Postoperative Venous Thromboembolism Rates Vary Significantly After Different Types of Major Abdominal Operations

  • Debraj Mukherjee
  • Anne O. Lidor
  • Kathryn M. Chu
  • Susan L. Gearhart
  • Elliott R. Haut
  • David C. Chang
ssat poster presentation

Abstract

Background

Venous thrombolism (VTE) is a significant cause of morbidity for surgical patients. Comparative risk across major procedures is unknown.

Methods

Retrospective analysis of the Nationwide Inpatient Sample (2001–2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age < 18, patients with multiple major surgeries, and those admitted for treatment of VTE were excluded. Primary outcome was occurrence of VTE. Independent variables included age, gender, race, Charlson score, hospital teaching status, elective procedures, cancer/metastasis, trauma, and year.

Results

Patients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03–3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65–2.05), associated with excess stay of 10.88days and $9,612 excess charges, translating into $55 million/year nationwide.

Conclusion

Highest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.

Keywords

Deep vein thrombosis Pulmonary embolism Bariatic surgery Major abdominal surgery 

References

  1. 1.
    Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol 2004;7:50–54. doi:10.1053/j.tvir.2004.02.001.PubMedCrossRefGoogle Scholar
  2. 2.
    Michota F. Venous thromboembolism: epidemiology, characteristics, and consequences. Clin Cornerstone 2005;7:8–15. doi:10.1016/S1098-3597(05)80098-5.PubMedCrossRefGoogle Scholar
  3. 3.
    Anderson FA Jr, Wheeler HB, Goldberg RJ et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151:933–938. doi:10.1001/archinte.151.5.933.PubMedCrossRefGoogle Scholar
  4. 4.
    Cushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol 2007;44:62–69. doi:10.1053/j.seminhematol.2007.02.004.PubMedCrossRefGoogle Scholar
  5. 5.
    Silverstein MD, Heit JA, Mohr DN et al.Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158:585–593. doi:10.1001/archinte.158.6.585.PubMedCrossRefGoogle Scholar
  6. 6.
    Huisman MV, Buller HR, ten Cate JW et al. Unexpected high prevalence of silent pulmonary embolism in patients with deep venous thrombosis. Chest 1989;95:498–502. doi:10.1378/chest.95.3.498.PubMedCrossRefGoogle Scholar
  7. 7.
    Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: systematic review. Eur J Vasc Endovasc Surg 2003;25:1–5. doi:10.1053/ejvs.2002.1778.PubMedCrossRefGoogle Scholar
  8. 8.
    Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis. Ann Surg 1988;208:227–240. doi:10.1097/00000658-198808000-00016.PubMedCrossRefGoogle Scholar
  9. 9.
    Pezzuoli G, Neri Serneri GG, Settembrini P et al. Prophylaxis of fatal pulmonary embolism in general surgery using low-molecular weight heparin Cy 216: a multicentre, double-blind, randomized, controlled, clinical trial versus placebo (STEP). STEP-Study Group. Int Surg 1989;74:205–210.PubMedGoogle Scholar
  10. 10.
    Mismetti P, Laporte S, Darmon JY et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg 2001;88:913–930. doi:10.1046/j.0007-1323.2001.01800.x.PubMedCrossRefGoogle Scholar
  11. 11.
    Colditz GA, Tuden RL, Oster G. Rates of venous thrombosis after general surgery: combined results of randomised clinical trials. Lancet 1986;2:143–146. doi:10.1016/S0140-6736(86)91955-0.PubMedCrossRefGoogle Scholar
  12. 12.
    Turpie AG, Levine MN, Hirsh J et al. A randomized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 1986;315:925–929.PubMedGoogle Scholar
  13. 13.
    Hull RD, Raskob GE, Gent M et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA 1990;263:2313–2317. doi:10.1001/jama.263.17.2313.PubMedCrossRefGoogle Scholar
  14. 14.
    Semrad TJ, O’Donnell R, Wun T et al. Epidemiology of venous thromboembolism in 9489 patients with malignant glioma. J Neurosurg 2007;106:601–608. doi:10.3171/jns.2007.106.4.601.PubMedCrossRefGoogle Scholar
  15. 15.
    Ghanim AJ, Daskalakis C, Eschelman DJ et al. A five-year, retrospective, comparison review of survival in neurosurgical patients diagnosed with venous thromboembolism and treated with either inferior vena cava filters or anticoagulants. J Thromb Thrombolysis 2007;24:247–254. doi:10.1007/s11239-007-0025-9.PubMedCrossRefGoogle Scholar
