Postoperative Venous Thromboembolism Prophylaxis Research Articles

Which individual components of a colorectal surgery enhanced recovery program are associated with improved surgical outcomes?

BackgroundEnhanced recovery programs improve surgical outcomes. However, the association of adherence to individual components and outcomes in a comprehensive enhanced recovery program remains unclear. MethodsWe performed a retrospective study of all elective colorectal surgery patients at our institution from 2019 to 2022 (n = 1,175). Data were acquired from our institution’s enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. Traditional analyses and machine-learning classification trees were used to identify enhanced recovery program components associated with length of stay, readmissions, and complication rates. ResultsThe average length of stay was 5.0 days, readmission rate was 12.3%, and complication rate was 32.6%. On linear regression analysis, adherence to preoperative education, regional analgesia, pre- and postoperative multimodal analgesia, no nasogastric tube, early mobilization, early regular diet, early discontinuation of maintenance intravenous fluids, postoperative venous thromboembolism prophylaxis, and early Foley catheter removal were associated with an decrease in length of stay by 0.7–7.1 days (P < .05). Patients who adhered to no prolonged fasting had a 4.1% decrease in readmission rate (P = .04). Patients who adhered to no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and discontinuation of maintenance intravenous fluids had decreases in complication rates ranging from 7.0 to 28.2% (P < .001). Machine learning demonstrated that no nasogastric tube and discontinuation of maintenance intravenous fluids were significant predictors of shorter length of stay and no nasogastric tube and early mobilization were significant predictors of reduced complication rates. ConclusionsAlthough multiple components were associated outcomes, no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and early discontinuation of maintenance intravenous fluids were associated with more than 1 outcome. Focusing on these components may make enhanced recovery program implementation more feasible for resource-limited hospitals.

Validation of the Safety and Efficacy of Apixaban as Postoperative Thromboembolism Prophylaxis for Patients with Gynecologic Malignancies.

Venous thromboembolism is a preventable complication of gynecologic cancer surgery that leads to postoperative morbidity and mortality. This study compared apixaban with enoxaparin to identify whether apixaban had the same safety and efficacy for patients undergoing gynecologic cancer surgery. The study identified patients with a gynecologic malignancy who underwent surgery and were prescribed apixaban at discharge between June 2020 and April 2023. International Classification of Diseases 10 codes were used to identify patients who had a thromboembolism within 90 days or a bleeding event within 60 days after surgery. The rates of events for patients prescribed apixaban were compared with those for a historical cohort of patients who received enoxaparin. Fisher's exact tests were used to compare categorical variables, and t tests were used to compare continuous variables. A logistic regression was performed to compare the odds of thromboembolism between the two groups. Baseline patient characteristics differed in terms of body mass index (BMI), race, route of surgery, and type of cancer. Of the 490 patients in the apixaban cohort, 12 (2.4%) had a thromboembolism compared with 3 (2.1%) of the 138 patients in the enoxaparin group (adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI] 0.30-4.70; p > 0.999). The odds ratio was adjusted for BMI, age, and route of surgery. A bleeding event occurred for 1 (0.2%) of the 490 patients in the apixaban group and for 1 (0.7%) of the 138 patients in the enoxaparin group. This validation study showed that apixaban is a safe and effective method of postoperative venous thromboembolism prophylaxis. The data provide support to previous data and guideline updates recommending the use of apixaban for postoperative prophylaxis.

