Postoperative Thromboprophylaxis Research Articles

PEDS4: Postoperative anticoagulation with bivalirudin versus heparin for HeartMate 3 in children

Background: Bivalirudin has become the standard of care for paracorporeal VAD support in children, although its utilization and outcomes in children with intracorporeal VADs have not been thoroughly studied. We compared the outcomes in children receiving bivalirudin versus unfractionated heparin (UFH) for early (<14 days) post-operative thromboprophylaxis. Methods: Using the ACTION network registry, we conducted a multicenter, retrospective analysis with all patients receiving bivalirudin or UFH for HeartMate 3 (HM3). Survival and adverse events in 14 days post VAD implantation were compared between patients receiving bivalirudin, UFH, or both agents. Results: Between 4/1/18-7/31/22, 171 patients with median age 15.3 years (IQR 12.9-17.3) and weight 62 kg (IQR 45-81) underwent HM3 implantation. Of these, 65 (38%) received bivalirudin, 91 (53%) received UFH and 15 (8.7%) received both agents. At 2 weeks, there was 100% survival in the bivalirudin group, 98% survival in the UFH group, and 100% survival in the bivalirudin/UFH group (p=0.65). Stroke incidence was similar across all anticoagulation agents [4 (6.1%) bivalirudin, 5 (5.5%) UFH, 1 (6.7%) bivalirudin/UFH, p=0.99]. Major bleeding incidence was similar across the anticoagulation agents [2 (3%) bivalirudin, 5 (5.5%) UFH, 1 (6.7%) bivalirudin/UFH, p=0.6). Hemolysis was lower in patients treated with bivalirudin [3 (4.6%)] versus UFH [7 (7.6%)] and bivalirudin/UFH [3 (33%)], p=0.006. Conclusions: In pediatric patients with a HeartMate3, anticoagulation with bivalirudin resulted in similar survival, stroke-free survival, and bleeding-free survival compared to UFH, with lower hemolysis with bivalirudin. More evaluation is required to understand the burden of post-operative hemocompatibility related adverse events.

Efficacy and Safety of Rivaroxaban for Postoperative Thromboprophylaxis in Patients After Bariatric Surgery

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality after bariatric surgery. Clinical end point studies on thromboprophylaxis with direct oral anticoagulants in patients undergoing bariatric surgery are lacking. To assess the efficacy and safety of a prophylactic dose of 10 mg/d of rivaroxaban for both 7 and 28 days after bariatric surgery. This assessor-blinded, phase 2, multicenter randomized clinical trial was conducted from July 1, 2018, through June 30, 2021, with participants from 3 academic and nonacademic hospitals in Switzerland. Patients were randomized 1 day after bariatric surgery to 10 mg of oral rivaroxaban for either 7 days (short prophylaxis) or 28 days (long prophylaxis). The primary efficacy outcome was the composite of deep vein thrombosis (symptomatic or asymptomatic) and pulmonary embolism within 28 days after bariatric surgery. Main safety outcomes included major bleeding, clinically relevant nonmajor bleeding, and mortality. Of 300 patients, 272 (mean [SD] age, 40.0 [12.1] years; 216 women [80.3%]; mean body mass index, 42.2) were randomized; 134 received a 7-day and 135 a 28-day VTE prophylaxis course with rivaroxaban. Only 1 thromboembolic event (0.4%) occurred (asymptomatic thrombosis in a patient undergoing sleeve gastrectomy with extended prophylaxis). Major or clinically relevant nonmajor bleeding events were observed in 5 patients (1.9%): 2 in the short prophylaxis group and 3 in the long prophylaxis group. Clinically nonsignificant bleeding events were observed in 10 patients (3.7%): 3 in the short prophylaxis arm and 7 in the long prophylaxis arm. In this randomized clinical trial, once-daily VTE prophylaxis with 10 mg of rivaroxaban was effective and safe in the early postoperative phase after bariatric surgery in both the short and long prophylaxis groups. ClinicalTrials.gov Identifier: NCT03522259.