  16. 16.
    Tabori U, Beni-Adani L, Dvir R et al. Risk of venous thromboembolism in pediatric patients with brain tumors. Pediatr Blood Cancer 2004;43:633–636. doi:10.1002/pbc.20149.PubMedCrossRefGoogle Scholar
  17. 17.
    Auguste KI, Quinones-Hinojosa A, Gadkary C et al. Incidence of venous thromboembolism in patients undergoing craniotomy and motor mapping for glioma without intraoperative mechanical prophylaxis to the contralateral leg. J Neurosurg 2003;99:680–684.PubMedCrossRefGoogle Scholar
  18. 18.
    Nurmohamed MT, van Riel AM, Henkens CM et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost. 1996;75:233–238.PubMedGoogle Scholar
  19. 19.
    Enyart JJ, Jones RJ. Low-dose warfarin for prevention of symptomatic thromboembolism after orthopedic surgery. Ann Pharmacother 2005;39:1002–1007. doi:10.1345/aph.1E536.PubMedCrossRefGoogle Scholar
  20. 20.
    Leizorovicz A, Turpie AG, Cohen AT et al. Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART study. J Thromb Haemost 2005;3:28–34. doi:10.1111/j.1538-7836.2004.01094.x.PubMedCrossRefGoogle Scholar
  21. 21.
    Gordois A, Posnett J, Borris L et al. The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery. J Thromb Haemost 2003;1:2167–2174. doi:10.1046/j.1538-7836.2003.00396.x.PubMedCrossRefGoogle Scholar
  22. 22.
    Reis SE, Hirsch DR, Wilson MG et al. Program for the prevention of venous thromboembolism in high-risk orthopaedic patients. J Arthroplasty 1991;6(Suppl):S11–S16.PubMedGoogle Scholar
  23. 23.
    Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ 1992;305:567–574.Google Scholar
  24. 24.
    Geerts WH, Heit JA, Clagett GP et al. Prevention of venous thromboembolism. Chest 2001;119:132S–175S. doi:10.1378/chest.119.1_suppl.132S.PubMedCrossRefGoogle Scholar
  25. 25.
    Seligsohn U, Lubetsky A. Genetic susceptibility to venous thrombosis. N Engl J Med 2001;344:1222–1231. doi:10.1056/NEJM200104193441607.PubMedCrossRefGoogle Scholar
  26. 26.
    Federman DG, Kirsner RS. An update on hypercoagulable disorders. Arch Intern Med 2001;161:1051–1056. doi:10.1001/archinte.161.8.1051.PubMedCrossRefGoogle Scholar
  27. 27.
    Heit JA. Venous thromboembolism epidemiology: implications for prevention and management. Semin Thromb Hemost 2002;28(Suppl 2):3–13. doi:10.1055/s-2002–32312.PubMedCrossRefGoogle Scholar
  28. 28.
    Geerts WH, Pineo GF, Heit JA et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126:338S–400S. doi:10.1378/chest.126.3_suppl.338S.PubMedCrossRefGoogle Scholar
  29. 29.
    Sue-Ling HM, Johnston D, McMahon MJ et al. Pre-operative identification of patients at high risk of deep venous thrombosis after elective major abdominal surgery. Lancet. 1986;1:1173–1176. doi:10.1016/S0140-6736(86)91158-X.PubMedCrossRefGoogle Scholar
  30. 30.
    Flordal PA, Berggvist D, Burmark US et al. Risk factors for major thromboembolism and bleeding tendency after elective general surgical operations. The Fragmin Multicentre Study Group. Eur J Surg 1996;162:783–789.PubMedGoogle Scholar
  31. 31.
    Huber O, Bounameaux H, Borst F et al. Postoperative pulmonary embolism after hospital discharge. An underestimated risk. Arch Surg 1992;127:310–313.PubMedGoogle Scholar
  32. 32.
    Wille-Jorgensen P, Ott P. Predicting failure of low-dose prophylactic heparin in general surgical procedures. Surg Gynecol Obstet 1990;171:126–130.PubMedGoogle Scholar
  33. 33.
    Nicolaides A, Irving D, Pretzell M et al. The risk of deep-vein thrombosis in surgical patients. Br J Surg 1973;60:312.Google Scholar
  34. 34.
    Hendolin H, Mattila MA, Poikolainen E. The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy. Acta Chir Scand 1981;147:425–429.PubMedGoogle Scholar
  35. 35.
    Sapala JA, Wood MH, Schuhknecht MP et al. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. Obes Surg. 2003;13:819–825. doi:10.1381/096089203322618588.PubMedCrossRefGoogle Scholar
  36. 36.
    Rocha AT, de Vasconcellos AG, da Luz Neto ER et al. Risk of venous thromboembolism and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery. Obes Surg. 2006;16:1645–1655. doi:10.1381/096089206779319383.PubMedCrossRefGoogle Scholar