Venous Thromboembolism Prophylaxis Prescribing Patterns in Minimally Invasive Gynecologic Surgery After Implementation of Caprini Score Risk Assessment [ID 2683387

INTRODUCTION: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity, mortality, and cost. Although the risk is low in minimally invasive gynecologic surgery, risk-based prophylaxis is recommended. The modifed Caprini score (CS) can assess risk of VTE and inform preoperative and postoperative prophylaxis. We assessed whether formal implementation of the CS in the Department of Minimally Invasive Gynecologic Surgery at a large academic center affected preoperative and postoperative VTE prophylaxis prescribing patterns. METHODS: Institutional review board exemption was obtained. A sample of 356 patients (156 in pre-implementation group and 190 in post-implementation group) undergoing presumed benign minimally invasive hysterectomy or myomectomy between October 2021 and September 2022 was retrospectively analyzed. The primary outcome investigated was adherence to recommended preoperative prophylaxis before and after implementation. Secondary outcomes included incidence of VTE and concern for bleeding. RESULTS: Patient demographics, VTE risk factors, CS, and surgical details were determined to be statistically comparable between the groups. The implementation of CS significantly improved preoperative VTE prophylaxis recommendation adherence from 65.4% to 85.2% (P&lt;.001). This was due to both an increase in indicated pharmacologic prophylaxis, as well as a decrease in nonindicated usage in low-risk patients (from 22.4% to 2.6%). VTE risk was similarly low in both groups, occurring in only one patient from the pre-implementation group. There was no significant difference in estimated blood loss. CONCLUSION: These results suggest that CS use in patients undergoing minimally invasive gynecologic surgery can improve adherence to recommended preoperative prophylaxis for VTE, while decreasing unnecessary overtreatment in low-risk patients.

Don't Fear the Bleed: Assessing Postoperative Bleeding Incidence After Instituting a Standardized Prophylactic Heparin Protocol in Bariatric Patients.

Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for ∼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.

Venous thromboembolism chemical prophylaxis after skull base surgery

PurposeThere is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.MethodsReview of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009–2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.ResultsOne thousand five hundred fifty-one patients were included with a median age of 52 years (range 16–89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.ConclusionPostoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Thromboembolic Events After Robotic Radical Cystectomy: A Comparative Analysis of Extended and Limited Prophylaxis

ObjectiveTo compare limited (only inpatient) venous thromboembolism (VTE) prophylaxis after robot-assisted radical cystectomy (RARC) to limited plus extended prophylaxis. There is little consensus on postoperative VTE prophylaxis regimens after RARC with data mostly extrapolated from other cancers. MethodsRetrospective review of all RARC patients at our center between 2014-2022, identifying two groups: patients after a prospectively implemented protocol (January 2018 to present) utilizing a prolonged 21-day postoperative course of either enoxaparin 40mg daily or apixaban 2.5mg twice daily after discharge, or patients prior to January 2018 receiving only limited VTE prophylaxis during their immediate postoperative inpatient stay. Primary outcome: incidence of symptomatic VTE confirmed with imaging within 90-days postoperatively. Secondary outcomes: major hemorrhage, complications, readmission, and mortality within 30-days postoperatively. Descriptive statistics depicted baseline patient characteristics, operative information, and complications. Differences were compared between groups. Logistic regression was used to determine associations between variables and primary outcome. ResultsEighty-six patients received limited prophylaxis and 364 received extended prophylaxis. Twelve (2.7%) patients experienced VTE within 90-days postoperatively: (10 [2.7%] extended vs. 2 [2.3%] limited, p = 0.9). Upon stratification into EAU “low-risk” or “high +intermediate-risk” groups, no statistically significant difference in VTE rates was seen between the extended or limited groups. When controlling for prophylaxis regimen, intracorporeal approach was found to be predictive of a lower with a lower risk of VTE (p = 0.019). ConclusionsLimited and extended prophylaxis showed no significant differences in VTE rates among RARC patients. Further studies are necessary for RARC patients to improve guidelines.

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.

Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis.

Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination. To review existing risk-stratification tools and compare their predictive abilities. MBSAQIP database. Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value. Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients. Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.

Impact of Reduced Enoxaparin Prophylactic Dosing on Bleeding and Thrombotic Risk for Low Body Weight Post-Operative Colorectal Surgery Patients.

