Risk of Venous Thromboembolism Outweighs Post-Hepatectomy Bleeding Complications: Analysis of 5,651 NSQIP Patients

Transcription

1 Risk of Venous Thromboembolism Outweighs Post-Hepatectomy Bleeding Complications: Analysis of 5,651 NSQIP Patients Ching-Wei D. Tzeng, MD Matthew H. G. Katz, MD; Jason B. Fleming, MD; Peter W. T. Pisters, MD; Jeffrey E. Lee, MD; Eddie K. Abdalla, MD; Steven A. Curley, MD; Jean-Nicolas Vauthey, MD; Thomas A. Aloia, MD IHPBA World Congress Paris, France July 2, 2012

2 Disclosures ACS NSQIP Disclosure The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Authors Disclosures None

3 Post-Hepatectomy Bleeding vs. Venous Thromboembolism (VTE) Historically, liver surgeons have been reluctant to use VTE chemoprophylaxis Fear of intra-op and post-hepatectomy hemorrhage Belief that patients are self-protected by autoanticoagulation from transient liver insufficiency If true, then Magnitude of Hepatectomy = VTE rate

4 Study Purposes To compare national rates of postoperative transfusions, returns to OR with transfusion, and VTE, in hepatectomy patients To stratify VTE rates with extent of hepatectomy

5 Patients and Methods American College of Surgeons National Quality Improvement Program (ACS NSQIP) Participant Use File Identified all elective open hepatectomies Excluded wedge resections (CPT 47100) and emergent cases Analyzed clinical factors associated with 30-day rates of (1) postoperative transfusion, (2) returns to OR with transfusion, and (3) VTE

6 Results: 5,651 Hepatectomies

7 Intraoperative Transfusion Rates

8 Postoperative Transfusion Rates p=0.045

9 Preoperative Factors Associated with Postoperative Transfusion Clinical Characteristic OR 95% CI p-value* ASA score Male <0.001 Preoperative albumin <4 g/dl Preoperative hematocrit <39% Bleeding disorder <0.001 *Multivariate analysis

10 Returns to OR with Transfusion p=0.077

11 Preoperative Factors Associated with Return to OR with Transfusion Clinical Characteristic OR 95% CI p-value* Preoperative albumin <4 g/dl Preoperative hematocrit <39% Major vs. partial hepatectomy Bleeding disorder <0.001 *Multivariate analysis

12 National Post-Hepatectomy VTE Rates p< /17 patients 1/34 patients

13 Factors Associated with VTE Clinical Characteristic OR 95% CI p-value* Preoperative AST 27 IU/L ASA score <0.001 Male <0.001 Operative time 222 min (median) Organ space infection <0.001 Major vs. partial hepatectomy <0.001 *Multivariate analysis

14 VTE Associated with Morbidity and Mortality 30-day morbidity VTE No VTE p-value Length of stay (LOS), days 11 6 <0.001 LOS 7 days 82.8% 41.2% < day mortality p=0.001

15 VTE >> Bleeding Events p<0.001 VTE Postoperative Transfusion Return to OR + Transfusion

16 Summary For all hepatectomies, VTE rates >> bleeding complications VTE rates increase with extent of hepatectomy

17 Conclusions Contrary to popular belief, transient postop liver insufficiency does not prevent VTE Magnitude of Hepatectomy = Perception Reality VTE rate Data support routine postoperative VTE chemoprophylaxis for all hepatectomies Including major resections requiring longer operative times

18 Risk of Venous Thromboembolism Outweighs Post-Hepatectomy Bleeding Complications: Analysis of 5,651 NSQIP Patients Ching-Wei D. Tzeng, MD Matthew H. G. Katz, MD; Jason B. Fleming, MD; Peter W. T. Pisters, MD; Jeffrey E. Lee, MD; Eddie K. Abdalla, MD; Steven A. Curley, MD; Jean-Nicolas Vauthey, MD; Thomas A. Aloia, MD IHPBA World Congress Paris, France July 2, 2012

19 VTE Chemoprophylaxis: Our Practice Major Hepatectomy Minor Hepatectomy Preop No No % Epidural Use 80% 50% Postop Yes Yes Post Discharge Yes-14d No DVT Rates 0.5% 0.09% PE Rates 0.75% 0.3%

20 VTE Chemoprophylaxis: Hospital Coverage vs. 30 Days? VTE before 30 days VTE before 90 days 6-10 Days Enoxaparin (n=167) Days Enoxaparin (n=165) p-value 12.0% 4.8% % 5.5% 0.01 Bergqvist et al., NEJM 2002

21 VTE Chemoprophylaxis Rates? Goal: routine VTE prophylaxis in all cases