289 The Timing of Pharmacologic Venous Thromboembolism Prophylaxis Initiation for Burn Patients with Concomitant Trauma

Abstract Introduction Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Clinical guidelines regarding thromboprophylaxis in burn patients with concomitant trauma are unclear. We aimed to compare the outcomes of early versus late thromboprophylaxis initiation for burn patients with concomitant trauma. Methods A 3-year analysis of 2017-2019 TQIP. We identified all adult burn patients with concomitant trauma who received thromboprophylaxis. We excluded patients that had severe TBI (Head AIS &amp;gt; 2), were transferred, those that died &amp;lt; 24 hours of admission and those that underwent hemorrhage control surgery. Patients were stratified based on the timing of initiation of postoperative thromboprophylaxis: Early (&amp;lt; 24 hours of admission) versus Late ( &amp;gt;24 hours). Multivariate regression analyses were performed. Outcome measures were odds of deep venous thrombosis (DVT), pulmonary embolism (PE), unplanned return to OR, unplanned ICU admission, post-prophylaxis PRBC transfusion and in-hospital mortality. Results 9,272 trauma patients with concomitant burns who received thromboprophylaxis were identified. Overall, mean age was 41.3 ± 13.4 years, 71.5% were male, and median ISS was 3 [1-8]. 53% had second degree burns, and 39% had more than 10% of total body surface area affected. Median time to thromboprophylaxis initiation was 11 [6-20.6] hours. On multivariate regression, patients who received thromboprophylaxis after 24 hours of admission had 1.8 times higher odds of developing DVT (aOR=1.8, 95% CI=1.04-3.11, p=0.03), 4.8 times higher odds of developing PE (aOR=4.8, 95% CI=1.9-11.9, p&amp;lt;.001), 2 times higher odds of unplanned ICU admission (aOR=2.1, 95% CI=1.4-3.1, p&amp;lt;0.001), and nonsignificant increase in the odds of unplanned return to OR (aOR=2, 95% CI=0.96-4.31, p=0.06). Further, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion (aOR=1.1, 95% CI=0.8-1.4, p=0.4), and in-hospital mortality (aOR=0.68, 95%CI=0.4-1.1, p=0.13) compared to patients who received late thromboprophylaxis. Conclusions Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population. Applicability of Research to Practice This work will guide the timing of initiation of venous thromboembolism prophylaxis in burn patients with concomitant trauma

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Although guidelines recommend the use of perioperative chemical thromboprophylaxis for antireflux surgery, the optimal timing for its initiation is unknown. The aim of this study was to investigate whether perioperative timing of chemical thromboprophylaxis affects bleeding, symptomatic venous thromboembolism, and complication rates in patients undergoing antireflux surgery. This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Overall, chemical thromboprophylaxis was given early (before surgery or intraoperatively) in 1099 (25.6 per cent) patients, and after surgery in 3202 (74.4 per cent) patients, with comparable exposure doses between the two groups. Symptomatic venous thromboembolism risk was unrelated to chemical thromboprophylaxis timing (0.5 versus 0.6 per cent for early and postoperative chemical thromboprophylaxis respectively (odds ratio (OR) 0.97, 95 per cent c.i. 0.41 to 2.47, P = 1.000). Postoperative bleeding developed in 34 (0.8 per cent) patients, and 781 intraoperative adverse events were identified in 544 (12.6 per cent) patients. Both intraoperative bleeding and complications were associated with significantly higher postoperative morbidity affecting multiple organ systems. Importantly, compared with postoperative chemical thromboprophylaxis, early administration increased the risk of postoperative bleeding ((1.5 versus 0.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 2.94, 95 per cent c.i. 1.48 to 5.84, P = 0.002)) and intraoperative adverse events ((16.1 versus 11.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 1.48, 95 per cent c.i. 1.22 to 1.80, P < 0.001)), as well as independently predicted their occurrences. Intraoperative adverse events and bleeding that occur during and after antireflux surgery are associated with significant morbidity. Compared with postoperative chemical thromboprophylaxis, early initiation of chemical thromboprophylaxis confers a significantly higher risk of intraoperative bleeding complications, without appreciable additional protection from symptomatic venous thromboembolism. Therefore, postoperative chemical thromboprophylaxis should be recommended for patients undergoing antireflux surgery.