Introduction: Colorectal surgery (CORS) patients are at the highest risk of any general surgery population for the development of post-operative venous thromboembolism (VTE) and are also at an increased risk for post-operative bleeding, especially with procedures related to early cancer stages. Low molecular weight heparin (LMWH) is recommended for VTE prophylaxis in this surgical population. Current guidelines and primary literature along with institutional protocols support dosage adjustments for obesity and impaired renal function, but literature providing optimal VTE prophylactic LMWH dosing is extremely limited for underweight, surgical patients. Objectives: The aim of this study was to evaluate both bleeding and VTE rates for hospitalized underweight colorectal surgery patients receiving post-operative VTE prophylaxis with standard enoxaparin 40 mg subcutaneously (SQ) every 24 hours versus reduced dose enoxaparin 30 mg SQ every 24 hours. Methods: This trial was a multicenter, retrospective chart review with data collected on post-operative CORS patients over a 10-year period. Patients were included if aged 18 years and older, weighed less than 50 kg, and received at least 1 dose of enoxaparin 40 mg or 30 mg post-operatively. The primary endpoint was a descriptive comparison of post-operative bleeding with use of standard enoxaparin 40 mg SQ every 24 hours compared to reduced dose enoxaparin 30 mg SQ every 24 hours for post-operative VTE prophylaxis. The secondary endpoint was the descriptive comparison of post-operative thrombotic event rates in the same population. Results: The total population investigated included 146 patients. One hundred twenty-nine (88.4%) received standard enoxaparin and 17 (11.6%) received reduced enoxaparin. Overall, 9 bleeding events (7.0%) and 2 major VTE events (1.6%) occurred, all within the standard enoxaparin group. Conclusion: Standard dose enoxaparin for post-operative VTE prophylaxis demonstrated increased bleeding and thrombotic events requiring medical and surgical intervention in comparison to reduced dose enoxaparin for low body weight CORS patients. The results of this study are hypothesis generating and continued research involving more robust systematic reviews are needed to evaluate both safety and efficacy of reduced VTE prophylaxis with LMWH in the underweight, surgical patient population.

Direct oral anticoagulants (DOACs) use for prolonged venous thromboembolism prophylaxis following surgery for gynaecological malignancies in Australia and New Zealand - A clinician survey.

Current international guidelines recommend 28 days of enoxaparin as venous thromboembolism (VTE) prophylaxis after surgery for gynaecologic cancer. Direct oral anticoagulants (DOACs) have been investigated as an alternative to enoxaparin for post-operative VTE prophylaxis. High-quality evidence to demonstrate safety and efficacy is lacking. We aim to investigate the current practice regarding VTE prophylaxis among gynaecological oncologists in Australia and New Zealand following laparotomy for gynaecological malignancy, in particular the use of DOACs for VTE prophylaxis. Sixty-seven practising gynaecologic oncologists (GO) were identified through Royal Australia and New Zealand College of Obstetricians and Gynaecologists database and emailed online surveys that asked about VTE prophylaxis practice and views of DOACs in this setting. Data were then collected through Survey Monkey and evaluated. The majority (77.1%) routinely prescribed 28 days of enoxaparin following laparotomy for gynaecological malignancies. In clinical circumstance such as laparoscopy for gynaecological malignancies and surgery for vulva malignancies, there was variation in thromboprophylaxis practices. No GO reported routine use of DOACs in any clinical circumstance. There were 56% of GOs who used a DOAC in their practice at some point. Barriers to routine use of DOACs in current practice included insufficient evidence (68%), issue with cost (40.4%) and concerns about safety (29.7%). Enoxaparin prescribed for 28 days remains the current clinical practice in preventing VTE following laparotomy for gynaecological malignancy. The main barrier to routine DOAC use as post-operative thromboprophylaxis is a lack of evidence which reflects the need for a larger prospective study.

Extended Venous Thromboembolism Chemoprophylaxis following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation.

