妇产科术后静脉血栓栓塞症的诊断和防治

静脉血栓栓塞症（venous thromboembolism,VTE）是妇产科手术后严重的并发症,妇产科手术时应注意预防;临床上对于VTE尤其是肺栓塞（pulmonary thromboeambolism,PTE）的早期发现、早期诊断和及时正确的治疗尤为关键;影像学检查在诊断上占有至关重要的地位;抗凝治疗是其主要治疗方法之一。     

Venous Thromboembolism in Cancer Patients Undergoing Major Surgery

Background  Cancer patients undergoing major abdominal or pelvic surgery are at considerable risk of venous thromboembolism (VTE). The genesis of thromboses in malignancy is complicated, and reflects the interaction and derangement of multiple molecular pathways. Furthermore, the nature and location of the cancer, as well as the type surgery involved, are thought to affect the level of VTE risk. These considerations may therefore affect treatment decisions. Methods  We performed multiple Medline searches with terms including but not limited to VTE, cancer, surgery, abdominal, colorectal, unfractionated heparin (UFH), and low-molecular-weight heparin (LMWH) to identify reviews, meta-analyses, nonrandomized and randomized controlled trials, and clinical guidelines relating to management of VTE in patients with abdominal cancer. Results  VTE incidence in patients with malignancy varied according to cancer type, location, stage of progression, and the use of catheters and/or chemotherapy. Thromboprophylaxis with UFH or LMWH reduces the risk of developing VTE in these patients. However, LMWHs have a favorable risk-benefit profile over UFH and extending the duration prophylaxis may improve outcomes. Conclusion  A number of recommendations can be made for the prevention of VTE in patients undergoing abdominal or pelvic surgery for cancer: (1) risk-stratify all patients according to defined evidence-based guidelines; (2) for most abdominal surgical oncology patients at risk, use of both an anticoagulant and mechanical means are indicated and beneficial; and (3) consider extended-duration prophylaxis (up to 28 days) in those patients with major abdominal/pelvic operations and impaired mobility, preferably with LMWH.     

普通外科择限期手术患者静脉血栓形成风险评估

目的：评估普外科择限期手术患者静脉血栓形成的危险程度。方法：分析行择限期手术的普外科患者604例,根据Caprini静脉血栓形成风险评分量表进行评估,分析不同病种发生静脉血栓的危险程度,并进行比较。结果：恶性疾患组患者232例,Caprini评分平均（6.50±1.77）分,良性疾患组患者372例,Caprini评分平均（3.69±1.52）分,P〈0.001;消化系统恶性疾患组患者172例,Caprini评分平均（7.14±1.47）分,非消化系统恶性疾患组患者60例,Caprini评分平均（4.64±1.17）分,P〈0.001。结论：不同病种的普通外科择限期手术的患者,发生静脉血栓的危险程度是不同的,对不同风险的患者应采取不同的预防措施,以减少围手术期静脉血栓形成的风险。     

Balancing Venous Thromboembolism and Hematoma After Breast Surgery

Purpose

The purposes of this study are (1) to determine our institution??s rate of venous thromboembolic events (VTE) and hematomas following breast surgery, and (2) to compare our breast surgery VTE rate with both our general surgery population and the National surgical quality improvement program (NSQIP) dataset.

Methods

Prospectively collected NSQIP data from April 2006 to June 2010 were analyzed. Our institution??s VTE rates, pharmacologic prophylaxis (PCP) utilization, and hematomas were reviewed for patients undergoing breast surgery. The VTE rate was compared with NSQIP patient populations.

Results

Among 4,579 breast operations at our institution over this time period, 988 (21.6?%) were analyzed through NSQIP. The VTE rate following breast operations was 4/988 (0.4?%): 0/236 for those with benign disease and 4/752 (0.5?%) for those with breast cancer (p?=?0.58). PCP was received by 147/752 (19.5?%) cancer patients. In cancer patients, the hematoma rate requiring reoperation was 3/147 (2.0?%) in those receiving PCP and 12/605 (2.0?%) in those not receiving PCP (p?=?1.0). Breast surgery patients had a similar VTE rate compared with the institutional general surgery population (0.7?%, p?=?0.254) and versus national general surgery patients from NSQIP (0.7?%, p?=?0.29). Our institution??s VTE incidence for patients with breast cancer undergoing mastectomy was significantly higher than ??like?? NSQIP centers.

Conclusions

Our breast surgery VTE rate was similar to our general surgery population. Our mastectomy population had a higher VTE incidence compared with other NSQIP sites. Patients undergoing mastectomy, especially if combined with axillary lymph node dissection or reconstruction, should be considered for routine PCP.     

