, four patients had de novo primary parotid tumours, and three patients had a recurrence of primary parotid tumours. The histopathologic diagnoses were squamous cell carcinoma in two patients, and adenosquamous carcinoma, malignant myoepithelial carcinoma, adenocarcinoma, adenoid cystic carcinoma and spindle cell sarcoma in the other patients. During the follow-up period, one patient died due to postoperative pulmonary embolism in the first month, and four patients died due to distant metastasis without local or regional recurrences. LTBR combined with radical parotidectomy in locally advanced primary malignant parotid gland tumours is a feasible surgical technique for local tumour control. However, the most common cause of death in these cases is distant metastases, despite appropriate resection.

Prospective implementation of a standardized screening protocol for deep venous thrombosis in abdominal surgical oncology patients.

Venous thromboembolism (VTE) remains a major cause of perioperative morbidity and mortality despite implementation of prophylaxis guidelines. We sought to identify risk factors for occult deep venous thrombosis (DVT) following abdominal surgery for cancer and measure the clinical impact of a prospectively implemented standardized postoperative DVT screening protocol. Patients undergoing abdominal surgery for malignant indication were screened with early postoperative lower extremity duplex to identify DVT. Clinical and pathologic factors associated with DVT were identified. Among 255 patients meeting study criteria, 25 (9.8%) had occult lower extremity DVT on routine postoperative screening. Prior history of VTE and lower preoperative hemoglobin were independently associated with DVT (OR, 9.05; P = 0.004;and OR, 1.27; P = 0.025, respectively). Preoperative chemotherapy within 1 year and thrombocytopenia were associated with DVT in univariate analyses only. Five patients developed postoperative pulmonary emboli (2.0%); three following negative duplex and two following positive duplex for distal DVT for which the patients were not therapeutically anticoagulated due to a contraindication. There were no pulmonary emboli in duplex-positive patients who were anticoagulated or who had vena cava filter placed. Despite prophylaxis, the prevalence of occult DVT in abdominal oncologic surgery patients is considerable. Postoperative screening duplex can identify these events to guide management.

Kyphoplasty with purified silicone VK100 (Elastoplasty) to treat spinal lytic lesions in cancer patients: A retrospective evaluation of 41 cases

ObjectivesBalloon Kyphoplasty (BKP) for vertebral compression fractures (VCFs) in cancer patients is more challenging than for osteoporotic ones. Cord compressions are frequent and the incidence of complications ten-fold greater. Polymethylmetacrylate (PMMA) is the gold standard material for BKP but has disadvantages: exothermic reaction, short working time, rapid solidification, absence of osteoconduction. VK100 is a mixture of Dimethyl Methylvinyl siloxane and Barium Sulphate. It is elastic, adhesive to bone, leaves 30 min before solidification without exothermic reaction, and shows a stiffness close to the intact vertebrae. The surgical procedure, called elastoplasty, is similar to a BKP. Clinical results obtained with this new silicone in pathological VCFs have been investigated. Patients and Methods41 cancer patients with symptomatic VCFs (70 vertebral bodies), underwent percutaneous and open elastoplasties. Post-operative leakages, pulmonary embolism (PE) and adjacent fractures were carefully evaluated with neuroimaging. KPS, VAS and Dennis Pain Score were calculated pre- post-operatively and at the last follow-up. ResultsThe mean volume of silicone inserted in each vertebra was 3.8 cc. Complications included seven leakages (17%), two asymptomatic PE (4.3%) and 3 post-operative adjacent fractures (7.3%). Median follow-up was 29 months. A significant improvement was observed in KPS, VAS and Dennis Pain Score (p < .0001). The 1-yr survival rate was 76.9%. ConclusionsElastoplasty appears a safe and effective palliative treatment of VCFs in oncologic patients. Useful qualities of VK100 are the lack of exothermic reaction and the wider working window. The influence of biomechanical properties of silicone on reduction of adjacent level fractures requires further investigations.

Preservation technique of the piriformis tendon is superior to reattachment technique in terms of contiguity and muscle atrophy: using magnetic resonance imaging.