Protocol - Acetylsalicylic acid alone or in combination with either enoxaparin or unfractionated heparin for postoperative thromboprophylaxis in coronary artery bypass surgery patients. A randomised clinical trial

Protocol - Acetylsalicylic acid alone or in combination with either enoxaparin or unfractionated heparin for postoperative thromboprophylaxis in coronary artery bypass surgery patients. A randomised clinical trial

Apixaban for extended postoperative thromboprophylaxis in gynecologic oncology patients undergoing laparotomy

IntroductionVenous thromboembolic events represent the second most frequent cause of mortality in cancer patients. Recent literature shows that direct oral anticoagulants (DOAC) are at least as effective and safe as low molecular weight heparin for postoperative thromboprophylaxis. However, this practice has not been broadly adopted in gynecologic oncology. The aim of this study was to evaluate clinical effectiveness and safety of apixaban for extended thromboprophylaxis in comparison to enoxaparin after laparotomies for gynecologic oncology patients. MethodsThe Gynecologic Oncology Division at a large tertiary center transitioned from enoxaparin 40 mg daily to apixaban 2.5 mg BID for 28 days after laparotomies for gynecologic malignancies in November 2020. This real-world study compared patients post-transition (November 2020 to July 2021 (n = 112)) to a historical cohort (January to November 2020 (n = 144)), using the institutional National Surgical Quality Improvement Program (NSQIP) database. All Canadian gynecologic oncology centers were surveyed to assess postoperative DOAC utilization. ResultsPatient characteristics were similar between groups. No difference was found between total venous thromboembolism rates (4% vs. 3%, p = 0.49). No difference was found in postoperative readmission (5% vs. 6%, p = 0.50). Of the 7 readmissions in the enoxaparin group, one was due to bleeding requiring transfusion; there were no readmissions for bleeding in the apixaban group. No patient required a reoperation for bleeding. Thirteen percent of the 20 Canadian centers have transitioned to extended apixaban thromboprophylaxis. ConclusionsApixaban for 28-day postoperative thromboprophylaxis was found to be an effective and safe alternative to enoxaparin after laparotomies in a real-world cohort of gynecologic oncology patients.

INTRAOPERATIVE STATE OF THE HEMOCOAGULATION SYSTEM IN PATIENTS WITH OPEN AND ENDOVASCULAR REVASCULARIZATION OF INFRAINGUAL ARTERIAL SEGMENT IN THE PRESENCE OF STENOTIC-OCCLUSIVE PROCESS OF TIBIAL ARTERIES

Background. Among all postoperative complications associated with revascularization of atherosclerotic steno-occlusive process of the femoral-distal artery, thrombosis of the reconstruction segment is 6-32%. Objective. Prevention of thrombotic complications through vascular revascularization of the lower extremity by using a pathogenetically reasonable system of postoperative thromboprophylaxis. Methods. The study involved 97 patients with atherosclerotic stenotic-occlusive process of the infrainguinal artery in cases of stenotic-occlusive lesions of the tibial arteries. In order to study the state of the hemocoagulation system on patients, the methods for studying the indicators of coagulation, fibrinolytic and aggregation systems were used. Results. Development of hypercoagulable disorders in the patients who underwent endovascular revascularization of the arterial segment is more intense than in those who underwent open vascular revascularization methods. Hypercoagulation of blood at the intraoperative stage of revascularization takes place primarily due to the activity of factor IIa of the hemocoagulation cascade. Taking into account these circumstances, already at the surgery stage for thromboprophylaxis non-fractionated heparin (NFH) should be prescribed. At the same time for prevention of thromboembolic complications double anti-thrombocyte therapy: clopidogrel, acetylsalicylic acid should be prescribed. Conclusion. Hypercoagulant ability of the blood system, which develops after arterial reconstructive interventions, takes place against the background of low activity of the fibrinolytic blood system, nevertheless a gradual increase in the activity of the aggregation capacity of the blood. Development of hypercoagulable disorders at the intraoperative stage of surgery in the patients with endovascular methods of arterial reconstructions is more intense than in those treated with open methods of arterial revascularization. Taking into account these circumstances, already at the surgery stage for thromboprophylaxis an anticoagulant should be prescribed that has a targeted effect on factor IIa of the hemocoagulant cascade with simultaneous prevention of thromboembolic complications – double anti-thrombocyte therapy.