Microsurgical breast reconstruction following mastectomy represents a high-risk patient group for venous thromboembolism (VTE), but there is limited consensus on postoperative prophylaxis duration. The aim of this study was to characterize the risk of VTE after microsurgical breast reconstruction, the risk reduction associated with postoperative outpatient VTE prophylaxis, the clinical factors associated with VTE events, and surgeon prescribing patterns regarding outpatient VTE prophylaxis. A commercially available database of 53 million unique patients, PearlDiver, was used to identify patients with breast cancer who underwent microsurgical breast reconstruction. Patients were grouped into those receiving any form of outpatient VTE prophylaxis at discharge and those who did not. Probability of VTE within 90 days was calculated for each group followed by absolute risk reduction and number needed to treat. A logistic regression, assuming binomial distribution, was performed to determine clinical factors associated with VTE events after surgery. A total of 22,606 patients underwent microsurgical breast reconstruction from 2010 to 2020. Of these patients, 356 (1.6%) were discharged with VTE prophylaxis and 22,250 (98.4%) were discharged without. No patients developed a VTE in the prophylaxis group, and 403 (1.8%) developed a VTE in the group without prophylaxis. The number needed to prevent one VTE was 55.25 patients. Most VTE events occurred after postoperative day 10 (71.3%). Outpatient chemoprophylaxis following breast reconstruction is underused despite the majority of VTE events occurring after the acute postoperative period. Breast microsurgeons should consider routine outpatient chemoprophylaxis as part of their postoperative care pathway to optimize VTE prevention. Therapeutic, III.

INCIDENCE OF VENOUS THROMBOEMBOLISM IN ELECTIVE HIP ARTHROPLASTY SURGERY: A REVIEW OF 8,890 PATIENTS RECEIVING POSTOPERATIVE ASPIRIN VTE PROPHYLAXIS

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis.Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed.8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE.Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis.

Evaluating patient experience with extended post-operative venous thromboembolism prophylaxis (eVTEp) after gynecologic oncology surgery: A cross-sectional quality improvement study.

International guidelines recommend extended post-operative venous thromboembolism prophylaxis (eVTEp) for up to 28 days after gynecologic oncology surgery. Our division implemented eVTEp with low-molecular weight heparin (LMWH) over a decade ago. We sought to understand the adherence and patient experience with LMWH in our population.

Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis.

Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.

Chemoprophylaxis Timing Is Not Associated With Postoperative Bleeding After Spinal Trauma Surgery

BackgroundLittle is known regarding appropriate timing for chemical venous thromboembolism (VTE) prophylaxis initiation in operative traumatic spinal injuries. We hypothesized that the incidence of post-operative bleeding leading to neurological decline or re-operation would not increase in patients who received early VTE prophylaxis (≤2 days post-surgery) as compared to those who received late VTE prophylaxis (≥ 3 days post-surgery). MethodsThis is a retrospective cohort study. Spine trauma patients who underwent spinal surgery, defined as anterior cervical discectomy and fusion, posterior cervical spinal fusion, anterior or posterior thoracic/lumbar spinal fusion, or vertebral percutaneous fixation from July 2015 to July 2020 were included. Demographics, pre-injury anti-thrombotics, operative characteristics, pre- and post-operative VTE prophylaxis, and post-operative complications, including spinal bleeding, and VTE were collected. Univariate analysis was performed, comparing baseline characteristics, VTE prophylaxis timing, and complications between the early and late groups. ResultsTwo-hundred-eighty-two patients were included; 189 were in the early group (1.7 ± 0.5 days), and 93 were in the late (4.4 ± 2.1 days) group. The late group received enoxaparin more often than patients in the early group (41.9 % vs. 19 %, p < 0.001). Baseline characteristics, hospital course, and surgical management were similar between the groups. The rate of post-operative complications, including hematoma and VTE was similar between the groups. None of the patients in the early group had post-operative bleeding. ConclusionIn this retrospective cohort study, VTE prophylaxis timing was not associated with clinically significant post-operative spinal bleeding and VTE in trauma patients.