The preservation technique of the piriformis tendon during the posterolateral approach in total hip arthroplasty (THA) is reportedly superior to the reattachment technique in terms of dislocation. However, the long-term effects of preservation of the piriformis tendon during THA remain unknown. In this study, we evaluated the contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle during a long-term postoperative follow-up using magnetic resonance imaging (MRI). We retrospectively evaluated 48 patients with available MRI. The 48 patients were classified into a P group ( n = 29), in which the piriformis tendon was preserved, and an R group ( n = 19), in which the piriformis was reattached after sectioning. The mean follow-up duration was 45.9 months. The contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle were evaluated in all patients. The piriformis tendon remained attached to the greater trochanter in all P-group patients and 68.4% of R-group patients. The mean piriformis muscle atrophy ratios were 15.9% ± 21.1% in the P group and 41.6% ± 19.1% in the R group ( p < 0.001). The conjoined tendon repair remained intact in 72.4% of P-group patients and 36.8% of R-group patients ( p < 0.05). The mean internal obturator muscle atrophy ratio was 31.4% ± 26.2% in the P group and 50.4% ± 19.1% in the R group ( p < 0.05). No postoperative pulmonary embolism, wound infection, deep infection, or hip dislocation occurred. In our study, we suggest that the preservation technique of the piriformis tendon is superior to the reattachment technique in terms of contiguity and muscle atrophy.

Prevalence and Predictors of Preoperative Venous Thromboembolism in Asymptomatic Patients Undergoing Major Oncologic Surgery

Postoperative venous thromboembolism (VTE) is a leading cause of in-hospital mortality for cancer patients; however, the prevalence of preoperative VTE remains unclear. The aim of this study was to evaluate the prevalence and risk factors associated with preoperative VTE in asymptomatic patients undergoing major oncologic surgery. Retrospective analysis of 346 patients identified from our prospectively maintained database of patients undergoing abdominopelvic oncologic surgery from 2009 to 2016. The prevalence of preoperative VTE found on screening venous duplex scan was 10.1%. Patients with a history of prior VTE were more likely to have a preoperative deep vein thrombosis (DVT) versus those with no prior VTE (42.9% vs. 4.5%, p<0.01). Relative risk for prior VTE was 8.2 [95% confidence interval (CI) 4.7-14.3]. Older age was also associated with preoperative VTE. Regression modeling determined that patients were 1.24-fold as likely to have a preoperative DVT for every 5-year increase in age (relative risk 1.24, 95% CI 1.09-1.42). Patients with preoperative DVT were more likely to have been diagnosed with sepsis 1month prior to surgery (8.6% vs. 1.6%, p=0.04). There were no postoperative pulmonary emboli. The overall postoperative complication rate was higher in those with a preoperative DVT (25.7% vs. 13.2%, p=0.071). Asymptomatic patients undergoing major oncologic surgery have a 10.1% prevalence of preoperative DVT. Increasing age, recent diagnosis of sepsis, and a history of prior VTE are significantly associated with preoperative DVTs. This suggests high-risk oncologic patients may benefit from screening lower extremity venous duplex ultrasound prior to Surgery.

Catheter Directed Thrombolysis in Treatment of Acute Iliofemoral Deep Venous Thrombosis : Determinants of Outcome