Venous Thromboembolism After Surgery for Benign Prostatic Hyperplasia

A systematic review has been performed on venous thromboembolism after surgery for benign prostatic hyperplasia. The risk of deep vein thrombosis is two to four times higher after open surgery than after transurethral resection. The risk after the newer transurethral methods (laser, radiofrequency, heat) is not known. Specific studies on thromboprophylaxis are few and have limited numbers of patients. Nonetheless, thromboprophylaxis (heparin) reduces the frequency of postoperative deep vein thrombosis after open surgery. Studies on patients undergoing transurethral resection are lacking. Antifibrinolytic treatment to diminish bleeding does not seem to increase the risk of thrombosis.     

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery

Background

In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis.

Methods

Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control.

Results

In total, 1179 patients who underwent major emergency abdominal surgery during 2010–2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11–2.16, P = 0.009).

Conclusion

In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

     

The Long-Term Risk of Venous Thromboembolism Following Bariatric Surgery

Background  

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality following bariatric surgery. The exact duration and magnitude of post-surgery risk for VTE, however, is unclear. We analyzed a large administrative database to determine the long-term risk and predictors for VTE in patients undergoing bariatric surgery.     

Current Practices in the Prophylaxis of Venous Thromboembolism in Bariatric Surgery

Background: Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of perioperative venous thromboembolism. Due to its clinically silent nature, primary prevention is the key to reduce morbidity and mortality. There is no clear consensus in the literature regarding the optimum approach to minimize this preventable phenomenon. Methods: Members of the American Society for Bariatric Surgery were surveyed regarding their current practices in the prophylaxis of venous thromboembolism in their bariatric patients. Results: 31% of the members completed the survey. 62% were in private practice, and 38% practiced in an academic hospital. The number of bariatric surgeries done per year ranged from 5 to 325, with a mean of 85 procedures per member. The gastric bypass was the most commonly performed procedure at 61.7%, followed by vertical banded gastroplasty at 23.3%, biliary pancreatic diversion at 9.3%, laparoscopic gastroplasty at 4.0%, laparoscopic gastric bypass at 1.6%, and horizontal banded gastroplasty at 0.1%. 86% felt that their bariatric patients were at high risk for developing deep vein thrombosis (DVT) and pulmonary embolism (PE) with a self-reported incidence of 2.63% and 0.95%, respectively. 48% had at least one death due to PE. Routine prophylaxis is used by over 95% of members. 62% ranked the various methods of prophylaxis from most preferred to least preferred, while 38% used a combination of 2 or more prophylactic methods simultaneously. Low-dose heparin was the most preferred prophylaxis by 50% of members, followed by intermittent pneumatic compression stockings at 33%, low molecular weight heparins at 13%, and other methods at 4%. Over 83% indicated that safety with few complications, ease of administration, and effectiveness were the most important criteria for selecting their most preferred prophylactic method. Only 2% routinely performed testing to rule out venous thromboembolism before discharge, and 11% routinely discharged patients with prophylaxis. Conclusions: The prevailing opinion of members of the American Society for Bariatric Surgery is that morbidly obese patients are at high risk for developing perioperative venous thromboembolism. A vast majority routinely use prophylaxis. Despite these measures, fatal PE is still widespread. A lack of consensus in the method of prophylaxis was seen. A multicentric randomized controlled study comparing the efficacy of the various methods of prophylaxis will be the only manner to determine the best prophylaxis and its usefulness. This study will be costly and probably not warranted due to the low incidence of this condition in the morbidly obese patient.     

Risk Stratification for Recurrent Venous Thromboembolism in Unprovoked Venous Thromboembolism Patients

Unprovoked venous thromboembolism (VTE) patients are at much higher risk of a recurrent VTE event than provoked VTE patients. Oral anticoagulation therapy (OAT) after a first unprovoked VTE has proved to effectively reduce the risk of recurrence during therapy however this benefit is lost after discontinuing OAT. A minimum of 6 to 12 months of OAT is recommended for first unprovoked VTE patients to prevent recurrence. However, there is evidence indicating that some patients are at ongoing high risk of recurrent VTE after discontinuation of therapy and that these patients may need indefinite anticoagulation to effectively prevent recurrences. Several risk factors for recurrent VTE have been identified that may be helpful to physicians when deciding whether OAT should be continued or discontinued in unprovoked VTE patients after initial therapy. The present article reviews risk factors for recurrent VTE including D-Dimer levels after discontinuation of OAT, elevated levels of Factor VIII, residual venous obstruction, post-throm-botic syndrome, male gender, and older age. Research is also underway to determine the predictive ability of these known VTE recurrence risk factors, combinations of these risk factors and their interrelationships as well as to actively search for additional potential predictors.