Preoperative Venous Thromboembolism Screening and Postoperative Selective Anticoagulant Therapy Effectively Prevents Postoperative Symptomatic Venous Thromboembolism in Gynecological Malignancies: A 15-Year, Single-Center Study.

The aim of this study was to determine which type of prophylaxis was effective for postoperative symptomatic venous thromboembolism (VTE) in patients with gynecological malignancies. A total of 1756 consecutive patients undergoing laparotomy as first-line treatment were included. In Period 1 (2004-2009), low-molecular weight heparin (LMWH) was not available for postoperative VTE prophylaxis, but available in after Period 2 (2009-2013). In Period 3 (2013-2020), patients with pretreatment VTE could switch from LMWH to direct oral anticoagulant (DOAC) as of 2015. Preoperative VTE was screened by measuring D-dimer, followed by venous ultrasound imaging, and computed tomography and/or perfusion lung scintigraphy. Postoperative symptomatic VTE occurred with an incidence of 2.8% by the measures without prophylactic LMWH administration in Period 1. The incidence of postoperative symptomatic VTE was 0.6% in Period 2 and 0.3% in Period 3, being significantly reduced compared with Period 1 (P < .01 and < .0001). The incidences were not significantly different between Periods 2 and 3, but no patient switching to DOAC in Period 3 (n = 79) developed symptomatic VTE. Our preoperative VTE screening and postoperative selective LMWH administration were significantly preventive against postoperative symptomatic VTE.

Are IBD Patients Underscored when Determining Postoperative VTE Risk?

BackgroundPatients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism (VTE) following colorectal surgery and there is currently no consensus on post-surgical VTE prevention or specific VTE risk assessment tools. We sought to evaluate VTE risk after colorectal surgery and determine if known risk factors used in risk assessment tools adequate correlate with VTE risk in IBD patients. MethodsRetrospective cohort study using the National Surgical Quality Improvement Project (NSQIP) Participant User File from 2010 to 2018. ResultsA total of 27,679 patients were included; 19,015 (68.7%) had Crohn’s disease (CD) and 8664 (31.3%) ulcerative colitis (UC). Of these, 16,749 (60.5%) underwent abdominopelvic procedures, 10,178 (36.8%) complex pelvic procedures, and 752 (2.7%) small bowel operations. The overall VTE rate was 2.3%. The VTE rate in patients with CD and UC was 1.8% and 3.6% (p < 0.001) respectively. Overall median time to VTE was 9 days after surgery. VTE rate was highest in patients who underwent complex pelvic procedures (3.6%; 361/10,178). A risk score was calculated using 16/40 available variables from the Caprini VTE Risk Assessment tool; risk score ranged from 3 to 12 points. Most patients that developed a VTE had a score between 3 and 5 points (75.6%), and only 24.5% had a score of 6 or higher. Patients with higher risk scores did not have a higher VTE incidence. ConclusionPost-surgical VTE rates are high in IBD patients. Over half of the events occurred following discharge and in patients with an apparent low-risk score. Additional studies are warranted to define a recommended postoperative VTE prophylaxis regimen for patients with IBD.

Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a modified Delphi Process.