Background: Acute deep vein thrombosis (DVT) of the lower limbs occurs in about 1.0 person per 1000 population per year and is associated with substantial morbidity. Although anticoagulation effectively prevents thrombus extension, pulmonary embolism, death, and recurrence may occur. Moreover, many patients develop venous dysfunction resulting in post-thrombotic syndrome (PTS). PTS is associated with reduced individual health-related quality of life and a substantially increased economic burden.Hence, additional and more aggressive treatment, including systemic thrombolysis, thrombectomy, and catheter- directed thrombolysis (CDT), has been introduced to accelerate thrombus removal. Numerous studies suggest that additional CDT may provide highly effective clot lysis.There is little doubt that the overall benefit of thrombolysis depends on multiple factors, including predisposing risks, symptom duration, thrombus extension, and technical approaches and interventional success. Aim of the Work: This study aimed to define predictors of immediate and mid-long-term anatomic and clinical failures to guide patient selection and to set a standard for patient and physician expectations. Patients and Methods: This is a prospective observational cohort study that enrolled 20 patients (22 limbs) who presented to the Ain Shams University hospitals in the period from 7/2015 to 7/2017 with acute iliofemoral deep venous thrombosis (IFDVT) and fulfilled the inclusion criteria (mentioned below). Intrathrombus catheter directed thrombolysis (CDT) was done. Assessments of predictors of immediate periprocedural success was based on degree of clot lysis and resolution of symptoms and signs. Incidence of postthrombotic syndrome (PTS) was calculated at 6 months postoperative using Villalta score (≥5 vs <5). Results: During the study duration, 20 patients (22 limbs) were recruited. The mean age was 40.95 ± 12.35 years old, 11 patients (12 limbs) were women. The indication for CDT was severe progressive pain/swelling (18 limbs), and phlegmasia cerulea dolens (4 limbs). 5 patients (7 limbs) had IVC thrombosis at the initial venography. 5 limbs had balloon dilatation only while iliac stenting was done in 12 limbs. 15 patients received CDT for 48 hours while 5 patients (7 limbs) received CDT for 24 hours (mean duration of CDT was 1.68 days). As regards bleeding, only 2 cases of those who had CDT for 24 hours had bleeding, while bleeding occurred in 12 cases of those who had CDT for 48 hours. There were no recurrent DVT, intra or postoperative pulmonary embolism nor death within the study population till the end of the follow up period (6months). 6 months post intervention, 7 limbs were free of PTS (Villalta score < 5), 15 limbs had mild to moderate PTS, and no patients had severe PTS. The mean Villalta score was 5.14 ± 1.859. Conclusion: In our study, determinants of outcome following CDT for acute IFDVT were: 1) access site, 2) dose of thrombolytic agent used, 3) duration of thrombolysis, and 4) thrombus score at the end of the procedure. More studies should be done comparing not only the effect of CDT on incidence of PTS but also its effect on its severity (e.g. Villalta score) on short and long term.

Utility of Viscoelastic Assays Beyond Coagulation: Can Preoperative Thrombelastography Indices Predict Tumor Histology, Nodal Disease, and Resectability in Patients Undergoing Pancreatectomy?

Hypercoagulability and malignancy have been linked since the 1860s. However, the impact of different neoplasms on multiple components of the coagulation system remains poorly understood. Thrombelastography (TEG) enables measurement of coagulation incorporating clotting through fibrinolysis. We hypothesize that specific TEG indices that are associated with hypercoagulability can be appreciated in patients with adenocarcinoma undergoing pancreatic resection. Blood samples were obtained from patients undergoing pancreatic resection before surgical incision and assayed with TEG. The 4 indices of coagulation measured by TEG included in the analysis were R time, angle, maximum amplitude, and lysis at 30 minutes. Patient tumor type, nodal disease, and mass resectability were contrasted with TEG indices. One hundred patients were enrolled over 18 months. The majority (63%) of patients had adenocarcinoma. Patients with adenocarcinoma had increased angle compared with other lesions (49 degrees [interquartile range {IQR} 37 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p= 0.011). When excluding patients that underwent neoadjuvant therapy, patients with adenocarcinoma had shorter R times (13 minutes [IQR 9 to 16 minutes] vs 14 minutes [IQR 12 to 18 minutes]; p= 0.051), steeper angles (49 degrees [IQR 40 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p= 0.010), and higher maximum amplitude (67 mm [IQR 61 to 69 mm] vs 62 mm [IQR 57 to 67 mm]; p= 0.017). Nodal disease was associated with a significantly increased angle (49 degrees [IQR 42 to 59 degrees] vs 40 degrees [IQR 32 to 50 degrees]; p= 0.002) and maximum amplitude (64 mm [IQR 61 to 69 mm] vs 62 mm [IQR 56 to 67 mm]; p= 0.017). Patients who underwent successful mass resection had longer R times (14 minutes [IQR 11 to 17 minutes] vs 10 minutes [IQR 9 to 15]; p=0.033) and shorter angles (44 degrees [IQR 35 to 55 degrees] vs 58 degrees [IQR 45 to 66 degrees]; p= 0.025). Patients with adenocarcinoma undergoing pancreatic resection have multiple TEG abnormalities consistent with hypercoagulability. These TEG outputs are associated with tumor type, nodal disease, and probability of a successful resection. The use of preoperative TEG has the potential to aid surgeon and patient discussions on anticipated disease burden and prognosis before resection.