Response to: Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery.

We are grateful for the interest and comments of Butt et al1 with regard to our recently published study.2 First, Butt et al1 noted that the overall exposure rate to intraoperative packed red blood cells (PRBCs) was 17.8% in our study compared to the reported rate of 12.8% to 60.3% in previous studies in similar patients. They then speculated that the relatively lower rate of intraoperative PRBC transfusion observed in our study was due to our decision to label missing information on intraoperative PRBC transfusion as “no transfusion.” In support of their argument, they cited a retrospective study of 8141 patients from 10 centers who had cardiac surgery between 2011 and 2014; these patients underwent either isolated coronary artery bypass grafting (CABG) surgery or aortic valve replacement, and Butt et al1 did not cite the risk-adjusted rate for intraoperative PRBC transfusion, which was found to be 4% to 59%.3 Thus, our reported rate of 17.8% is likely reflective of the more contemporary and average national rate of intraoperative PRBC transfusion for isolated CABG surgery. Furthermore, Butt et al1 highlighted that labeling missing data for intraoperative PRBC transfusions as “no transfusion” as justified in the methodology section of our manuscript, and omission of any postoperative transfusion before any hospital-acquired venous thromboembolic (HA-VTE) complications might have biased the association between intraoperative PRBC transfusion and HA-VTE complications. To address this, we performed a sensitivity analysis which indicated that after removing patients with missing data for intraoperative PRBC transfusion the association between intraoperative PRBC transfusion and HA-VTE remained (odds ratios [ORs] for 1, 2, 3, and ≥4 units of PRBC versus none: 1.16 [1.09 to 1.23], 1.19 [1.12 to 1.26], 1.59 [1.49 to 1.68], 1.49 [1.40 to 1.58]). Postoperative transfusion before any HA-VTE complications was not collected by the Society of Thoracic Surgeons Adult Cardiac Surgery Database and was not available for analysis. Second, Butt et al1 also indicated that a causality relationship between intraoperative PRBC transfusion and HA-VTE complications was not supported by the lower odds of HA-VTE complications in women. To address this comment, we reiterate the following: i) given the retrospective nature of our study it was not meant to definitively ascertain a causality, but rather reinforce a previously described association between intraoperative PRBC transfusion and HA-VTE complications in a large-scale national registry; ii) our propensity score-weighted, and covariate-adjusted analysis including adjusting for sex indicated that intraoperative PRBC transfusion was independently associated with HA-VTE complications after isolated CABG surgery; iii) only a small proportion of patients had missing data for height (0.03%) and weight (0.02%), and thus, the calculated body mass index (BMI) was observed in nearly all patients (missing, 0.03%). Therefore, our conditional imputation for 0.03% of the missing BMI is highly unlikely that it may have impacted the association of BMI and intraoperative PRBC transfusion in the development of the propensity score. We agree with Butt et al1 that it would have been potentially valuable to study the impact of geographic location on our selected patient- and procedure-related characteristics, but this information was not available through the participant user file research mechanism via which our study was approved. Third, we agree with the comment that delayed thromboprophylaxis during a prolonged hospital length of stay may also exacerbate HA-VTE complications independently or in combination with intraoperative and postoperative PRBC transfusions. As indicated by Butt and colleagues1 the Society of Thoracic Surgeons Adult Cardiac Surgery Database does not capture data on delayed thromboprophylaxis during a prolonged hospital length of stay, and thus we were not able to study its respective association with prolonged length of stay. Butt et al1 speculate that our approach of implementing a propensity score-weighted method using matching inverse probability of treatment weighting to account for potential confounding of the association between intraoperative PRBC transfusion and our outcomes may have been impacted by handling of extreme weights.4 To address the possibility of residual confounding, we considered the evidence for causality (E value),5 which is considered as an alternative approach to sensitivity analyses for potential unmeasured confounding, and were able to demonstrate that there was a low potential for unmeasured confounding significantly influencing the association between intraoperative PRBC transfusion and our primary outcome of HA-VTE. Finally, we agree with Butt et al1 that there is a need to better predict HA-VTE. We also strongly believe that there is a potentially unmet need for current and future “studies to explore interventions aimed at improving perioperative anemia and blood management while maintaining appropriate postoperative thromboprophylaxis, thereby significantly decreasing the need for PRBC transfusions in this setting and potentially decreasing the incidence of postoperative venous thromboembolism after cardiac surgery.”2