Delphi method. 1) When should AC/AP medication be stopped before elective spine surgery?; 2) When should AC/AP medication be restarted after elective spine surgery?; 3) When, how, and in whom should VTE chemoprophylaxis be started after elective spinal surgery? Venous thromboembolism (VTE) can lead to significant morbidity after adult spine surgery, yet postoperative VTE prophylaxis practices vary considerably. The management of preoperative anticoagulation/antiplatelet (AC/AP) medication is similarly heterogeneous. Delphi method of consensus development consisting of three rounds (01/26/21-06/21/21). 21 spine surgeons were invited, and 20 surgeons completed all rounds of questioning. Consensus (>70% agreement) was achieved in 26/27 items. Group consensus stated that preoperative Direct Oral Anticoagulants (DOAC) should be stopped 2 days prior to surgery, warfarin stopped 5 days before surgery, and all remaining AC/AP medication and aspirin should be stopped 7 days prior to surgery. For restarting AC/AP medication postoperatively, consensus was achieved for low/medium/high risk patients in 5/5 risk factors (VTE history/cardiac/ambulation status/anterior approach/operation). The low/medium/high thresholds were: POD7/POD5/POD2, respectively. For VTE chemoprophylaxis, consensus was achieved for low/medium/high risk patients in 12/13 risk factors (age/BMI/VTE history/cardiac/cancer/hormone therapy/operation/anterior approach/staged separate days/staged same days/operative time/transfusion). The one area that did not gain consensus was same-day staged surgery. The low/medium/high threshold ranges were: POD5 or none/POD3-4/POD1-2, respectively. Additional VTE chemoprophylaxis considerations that gained consensus were: POD1 defined as the morning after surgery regardless of operating finishing time, enoxaparin as the medication of choice, and standardized, rather than weight-based, dose given once/day. In the first known study to address anticoagulation/antiplatelet recommendations for elective spine surgery (preoperatively and postoperatively), our Delphi consensus recommendations from 20 spine surgeons achieved consensus on 26/27 items. These results will potentially help standardize the management of preoperative AC/AP medication and VTE chemoprophylaxis after adult elective spine surgery.

7893 Venous Thromboembolism Prophylaxis after Hysterectomy for Endometrial Malignancy in Class III Obesity: Patient Preferences and Outcomes

<h3>Study Objective</h3> This study assessed patient preference between two anticoagulants for postoperative venous thromboembolism (VTE) prophylaxis following hysterectomy for endometrial intraepithelial neoplasia (EIN) or grade 1 endometrioid adenocarcinoma in patients with class III obesity. <h3>Design</h3> Prospective quality improvement study. <h3>Setting</h3> Canadian urban, tertiary-care hospital. <h3>Patients or Participants</h3> All patients undergoing hysterectomy for EIN or grade 1 endometrial cancer with a body mass index (BMI) ≥ 40 between February 2021 and March 2022 who were eligible for extended postoperative anticoagulation, which is recommended in this population due to the high risk of VTE. <h3>Interventions</h3> Patients were provided with information about dalteparin, an injectable low-molecular weight heparin, and apixaban, a direct oral anticoagulant, prior to surgery. Postoperatively, patients were surveyed about their anticoagulation preference and discharged home with their preferred anticoagulant. Patients were followed up six weeks postoperatively to assess for medication adherence and adverse events. <h3>Measurements and Main Results</h3> 42 patients were included in the study with a mean BMI of 48.7 ± 7.32 kg/m². One patient had an abdominal hysterectomy, all others underwent robotic hysterectomy. Significantly more patients chose apixaban over dalteparin (30/42, p = 0.008). Route of administration was the most common reason for choosing apixaban, with doctor recommendation and medication cost as other commonly cited reasons. For patients choosing dalteparin, the available evidence and known efficacy in people weighing more than 100 kgs were the main reasons for selection. At 6 weeks post-hysterectomy there were no significant differences in rates of medication adherence, postoperative VTE, or clinically relevant bleeding between the groups. <h3>Conclusion</h3> The majority of patients with class III obesity selected apixaban over dalteparin for postoperative VTE prophylaxis. Although apixaban has less data supporting its use in this population, there were no adverse events in this study. Both anticoagulation options should be offered as this supports patient values and preferences in informed decision making and may improve accessibility.

A003 Extended Postoperative Venous Thromboembolism Prophylaxis after Bariatric Surgery: A Comparison of Existing Risk Stratification Tools and 5-Year MBSAQIP Analysis

A003 Extended Postoperative Venous Thromboembolism Prophylaxis after Bariatric Surgery: A Comparison of Existing Risk Stratification Tools and 5-Year MBSAQIP Analysis