  37. 37.
    Wu EC, Barba CA. Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg 2000;10:7–13. doi:10.1381/09608920060674021.PubMedCrossRefGoogle Scholar
  38. 38.
    Nguyen NT, Hinojosa MW, Fayad C et al. Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery. Ann Surg 2007;246:1021–1027.PubMedGoogle Scholar
  39. 39.
    Samama CM, Albaladejo P, Benhamou D et al. Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. Eur J Anaesthesiol 2006;23:95–116. doi:10.1017/S0265021505002164.PubMedCrossRefGoogle Scholar
  40. 40.
    Torngren S. Pulmonary embolism and postoperative death. Acta Chir Scand 1983;149:269–271.PubMedGoogle Scholar
  41. 41.
    Cossu ML, Pilo L, Piseddu G et al. Prophylaxis of venous thromboembolism in bariatric surgery. Chir Ital 2007;59:331–335.PubMedGoogle Scholar
  42. 42.
    Frezza EE, Wachtel MS. A simple venous thromboembolism prophylaxis protocol for patients undergoing bariatric surgery. Obesity (Silver Spring) 2006;14:1961–1965. doi:10.1038/oby.2006.229.CrossRefGoogle Scholar
  43. 43.
    Cohen AT, Tapson VF, Bergmann JF et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008;371:387–394. doi:10.1016/S0140–6736(08)60202–0.PubMedCrossRefGoogle Scholar
  44. 44.
    Alizadeh K, Hyman N. Venous thromboembolism prophylaxis in colorectal surgery. Surg Technol Int 2005;14:165–170.PubMedGoogle Scholar
  45. 45.
    Beekman R, Crowther M, Farrokhyar F et al. Practice patterns for deep vein thrombosis prophylaxis in minimal-access surgery. Can J Surg 2006;49:197–202.PubMedGoogle Scholar
  46. 46.
    Wennberg JE. Physician uncertainty, specialty ideology, and a second opinion prior to tonsillectomy. Pediatrics 1977;59:952.PubMedGoogle Scholar
  47. 47.
    McPherson K, Wennberg JE, Hovind OB et al. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med 1982;307:1310–1314.PubMedGoogle Scholar
  48. 48.
    Birkmeyer JD, Sharp SM, Finlayson SR et al. Variation profiles of common surgical procedures. Surgery 1998;124:917–923.PubMedGoogle Scholar
  49. 49.
    Caprini JA, Tapson VF, Hyers TM et al. Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J Vasc Surg 2005;42:726–733. doi:10.1016/j.jvs.2005.05.053.PubMedCrossRefGoogle Scholar
  50. 50.
    Mommertz G, Sigala F, Glowka TR et al. Differences of venous thromboembolic risks in vascular general and trauma surgery patients. J Cardiovasc Surg (Torino) 2007;48:727–733.Google Scholar
  51. 51.
    Nicolaides AN, Irving D. Clinical factors and the risk of deep venous thrombosis. In Nicolaides AN, ed. Thromboembolism etiology: advances in prevention and management. Baltimore, MD: Thromboembolism etiology: advances in prevention and management, 1975 193–204.Google Scholar
  52. 52.
    Gillum RF. Pulmonary embolism and thrombophlebitis in the United States, 1970–1985. Am Heart J 1987;114:1262–1264. doi:10.1016/0002-8703(87)90212-2.PubMedCrossRefGoogle Scholar
  53. 53.
    Gjores JE. The incidence of venous thrombosis and its sequelae in certain districts of Sweden. Acta Chir Scand Suppl. 1956;206:1–88.PubMedGoogle Scholar
  54. 54.
    Alcalay A, Wun T, Khatri V et al. Venous thromboembolism in patients with colorectal cancer: incidence and effect on survival. J Clin Oncol. 2006;24:1112–1118. doi:10.1200/JCO.2005.04.2150.PubMedCrossRefGoogle Scholar
  55. 55.
    Proctor MC, Wainess RM, Henke PK et al. Venous thromboembolism: regional differences in the nationwide inpatient sample, 1993 to 2000. Vascular. 2004;12:374–380. doi:10.2310/6670.2004.00037.PubMedCrossRefGoogle Scholar
  56. 56.
    Brasileiro AL, Miranda F Jr, Ettinger JE et al. Incidence of lower limbs deep vein thrombosis after open and laparoscopic gastric bypass: a prospective study. Obes Surg. 2008;18:52–57. doi:10.1007/s11695-007-9268-y.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • Debraj Mukherjee
    • 1
  • Anne O. Lidor
    • 1
  • Kathryn M. Chu
    • 1
  • Susan L. Gearhart
    • 1
  • Elliott R. Haut
    • 1
  • David C. Chang
    • 1
  1. 1.Department of SurgeryJohns Hopkins School of MedicineBaltimoreUSA

Personalised recommendations