The early and long-term occurrence of symptomatic venous thromboembolism after lung cancer surgery without extended thromboprophylaxis-a single center experience with 435 patients.

The incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), after lung cancer resections varies in the literature, and there is limited evidence regarding the optimal duration of thromboprophylaxis. This study aimed at determining the early and long-term occurrence of thromboembolic complications in patients who received in-hospital thromboprophylaxis and underwent resective surgery for lung cancer. The study included all patients who underwent lung cancer surgery at Tampere University Hospital between 2004 and 2016. Postoperative thromboprophylaxis was administered for the duration of the hospitalization. Data on subsequent episodes of VTE and survival were obtained from national registries. The results were compared to a demographically matched reference population. The study comprised 435 patients and 4,338 individuals in the reference population. The overall occurrence of VTE in patients and the reference group was 0.3% vs. 0.2% at 90 days (P=0.56), 3.5% vs. 0.7% at 1 year (P<0.001), 9.2% vs. 2.2% at 3 years (P<0.001), and 18.7% and 3.9% at 5 years (P<0.001), respectively. The majority of cases represented PE. The overall mortality at 5 years was 44.4% vs. 11.6% (P<0.001). No associations between patient characteristics and the occurrence of VTE during follow-up were detected. Patients undergoing lung cancer surgery and who receive in-hospital medical thromboprophylaxis do not seem to be in high risk for symptomatic VTE during the early postoperative period. However, during long-term follow-up the occurrence of symptomatic VTE was significant.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Postoperative venous thromboembolism risk stratification in patients with uterine cancer

Uterine cancers are associated with a high risk for venous thromboembolisms. The American Society of Clinical Oncology practice guidelines recommend that all patients undergoing pelvic surgery for cancer should receive extended pharmacologic thromboprophylaxis with the duration being dependent on risk. However, risk stratification for patients with uterine cancer is not clearly defined. The Caprini score is the most widely used risk assessment model but it has been found to have limited use in the gynecologic oncology population. A modified Caprini score has been explored in other populations. The Khorana score is an additional risk assessment model that has not been studied in this context. Our objective was to evaluate the ability of a modified Caprini model and the Khorana score to risk stratify patients with uterine cancer for postoperative venous thromboembolisms within 90 days of surgery. Following institutional review board approval, a retrospective cohort study was performed, and all patients with uterine cancer who underwent a hysterectomy over a 4-year period were included. The Caprini and Khorana scores were calculated for each patient. The Caprini score cutoff for highest risk was evaluated at ≥7, ≥8, and ≥9 (modified Caprini) and the Khorana score cutoff was evaluated at ≥2 and ≥3. To determine the prognostic use of each score and other clinico-pathologic criteria related to the development of a venous thromboembolism, univariate analyses were performed using independent ttests, chi-square tests, or Fisher's exact tests; a multivariate analysis was performed using logistic regression. A total of 954 patients were included. The rate of venous thromboembolism development was 1.7% (16/954). A minimally invasive surgical approach was used in 90.5% (863/954) of patients. The mean Caprini score for patients with a venous thromboembolism was 10.3 compared with 8.1 for patients without a venous thromboembolism (95% confidence interval, 1.17-3.33; P<.0001). The mean Khorana score for the venous thromboembolism group was 2.4 vs 1.9 for those without (95% confidence interval, 0.04-0.82; P=.03). Both the Caprini and Khorana scores were found to be associated with venous thromboembolisms, but only a Caprini score with a cutoff of ≥8 or ≥9 was statistically significant (risk ratio, 31.25; 95% confidence interval, 1.88-519.49; risk ratio, 4.59; 95% confidence interval, 1.49-14.13, respectively), with high accuracy based on the area under the curve (0.75 and 0.68, respectively). Of the minimally invasive subgroup, 11.7% (101/863) of patients had same-day discharge with no postoperative thromboprophylaxis; none of these patients developed venous thromboembolisms. Despite extended prophylaxis among the laparotomy patients (30 days), the rate of venous thromboembolisms was more than 3 times that of the minimally invasive group (5.49% vs 1.7%). Advanced tumor stage and leukocytosis were noted to be independent risk factors for venous thromboembolisms. Our study suggests that using a modified Caprini score could help to identify the highest-risk patients who would benefit from prolonged thromboprophylaxis, could reduce the incidence of postoperative venous thromboembolisms, and could minimize the cost and harm of overtreatment. These findings need to be validated in a prospective manner, and further research is needed to determine the optimal duration of therapy.