A Higher Altitude Is an Independent Risk Factor for Venous Thromboembolisms After Total Hip Arthroplasty

BackgroundHigh altitudes lead to physiological changes that may predispose to venous thromboembolisms (VTEs) including deep vein thrombosis and pulmonary embolism (PE). No prior study has evaluated if there is also a higher risk of VTEs for total hip arthroplasties (THAs) performed at higher elevations. The purpose of this retrospective study was to identify if undergoing THA at a higher altitude center (>4000 feet above sea level) is an independent risk factor for a postoperative VTE. MethodsA thorough evaluation of the Pearl Diver Database was performed for patients undergoing THAs from 2005 to 2014. Using International Classification of Diseases Ninth Edition facilitated in ascertaining patients who underwent THA. Using the ZIP codes of the hospitals where the procedure occurred, we separated our groups into high-altitude (>4000 ft) and low-altitude (<100 ft) groups. ResultsIn the first 30 postoperative days, patients undergoing THA at a higher altitude experienced a significantly higher rate of PEs (odds ratio, 1.74; P = .003) when compared to similar patients at lower altitudes. This trend was also present for PE (odds ratio, 1.59; P < .001) at 90 days postoperatively. ConclusionTHAs performed at higher altitudes (>4000 feet) have a higher rate of acute postoperative PEs in the first 30 days and also 90 days postoperatively when compared to matched patients receiving the same surgery at a lower altitude (<100 feet). THA patients at high altitude should be counseled on these increased risks; however, owing to retrospective nature and confounders, prospective studies are necessary to explore this outcome in more detail.

Facilitating technologies in minimally invasive aortic valve replacement: a propensity score analysis.

Minimally invasive aortic valve replacement (MIAVR) can be technically demanding and may lead to prolonged operative time. We evaluated the intraoperative and postoperative patient outcomes following implementation of 2 facilitating technologies (FT) in MIAVR: the Cor-Knot titanium fastener and Custodiol-histidine-tryptophan-ketoglutarate solution. A total of 299 patients underwent MIAVR from 2008 to 2016; 172 (57.5%) patients were included in the FT group and 127 (42.5%) patients in the control group (No-FT). We performed a propensity score analysis, matching 94 pairs. Primary end points were cardiopulmonary bypass and cross-clamp times. Secondary end points were blood product utilization, postoperative ejection fraction, intensive care unit and hospital lengths of stay, the in-hospital mortality rate and the incidence of stroke, sepsis, renal failure, atrial fibrillation, pulmonary embolism, pneumonia and prolonged mechanical ventilator support. The 2 matched groups had similar baseline characteristics. Significant reductions in cardiopulmonary bypass (104 ± 22 vs 118 ± 30 min, P < 0.001) and cross-clamp times (78 ± 17 vs 90 ± 21 min, P < 0.001) were noted in the FT group. Intraoperative red blood cell and cryoprecipitate transfusions (P < 0.001), prolonged mechanical ventilator support (P = 0.013), postoperative renal failure (P = 0.031) and hospital length of stay (P = 0.002) were all significantly decreased. There was insufficient evidence to detect a difference in postoperative ejection fraction, stroke, sepsis, pneumonia, pulmonary embolism or atrial fibrillation (P > 0.49). FT decreased intraoperative times, intraoperative red blood cell and cryoprecipitate transfusions, the need for prolonged mechanical ventilator support, renal failure and hospital length of stay. Using FT in MIAVR will allow for more reproducible, widespread adoption of minimally invasive approaches for aortic valve replacement.

Bariatric Surgery in Patients on Chronic Anticoagulation Therapy.

