Postoperative Venous Thromboembolism in Patients Undergoing Abdominal Surgery for IBD: A Common but Rarely Addressed Problem

Abstract

BACKGROUND: Venous thromboembolism after abdominal surgery occurs in 2% to 3% of patients with Crohn’s disease and ulcerative colitis. However, no evidence-based guidelines currently exist to guide postdischarge prophylactic anticoagulation. OBJECTIVE: We sought to determine the use of postoperative postdischarge venous thromboembolism chemical prophylaxis, 90-day venous thromboembolism rates, and factors associated with 90-day thromboembolic events in IBD patients following abdominal surgery. DESIGN: This was a retrospective evaluation of an administrative database. DATA SOURCE: Data were obtained from Optum Labs Data Warehouse, a large administrative database containing claims on privately insured and Medicare Advantage enrollees. PATIENTS: Seven thousand seventy-eight patients undergoing surgery for Crohn’s disease or ulcerative colitis were included in the study. MAIN OUTCOME MEASURES: Primary outcomes were rates of postdischarge venous thromboembolism prophylaxis and 90-day rates of postdischarge thromboembolic events. In addition, patient clinical characteristics were identified to determine predictors of postdischarge venous thromboembolism. RESULTS: Postdischarge chemical prophylaxis was given to only 0.6% of patients in the study. Two hundred thirty-five patients (3.3%) developed a postdischarge thromboembolic complication. Postdischarge thromboembolism was more common in patients with ulcerative colitis than with Crohn’s disease (5.8% vs 2.3%; p < 0.001). Increased rates of venous thromboembolism were seen in patients undergoing colectomy or proctectomy with simultaneous stoma creation compared with colectomy or proctectomy alone (5.8% vs 2.1%; p < 0.001). The strongest predictors of thromboembolic complications were stoma creation (adjusted OR, 1.95; 95% CI, 1.34–2.84), J-pouch reconstruction (adjusted OR, 2.66; 95% CI, 1.65–4.29), preoperative prednisone use (adjusted OR, 1.57; 95% CI, 1.19–2.08), and longer length of stay (adjusted OR, 1.89; 95% CI, 1.41–2.52). LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: The use of postdischarge venous thromboembolism prophylaxis in this patient sample was infrequent. Development of evidence-based guidelines, particularly for high-risk patients, should be considered to improve the outcomes of IBD patients undergoing abdominal surgery.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

“…In a retrospective study of just under 9000 patients who had undergone abdominal and pelvic surgery for IBD, the 30‐day postoperative venous thromboembolic rate was 2.7%, giving an odds ratio (OR) of 1.26 (95% CI: 1.021–1.56) compared with 37 000 patients undergoing cancer surgery . The strongest predictors of thromboembolic complications after surgery for IBD were stoma formation, with an adjusted OR of 1.95 (95% CI: 1.34–2.84), preoperative steroid administration [adjusted OR 1.57 (95% CI: 1.19–2.08)], ileoanal pouch formation [adjusted OR 2.66 (95% CI: 1.65–4.29)] and longer length of stay [adjusted OR 1.89 (95% CI: 1.41–2.52)] .…”

“…The strongest predictors of thromboembolic complications after surgery for IBD were stoma formation, with an adjusted OR of 1.95 (95% CI: 1.34-2.84), preoperative steroid administration [adjusted OR 1.57 (95% CI: 1.19-2.08)], ileoanal pouch formation [adjusted OR 2.66 (95% CI: 1. 65-4.29)] and longer length of stay [adjusted OR 1.89 (95% CI: 1.41-2.52)] [65].…”

“…Several authors have noted the high rates of postoperative venous thromboembolism in IBD patients and have suggested the extended use of venous thromboembolism prophylaxis [64][65][66]69] along the same lines as in current standard practice for patients undergoing colorectal cancer resection.…”

Letter: previous exposure to corticosteroids increases the risk of post‐discharge venous thromboembolic events in patients with inflammatory bowel disease

“…Four studies were included in this meta-analysis, comprising 36 209 patients with IBD-related hospitalisation or surgery; of these, 615 developed VTE after hospital discharge. 1,[3][4][5] These studies investigated the impact of previous exposure (before hospitalisation, during hospitalisation or preoperative exposure) to IBD-related medications on the risk of VTE after hospital discharge. Previous corticosteroid exposure significantly increased the risk of post-discharge VTE (OR 1.74, 95% CI 1.46-2.07, P < 0.001; Figure 1A).…”

Letter: previous exposure to corticosteroids increases the risk of post‐discharge venous thromboembolic events in patients with inflammatory bowel disease—author's reply

“…[3][4][5] Traditionally, corticosteroids have been associated with VTE risk in IBD. Zeng and Gan for their interest in our study and thoughtful comments.…”