Heightened Procoagulation after Post-Operative Thromboprophylaxis Completion in Patients with Metastatic Bone Disease from Primary Colorectal Cancer.

Platelets play a role in venous thromboembolism (VTE) and in mediating colorectal cancer (CRC) progression. Still, platelets' role in hypercoagulability after surgical intervention for metastatic bone disease (MBD) is ill-defined. In this quantitative observational study, we utilized a high-resolution imaging approach to temporally examine platelet procoagulant membrane dynamics (PMD) in four patients with MBD from primary CRC (CRC/MBD), before and after surgical intervention, over a 6-month period. We coupled this investigation with thrombelastography, quantitative plasma shotgun proteomics, and biochemical analysis. The plasma of CRC/MBD patients was enriched in ADAM1a, ADAMTS7, and physiological ligands for platelet glycoprotein-VI/spleen tyrosine kinase (GPVI/Syk) activation. Thromboprophylaxis attenuated procoagulation upon its initial prescription (post-operative day one, POD1); however, all patients experienced rebound procoagulation between POD3 and POD14, which was associated with Syk activation (Y525/Y526) in all patients, and a VTE event in two patients. Plasma levels of DNA-histone complexes increased steadily after surgery and remained elevated throughout the study period. Additionally, we increasingly sighted both homotypic and heterotypic platelet microaggregates after surgery in CRC/MBD patients, but not in healthy control participants' plasma. Our data elucidates the cell biology of a prothrombo-inflammatory state caused by disease and vascular injury, and recalcitrant to thromboprophylaxis. New mechanistic insights into hypercoagulability in CRC/MBD patients may identify novel drug targets for effective thromboprophylaxis type and duration after orthopaedic surgery.

Implementation of Enhanced Recovery After Surgery Protocol in a Second-level Hospital

Background: Enhanced recovery after surgery (ERAS) became standard perioperative care in the western world. However, little is known about the implementation of fast-track pathways (FTP) in developing countries. The objectives of the study were to assess the feasibility of the FTP program and adherence to the ERAS protocol in general surgery patients implemented in low-resource setting. Methods: In this retrospective, observational study, we evaluated perioperative care for elective and emergency surgical population changed in accordance with the ERAS program in a second-level hospital in Zambia. Ninety-eight patients aged two weeks to 87 years (median 32 years) with a male to female ratio of 2.3:1 and categorised by the American Society of Anaesthesiologists (ASA) in classes I to IV were included. Outcomes of interest were functional recovery, postoperative complications, length of hospital stay, and compliance with the protocol. Results: All elements of the ERAS protocol, including minimal access surgery (through mini-laparotomy incisions) and accelerated postoperative care, were employed. A successful recovery with discharge home by day 4 after the operation and the absence of complications and readmissions was achieved in 45.5% of patients. The postoperative period was complicated in 18.8% of cases, with a total mortality rate of 6.3%. The overall adherence level to the protocol was 72.2%. The highest levels of adaptation (≥95%) were reported for preoperative stratification, antimicrobial prophylaxis, modification of preanaesthetic medications, and prevention of intraoperative hypothermia. The poor compliance to the program was recorded for fasting and carbohydrate loading before surgery and postoperative thromboprophylaxis (17.9% and 21.4%, respectively). Conclusion: The study indicates that the employment of the ERAS program for the general surgery population at a second-level hospital is feasible and safe. It is possible to achieve a high level of adherence to the ERAS pathway in a resource-limited environment. A reasonable modification of the protocol can bring additional clinical benefits. Integrating elements of FTP into perioperative care and including the ERAS program in postgraduate education in developing nations is recommended. Further studies are needed, first, to frame ERAS pathways for application in emergency general surgery, and second, to present the local initiatives and identify barriers to the implementation of FTP in low-income countries. Doi: 10.28991/SciMedJ-2022-04-04-04 Full Text: PDF