Perioperative management of chronically anti-coagulated patients undergoing bariatric surgery requires a balance of managing hemorrhagic and thromboembolic risks. The aim of this study is to evaluate the incidence of hemorrhagic complications and their management in chronically anticoagulated (CAT) patients undergoing bariatric surgery. A retrospective review of CAT patients undergoing bariatric surgery at an academic center from 2008 to 2015 was studied. A total of 153 patients on CAT underwent surgery [Roux-en-Y gastric bypass (n = 79), sleeve gastrectomy (n = 63), and adjustable gastric banding (n = 11)] during the study period: 85 patients (55%) were females; median age was 56years (interquartile range [IQR] 49-64), and median BMI was 49kg/m2 (IQR 43-56). The most common indications for CAT were venous thromboembolism (n = 87) and atrial fibrillation (n = 83). Median duration of procedure and estimated intraoperative blood loss was 150min (IQR 118-177) and 50ml (IQR 25-75), respectively. Thirty-day postoperative complications were reported in 33 patients (21.6%) including postoperative bleeding (n = 19), anastomotic leak (n = 3), and pulmonary embolism (n = 1). Nineteen patients (12%) with early postoperative bleeding were further categorized to intra-abdominal (n = 10), intraluminal (n = 6), and at the port site or abdominal wall (n = 3). All-cause readmissions within 30days of surgery occurred in 19 patients (12%). There was no 30-day mortality. In our experience, patients who require chronic anticoagulation medication are higher than average risk for postoperative complications and all-cause readmission rates. Careful surgical technique and close attention to postoperative anticoagulation protocols are essential to decrease perioperative risk in this high-risk cohort.

Venous Thromboembolism after Inpatient Surgery in Administrative Data vs NSQIP: A Multi-Institutional Study

Previous studies have documented significant differences between administrative data and registry data in the determination of postoperative venous thromboembolism (VTE). The goal of this study was to characterize the discordance between administrative and registry data in the determination of postoperative VTE. This study was performed using data from the American College of Surgeons NSQIP merged with administrative data from 8 different hospitals (5 different medical centers) between 2013 and 2015. Occurrences of postoperative vein thrombosis (VT) and pulmonary embolism (PE) as ascertained by administrative data and NSQIP data were compared. In each situation where the 2 sources disagreed (discordance), a 2-clinician chart review was performed to characterize the reasons for discordance. The cohort used for analysis included 43,336 patients, of which 53.3% were female and the mean age was 59.5 years. Concordance between administrative and NSQIP data was worse for VT (κ 0.57; 95% CI 0.51 to 0.62) than for PE (κ 0.83; 95% CI 0.78 to 0.89). A total of 136 cases of discordance were noted in the assessment of VT; of these, 50 (37%) were explained by differences in the criteria used by administrative vs NSQIP systems. In the assessment of postoperative PE, administrative data had a higher accuracy than NSQIP data (odds ratio for accuracy 2.86; 95% CI 1.11 to 7.14) when compared with the 2-clinician chart review. This study identifies significant problems in ability of both NSQIP and administrative data to assess postoperative VT/PE. Administrative data functioned more accurately than NSQIP data in the identification of postoperative PE. The mechanisms used to translate VTE measurement into quality improvement should be standardized and improved.

The role of preoperative deep vein thrombosis screening in neurooncology.

OBJECTIVEVenous thromboembolism (VTE) is a major cause of morbidity in patients undergoing neurosurgical intervention. The authors postulate that the introduction of a routine preoperative deep vein thrombosis (DVT) screening protocol for patients undergoing neurosurgical intervention for brain tumors would result in a more effective diagnosis of DVT in this high-risk subgroup, and subsequent appropriate management of the condition would reduce pulmonary embolism (PE) rates and improve patient outcomes.METHODSThe authors conducted a prospective study of 115 adult patients who were undergoing surgical intervention for a brain tumor. All patients underwent preoperative lower-limb Doppler ultrasonography scanning for DVT screening. Patients with confirmed DVT underwent a period of anticoagulation therapy, which was stopped prior to surgery. An inferior vena cava (IVC) filter was inserted to cover the perioperative period during which anticoagulation therapy was avoided due to bleeding risk before restarting the therapy at a later date. Patients underwent follow-up performed by a neurooncology multidisciplinary team, and subsequent complications and outcomes were recorded.RESULTSSeven (6%) of the 115 screened patients had DVT. Of these patients, one developed postoperative PE, and another had bilateral DVT postoperatively. None of the patients without preoperative DVT developed VTE postoperatively. Age, symptoms of DVT, and previous history of VTE were significantly higher in the group with preoperative DVT. There were no deaths and no complications from the anticoagulation or IVC filter insertion.CONCLUSIONSPreoperative screening for DVT is a worthwhile endeavor in patients undergoing neurosurgical intervention. A multidisciplinary approach in management of anticoagulation and IVC filter insertion is safe and can minimize further VTE in such patients.

