Chemical thromboprophylaxis before skin closure increases bleeding risk after major ventral hernia repair: A multicenter cohort study

Liu, David S.; Wong, Darren; Crowe, Amy; Liew, Chon Hann; Watson, David I.; Wong, Enoch; Fong, Jonathan J.; Mori, Krinal; Wee, Melissa; Stevens, Sean; Gill, Anna Sonia; Fleming, Nicola; Bennet, Simon; Jamel, Wael; Choy, Kay Tai; Beh, Pith Soh; Lee, Sharon; Lew, Chen; Lie, Elisa; Sorensen, James C.; Cheung, King Tung; Yao, Ming; Lin, Olivia Miki; Pathirana, Poojani; Ward, Salena; Shashishekara, Surabhi; Bedford, T.; Fitt, Emily; Paynter, Jessica; Guiney, Natalie; Brown, Patrick; Hii, Amanda; Grantham, James P.; Ng, Stephanie; Tran, Steven; Bright, Tim; Tan, Zhi; Hughes, Jed; Bae, Lily; Nadaraja, Roshini

doi:10.1016/j.surg.2022.01.023

Cited by 9 publications

(8 citation statements)

References 18 publications

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“…Overall, these rates of clinical VTE, postoperative bleeding, and non-bleeding complications are comparable to contemporary international literature 13–16 . The observation that postoperative chemical thromboprophylaxis is associated with a lower risk of bleeding than early usage in antireflux surgery is consistent with studies in gallbladder 9 , liver 17 , ventral hernia 10 , bariatric 18 , breast 19 , hip 20 , and abdominal visceral surgery 8 . Additionally, within major abdominal surgery, subgroup analysis of patients with an inherently high thromboembolic risk also favours postoperative chemical thromboprophylaxis over early usage 21 .…”

Section: Discussionsupporting

confidence: 83%

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

Liu,

Wong,

Goh

et al. 2023

BJS Open

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Background 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. Methods This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Results 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. Conclusion 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.

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Section: Discussionsupporting

confidence: 83%

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

Liu,

Wong,

Goh

et al. 2023

BJS Open

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“…A retrospective analysis of pooled data from 4 multicenter studies was conducted by PROTECTinG investigators, which examined the impact of perioperative timing of chemoprophylaxis following elective cholecystectomies [ 6 ], abdominal visceral resections [ 7 ], major ventral hernia repairs [ 8 ], and anti-reflux surgery. Details of these studies are summarized in Table S1-2.…”

Section: Methodsmentioning

confidence: 99%

“…This included patient demographics, comorbidities, perioperative parameters, operative details, postoperative timing of chemoprophylaxis, postoperative bleeding, and VTE events. As described in each PROTECTinG study, an array of quality assurance measures was undertaken to maximize data accuracy and minimize inter-observer discrepancies [ 6 – 8 ]. Consequently, a random audit of 10% of data fields for each study demonstrated a mean accuracy rate of 98.1% (range 97.7–98.4%), as outlined in Table S1.…”

Section: Methodsmentioning

confidence: 99%

“…We defined clinical VTE as radiologically proven (CTPA, V/Q scintigraphy, venous ultrasound) symptomatic disease occurring within 30 days post-surgery. The criteria for major bleeding included either the need for blood transfusion, reintervention (surgical, endoscopic or radiological), or a >20 g/L fall in hemoglobin from baseline [ 6 – 8 ]. Minor bleeding refers to any bleeding event failing to meet major bleeding criteria.…”

Section: Methodsmentioning

confidence: 99%

“…The PROTECTinG (Perioperative Timing of Elective Chemical Thromboprophylaxis in General Surgery) research group within the VERITAS (Victorian-collaborative for Education, Research, Innovation, Training and Audit by Surgical trainees) collaborative was established to address this gap in perioperative guidelines. Our studies have shown that postoperative chemoprophylaxis is favored over early (preoperative and intraoperative) administration in the settings of elective cholecystectomy [ 6 ], major abdominal resection [ 7 ], ventral hernia repair [ 8 ], and anti-reflux surgery. These findings were subsequently validated in patients with high baseline VTE risk [ 9 ], and by meta-analysis of published literature, which focused on patients undergoing major abdominal surgery [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

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Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

2023

World j. surg.

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Background Major abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery. Methods Analysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery. Results Overall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis. Conclusion Chemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

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Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

Liu

Newbold

Stevens

et al. 2022

Journal of Gastrointestinal Surgery

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Background Abdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. Methods Retrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. Results A total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7–27) versus 7 (5–11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05–1.93, p = 0.038) and independently predicted its occurrence. Conclusions The risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

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Chemical thromboprophylaxis before skin closure increases bleeding risk after major ventral hernia repair: A multicenter cohort study

Cited by 9 publications

References 18 publications

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

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

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study

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