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Cangrelor Dosing and Monitoring for Prevention of Acute Systemic-to-Pulmonary Artery Shunt Thrombosis in Neonates.

Systemic-to-pulmonary artery shunts are amongst the most common palliative procedures performed in neonates with congenital heart defects. These procedures require immediate postoperative thromboprophylaxis to prevent life-threatening shunt thrombosis. The novel use of intravenous P2Y12 platelet receptor antagonists has led to a need for dosing recommendations and monitoring. This study aims to determine cangrelor dosing in neonates through laboratory assessment of P2Y12 receptor reactivity and adverse events. Observational retrospective cohort study on the use of cangrelor for thromboprophylaxis in the immediate postoperative period of neonates undergoing placement of systemic-to-pulmonary artery shunts in a tertiary children's hospital from March 2020 to March 2021. Ten neonates receiving cangrelor post systemic-to-pulmonary artery shunt placement were included in the study. Median age and weight were 4 days (IQR, 2.75-5.25) and 3.49 kg (IQR, 3.1-3.75), respectively. Five (50%) patients received a 3.5-mm shunt, while the remaining patients received a 4-mm shunt. For thrombin inhibition, 5 (50%) patients received heparin and 5 (50%) received bivalirudin. Median cangrelor dose was 0.1 mcg/kg/min (IQR, 0.1-0.1). Median achieved P2Y12 reaction units (PRU) at this cangrelor dose was 127.5 (IQR, 72.5-173.75). No shunt thrombosis occurred in these patients; however, there was 1 minor hemorrhagic event. Our study suggests that a cangrelor dose of 0.1 mcg/kg/min is associated with therapeutic PRU and prevents shunt thrombosis in neonates post systemic-to-pulmonary artery shunt, with minimal hemorrhagic complications.

Extended postoperative thromboprophylaxis after pancreatic resection for pancreatic cancer is associated with decreased risk of venous thromboembolism in the minimally invasive approach.

Pancreatic ductal adenocarcinoma (PDAC) is associated with increased venous thromboembolism (VTE). We sought to compare rates of bleeding complications and VTE in patients receiving extended postoperative thromboprophylaxis (EPT) to those who did not, and identify risk factors for VTE after pancreatectomy for PDAC. This is a retrospective review of pancreatectomies for PDAC. EPT was defined as 28 days of low molecular weight heparin. Multivariable analysis (MVA) was performed to identify independent risk factors of VTE. Of 269 patients included, 142 (52.8%) received EPT. Of those who received EPT, 7 (4.9%) suffered bleeding complications, compared to 6 (4.7%) of those who did not (p = 0.938). There was no significant difference in VTE rate at 90 days (2.8% vs. 2.4%, p = 0.728) or at 1 year (6.3% vs. 7.9%, p = 0.624). On MVA, risk factors for VTE included worse performance status, lower preoperative hematocrit, R1/R2 resection, and minimally invasive (MIS) approach. Among those who received EPT, there was no difference in VTE rate between MIS and open approach. EPT was not associated with a difference in VTE risk or bleeding complications. MIS approach was associated with a higher risk of VTE; however, this was significantly lower among those who received EPT.