Complications following radical surgery for malignant pleural mesothelioma—prevention and management

Radical surgery for malignant pleural mesothelioma (MPM) is a major undertaking for any patient and whilst it cannot be assumed to lead to a cure from the disease it is performed with the intent of prolonging survival. The surgical techniques used are either extra-pleural pneumonectomy (EPP) or extended pleurectomy/decortication (EPD). Patients undergoing EPD surgery have a lower short-term mortality compared to those undergoing EPP surgery. The better perioperative mortality has led to a recent trend towards preference to EPD, whenever possible. The prompt treatment of post-operative complications, may improve the patients survival, therefore, heightened awareness of their possibility and where possible preventive measures should be employed. Complications following surgery for MPM can be considered in three categories—pleuropulmonary: parenchymal atelectasis, pneumonia, pulmonary oedema, acute respiratory distress syndrome (ARDS), bronchopleural fistula (BPF), persistent air leak and pleural empyema—cardiovascular: post-operative hypotension, arrhythmias, cardiac herniation and pulmonary embolism (PE)—technical: haemothorax, chylothorax, prosthetic patch dehiscence and oesophagopleural fistula. We discuss the early warning signs, preventative actions and management strategies.

Prevalence and risk factors of venous thromboembolism in postoperative patients: A retrospective study.

Objective:To investigate the prevalence of and risk factors for Venous Thromboembolism (VTE) in postoperative patients.Methods:This descriptive, cross-sectional, retrospective study was conducted from August 2016 to October 2016 at two university hospitals and one public hospital. Total 217,354 patients records who underwent surgery in between 2010 and 2015 were examined. The study sample consisted of 123 patients who had postoperative venous thrombosis and pulmonary embolism, and whose discharge details, consultation data, diagnostic reports, and tests were examined in detail.Results:The prevalence of VTE in postoperative patients was 5.6/10,000. The mean age of the patients was 60.22±18.56 years. Of 123 patients, 51.20% were male, 30.90% were smokers, 46.30% had a comorbid disease, and 27.60% were diagnosed with cancer. Of the patients who had postoperative VTE, 65.0% had major surgery. Pharmacologic thromboprophylaxis was used in only 24.4% of patients (n=30).Conclusion:The prevalence of VTE in the present study is lower than that in other studies. Because surgery is a risk factor for VTE, patients who will be operated should be assessed. Considering the present results, we can assume that patients’ conditions are not being assessed appropriately. In addition, findings indicate that a standard for preventing VTE has not yet been established.

Anaesthetic management of robotic-assisted gynaecology surgery in the morbidly obese - A case series of 46 patients in a UK university teaching hospital.

Background and Aims:The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position.Methods:We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis.Results:The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days.Conclusion:Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.

Appendectomy for Appendicitis Has Worse Hospital Outcomes in Inflammatory Bowel Disease Patients

Background and Aims: Appendectomy is the choice of surgery for appendicitis but little is known about its outcomes in patients with Inflammatory Bowel Disease (IBD). We sought to compare hospital outcomes of appendectomy for appendicitis between patients with and without IBD. Methods: This is a cross-sectional study utilizing the Nationwide Inpatient Sample between 2009 and 2013. Patients with appendicitis undergoing appendectomy were identified using appropriate International Classification of Diseases codes. Primary outcomes of interest included length of stay (LOS), hospital costs, and post-surgical complications. Univariate and multivariate analyses were used to compare these outcomes between patients with and without IBD. Results: A total of 849,312 patients with appendicitis undergoing appendectomy were included in this study, of which 4261 patients had IBD. IBD patients had longer LOS and increased hospital costs. Crohn’s disease (CD) patients were more likely to develop post-operative pulmonary embolism (adjusted odds ratio (aOR) 7.06, 95% Confidence Interval (CI) (2.19, 22.79)) and anemia (aOR 2.23, 95% CI (1.21, 4.10)), whereas ulcerative colitis patients were more likely to develop post-operative deep vein thrombosis (aOR 9.79, 95% CI (2.41, 39.75)). CD patients were more likely to have perforated ap-pendicitis (aOR 1.37, 95% CI (1.67, 1.11)) and open appendectomy (aOR 1.56, 95% CI (1.96, 1.27)). Conclusions: Appendectomy for appendicitis in IBD patients is associated with adverse hospital outcomes. Focused attempts are needed to decrease the risk of DVT and PE in these patients. Treating patient’s pre-surgical anemia and proactive venous thromboembolism prophylaxis in IBD patients undergoing appendectomy for appendicitis might improve hos-pital outcomes.

