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
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
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
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
Patients and Methods American College of Surgeons National Quality Improvement Program (ACS NSQIP) 2005-09 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
Results: 5,651 Hepatectomies
Intraoperative Transfusion Rates
Postoperative Transfusion Rates p=0.045
Preoperative Factors Associated with Postoperative Transfusion Clinical Characteristic OR 95% CI p-value* ASA score 3 2.13 1.24-3.64 0.006 Male 2.92 2.15-3.98 <0.001 Preoperative albumin <4 g/dl 2.74 1.33-5.65 0.006 Preoperative hematocrit <39% 2.56 1.33-4.93 0.005 Bleeding disorder 16.95 9.90-29.41 <0.001 *Multivariate analysis
Returns to OR with Transfusion p=0.077
Preoperative Factors Associated with Return to OR with Transfusion Clinical Characteristic OR 95% CI p-value* Preoperative albumin <4 g/dl 3.19 1.19-8.55 0.021 Preoperative hematocrit <39% 2.99 1.28-6.99 0.012 Major vs. partial hepatectomy 2.92 1.39-6.10 0.005 Bleeding disorder 15.15 8.47-27.03 <0.001 *Multivariate analysis
National Post-Hepatectomy VTE Rates p<0.001 1/17 patients 1/34 patients
Factors Associated with VTE Clinical Characteristic OR 95% CI p-value* Preoperative AST 27 IU/L 1.41 1.05-1.89 0.022 ASA score 3 1.90 1.42-2.53 <0.001 Male 2.92 2.15-3.98 <0.001 Operative time 222 min (median) 1.37 1.01-1.86 0.043 Organ space infection 10.64 8.13-13.89 <0.001 Major vs. partial hepatectomy 2.58 1.93-3.47 <0.001 *Multivariate analysis
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% <0.001 30-day mortality p=0.001
VTE >> Bleeding Events p<0.001 VTE Postoperative Transfusion Return to OR + Transfusion
Summary For all hepatectomies, VTE rates >> bleeding complications VTE rates increase with extent of hepatectomy
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
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
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%
VTE Chemoprophylaxis: Hospital Coverage vs. 30 Days? VTE before 30 days VTE before 90 days 6-10 Days Enoxaparin (n=167) 27-31 Days Enoxaparin (n=165) p-value 12.0% 4.8% 0.02 13.8% 5.5% 0.01 Bergqvist et al., NEJM 2002
VTE Chemoprophylaxis Rates? Goal: routine VTE prophylaxis in all cases