Anticoagulant Usage After Anterior Cruciate Ligament Reconstruction Is Associated With Increased Rate of Manipulation Under Anesthesia.

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR. The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA. We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001). In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

Experience of treating patients with complicated forms of gallstone disease on the background of liver cirrhosis

Annotation. In recent years, further improvement of minimally invasive surgical interventions has been noted. Surgical treatment of complicated gallstone disease has become quite standardized all over the world. However, accompanying cirrhosis of the liver remains the most severe comorbid condition. The purpose of this study is to determine the optimal treatment strategy of this category of patients. We analyzed the results of surgical treatment of 79 patients with complicated forms of gallstone disease and concomitant liver cirrhosis. All patients were conditionally divided into 2 groups: a control group of patients who were treated according to the standard program – 38 patients and the main group of patients who were treated using an improved diagnostic and treatment program – 41 patients. The patients of the retrospective group underwent a standard diagnostic and treatment program according to the recommendations for diagnosis and treatment of patients with complicated forms of gastrointestinal tract with correction of hepatorenal insufficiency. Since 2016, an updated diagnostic and treatment algorithm has been introduced in patients with complicated forms of gastrointestinal tract against the background of liver cirrhosis. All patients underwent a balanced approach in the analysis of manifestations of liver cirrhosis, which manifested itself in the introduction of the principles of controlled antibacterial therapy according to the level of C-reactive protein; differentiated implementation of thromboprophylaxis: according to the standard scheme and early postoperative thromboprophylaxis based on the risks of hemorrhagic complications. The results of this research were statistically analyzed using chi-square test and statistical comparison of both groups. According to the results of a comparative analysis of the results of the treatment of patients in both groups was performed, it was established that postoperative complications occurred both in patients of the main group and in the comparison group. However, the frequency of occurrence of complications in the groups of studied patients has a significant difference. In the main group, complications were 14.6% versus 34.2% (in the comparison group) at p≤0.05 (χ2=4.14), which indicates that the improved diagnostic and treatment program made it possible to significantly reduce postoperative complications, and the outcome of treatment of patients with complicated forms of gallstone disease.

Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial

ObjectiveTo determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer.DesignMulticentre, open label, randomised...

Total Joint Arthroplasty in Patients With Atrial Septal Defects: What Are the 90-Day Complications?

BackgroundCongenital heart defects, such as atrial septal defects (ASDs) and patent foramen ovale (PFO), may increase the risk of embolic events in total hip or knee arthroplasty (THA/TKA). The objective of this study was to determine the 90-day incidence of intraoperative and postoperative embolic events and all other complications in patients with a known ASD/PFO who underwent primary hip and knee arthroplasty. MethodsThis is a retrospective review of 160 patients with ASD/PFO undergoing 196 primary arthroplasties (94 THAs, 102 TKAs) at a single institution. The mean age was 64 years (standard deviation [SD] 11.1), 40.6% were male, and average body mass index was 31 kg/m2 (SD 7.2). The mean follow-up period was 19 months (SD 16). Forty-three percent of patients were on anticoagulation preoperatively. All patients received postoperative thromboprophylaxis (48% aspirin, 31% direct oral anticoagulants, 18% warfarin, 3% enoxaparin). ResultsThere were no embolic events identified. Fourteen patients (7%) developed complications within 90 days. Three had bleeding complications, and 8 had other nonoperative complications, which were all managed conservatively and had uneventful recoveries. Additionally, 3 patients had complications requiring reoperations: 2 for periprosthetic fractures (1 THA, 1 TKA) and 1 for a periprosthetic infection (TKA). ConclusionsIn this cohort of patients with a known ASD/PFO undergoing THAs and TKAs, there were no cases of embolic events. However, it would be advisable to have a thorough cardiology evaluation to assess potential risks and benefits of defect repair prior to total joint arthroplasty and to reduce the risk of paradoxical embolic events and the necessity of potent anticoagulation. Level of evidencePrognostic Level IV.