Novel venous thromboembolic disease (VTED) prophylaxis for total knee arthroplasty-aspirin and fish oil.

Despite the demonstrated success of multiple anticoagulation therapies for post-operative prophylaxis of thromboembolic disease in lower extremity arthroplasties, each modality comes with a unique set of limitations. Thus, the ideal anticoagulation medication which provides adequate therapy with minimal cost, complications, or added patient work is yet to be defined. One promising novel thrombophylactic supplement is fish oil, as many preliminary clinical trials have demonstrated a protective effect of fish oil against thrombosis in multiple clinical settings. In addition, others have demonstrated synergistic effect when combined with aspirin. However, there are paucity of studies that compared combined aspirin and fish oil therapy for venous thromboembolism prophylaxis with other pharmacological agents, especially in the field of orthopaedics. Therefore, this study evaluated: (I) risk of post-operative deep vein thrombosis (DVT) and pulmonary embolism (PE), and (II) bleeding complications; among patients who had primary total knee arthroplasty (TKA) and received one of the following regimens: (i) 325 mg aspirin and mechanical pulsatile stocking; (ii) rivaroxaban; or (iii) 325 mg aspirin and 1,000 mg fish oil. This was a 6-year prospective study analyzing the postoperative thromboembolic prophylaxis received by patients who underwent primary TKA. Patients who had a previous history of thromboembolic disease were excluded from the study due to an increased risk of recurrent clot formation. A total of 850 patients were enrolled. A total of 300 patients enrolled between October 2011 and June 2013 received 325 mg aspirin and mechanical pulsatile stocking, while 250 patients enrolled between June 2013 and December 2014 received rivaroxaban. A total of 300 patients enrolled between January 2015 and July 2017 received 325 mg aspirin and 1,000 mg fish oil. Major venous thromboembolic events (VTEs) and bleeding complications within the first 90 days post-operatively were recorded in each cohort. The odds ratios (ORs) and 95% confidence intervals (CIs), for thromboembolic and bleeding events were calculated and compared between the aspirin and fish oil cohort vs. aspirin and pulsatile stocking cohort, and aspirin and fish oil cohort vs. rivaroxaban cohort. A P value of <0.05 was used to determine statistical significance. A total of 25 DVT events were recorded including 1 of 300 (0.33%) in the aspirin and fish oil cohort, 22 of 300 (7.33%) in the aspirin and pulsatile stocking cohort and 2 of 250 (0.8%) in the rivaroxaban cohort. When comparing ORs, patients who received aspirin and fish oil demonstrated significantly lower risk for thromboembolic events when compared to the aspirin and pulsatile stocking group (OR: 0.045; 95% CI: 0.0061-0.3394; P<0.05). When compared to the rivaroxaban cohort the ORs did not differ significantly (OR: 0.416; 95% CI: 0.0376-4.6223; P>0.05). In addition, no PE events were recorded in any of the cohorts. When compared to rivaroxaban, the fish oil and aspirin cohort demonstrated significantly lower incidence of bleeding episodes (1 of 300, 0.33% vs. 30 of 250 patients, 12%; OR: 0.0278; 95% CI: 0.0038-0.2051; P<0.05). No bleeding events were recorded in the aspirin and pulsatile stocking cohort. This study demonstrated the potentially synergistic anti-thromboembolic effect of aspirin and fish oil in the prevention of post-operative venous thromboembolism in primary TKA patients. Based on the results from this study, the authors conclude that the combination of aspirin and fish oil maybe an excellent thromboprophylactic modality for patients to use after TKA. These results warrant further, larger prospective studies analyzing the use of fish oil supplements in VTE prophylaxis.

The risk of postoperative hemorrhage and efficacy of heparin for preventing deep vein thrombosis and pulmonary embolism in adult patients undergoing neurosurgery: a systematic review and meta-analysis

The aim of this meta-analysis was to examine the risk of postoperative bleeding and efficacy of heparin for preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in adult patients...

Determining risk of postoperative pulmonary embolism in the gynecologic oncology population

Determining risk of postoperative pulmonary embolism in the gynecologic oncology population