Prevalence of Preoperative Lower Extremity Deep Vein Thrombosis in Bilateral Calcaneal Fractures

There are no studies on epidemiologic characteristics of deep vein thrombosis (DVT), when specified at in patients with bilateral calcaneal fractures. This study aimed to address the preoperative DVT in bilateral calcaneal fractures. Between October 2014 and December 2018, adult patients presenting with bilateral calcaneal fractures and having preoperative Duplex ultrasound (DUS) of bilateral lower extremities for detection of DVT were included. Their medical data were collected, with regards to demographics, comorbidities, injury-related data and biomarkers. Baseline characteristics between patients with and without DVT were compared using bivariate tests. The further multivariate logistics regression analysis was conducted to identify independent factors associated with DVT. In total, 258 patients with bilateral calcaneal fractures were included, with 21 (8.1%) having preoperative DVT, diagnosed at 7.7 ± 4.2 days after injury. The prevalence rate of proximal DVT was 1.9% and of distal DVT was 6.2%. Thirty five thrombi were found, with 6 (17.1%) in proximal veins and 29 (82.9%) in distal veins. Nine patients had DVTs in multiple veins, and 2 patients had bilateral DVTs. The multivariate analyses showed history of allergy (odds ratio [OR] = 2.17), concurrent other fractures (OR = 4.53), prolonged time since injury (for each day, OR = 1.16), elevated plasma D-dimer level (≥1.73 vs <1.73 mg/L, OR = 3.74) and reduced albumin level (<34.2 g/L vs ≥34.2 g/L, OR = 2.92) were independent factors associated with DVT. Multiple factors were identified to be associated with DVT and greater consideration should be given to the use of pharmacologic prophylaxis in patients involving these factors, to reduce DVT occurrence.     

Incidence and risk factor for preoperative deep vein thrombosis (DVT) in isolated calcaneal fracture,a prospective cohort study

BackgroundsDeep vein thrombosis (DVT) occurring during the preoperative waiting period may affect the prognosis of traumatic patients, but there still lack of relevant data. This study aimed to address the preoperative DVT in isolated calcaneal fractures.MethodsPatients who presented with isolated calcaneal fracture and received preoperative Duplex ultrasound scanning of bilateral lower extremities for detection of DVT between October and December 2018 were eligible for inclusion. Relevant data were prospectively collected, including demographics, comorbidities, lifestyles, injury, and laboratory biomarkers at admission. Univariate analyses were used to compare the difference of each variable between patients with and without DVT. Multivariate logistics regression analysis was used to identify the independent risk factors for DVT.ResultsTotally, 770 patients met the criteria and were included, and 24 (3.1%) had preoperative DVT diagnosed at mean of 5.3 days after injury, all of which were asymptomatic. Among patients with DVTs, 36 thrombi were found and 29 (80.6%) were in distal veins. Eight patients had DVTs in multiple veins, but no patients had bilateral DVTs. The multivariate analyses showed older age (≥58 vs <58 years, OR = 3.84), delay from injury to DUS (in each day, OR = 1.23) and elevated plasma D-dimer level (≥1.79 vs <1.79 mg/L, OR = 2.53) were independent risk factors associated with DVT.ConclusionsDue to low prevalence of DVT in isolated fracture, routine throboprophylaxis is not recommended. However, emphasis should be given in older patients with delay to admission and elevated plasma D-dimer level for targeted detection of DVT and rapid therapeutic intervention.     

Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank

OBJECTIVE: Venous thromboembolic events (VTE) are potentially preventable causes of morbidity and mortality after injury. We hypothesized that the current clinical incidence of VTE is relatively low and that VTE risk factors could be identified. METHODS: We queried the ACS National Trauma Data Bank for episodes of deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We examined demographic data, VTE risk factors, outcomes, and VTE prophylaxis measures in patients admitted to the 131 contributing trauma centers. RESULTS: From a total of 450,375 patients, 1602 (0.36%) had a VTE (998 DVT, 522 PE, 82 both), for an incidence of 0.36%. Ninety percent of patients with VTE had 1 of the 9 risk factors commonly associated with VTE. Six risk factors found to be independently significant in multivariate logistic regression for VTE were age > or = 40 years (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.74 to 2.32), lower extremity fracture with AIS > or = 3 (OR 1.92; 95% CI 1.64 to 2.26), head injury with AIS > or = 3 (OR 1.24; 95% CI 1.05 to 1.46), ventilator days >3 (OR 8.08; 95% CI 6.86 to 9.52), venous injury (OR 3.56; 95% CI 2.22 to 5.72), and a major operative procedure (OR 1.53; 95% CI 1.30 to 1.80). Vena cava filters were placed in 3,883 patients, 86% as PE prophylaxis, including in 410 patients without an identifiable risk factor for VTE. CONCLUSIONS: Patients who need VTE prophylaxis after trauma can be identified based on risk factors. The use of prophylactic vena cava filters should be re-examined.     

The role of surveillance duplex scanning in preventing venous thromboembolism in trauma patients

BACKGROUND: This study was performed to determine the role of duplex scanning in preventing pulmonary embolism (PE), the correlation of venous thromboembolism (VTE) risk score with the incidence of deep venous thrombosis (DVT), and patients who may benefit from surveillance duplex scanning. METHODS: Age, sex, Injury Severity Score (ISS), VTE score, length of stay, diagnoses, and bleeding risk were recorded from the trauma registry in patients who had a duplex scan from 1995 to 2000. RESULTS: There were 1,513 duplex scans obtained (10,141 trauma admissions), 253 (2.5%) cases of DVT (52% above-knee, 8% upper extremity), and 30 cases of PE (0.3%). Only 5 of 21 duplex scans were positive in PE patients. DVT patients were older (52.9 vs. 46.7 years), with higher ISS (24.0 vs. 20.8) than patients without DVT. Regression analysis showed poor correlation between VTE score and DVT incidence (r2 = 0.27). Univariate analysis identified age, ISS, and VTE score as risk predictors for DVT. CONCLUSION: Adherence to an evidence-based VTE prophylaxis protocol is more important than surveillance duplex scanning in preventing VTE in trauma patients.     

Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem?

Deep venous thrombosis (DVT) and pulmonary embolism (PE) affect high-risk trauma patients (HRTP). Accurate incidence and clinical importance of DVT and PE in HRPT may be overstated. We performed a ten-year retrospective analysis of HRTP of the Pennsylvania Trauma Outcome Study. High-risk factors (HRF) included pelvic fracture (PFx), lower extremity fracture (LEFx), severe head injury (CHI) (AIS - head > or =3), and spinal cord injury. HRF alone or in combination, age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) were examined for association with DVT/PE. A total of 73,419 HRTP were included: 1377 (1.9%) had DVT, 365 (0.5%) had PE. The incidence of DVT in level I trauma centers was 2.2 per cent and was 1.5 per cent in level II centers. The lowest incidence of DVT was 1.3 per cent for isolated LEFx; highest was 5.4% for combined PFx, LEFx, and CHI. Variables associated with DVT included age, ISS, and GCS (all P < 0.001). In logistic regression analysis, only ISS was consistently predictive for DVT and PE. Though increased during the past decade, the overall incidence of DVT in HRTP remains below 3 per cent. Only the combination of multiple injuries or an ISS >30 result in DVT incidence of > or =5 per cent. We believe that current guidelines for screening for DVT may need to be reevaluated.     

Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs

OBJECTIVES: To assess the treatment of venous thromboembolism (VTE) in hospitalized patients enrolled in a national, multicenter database. METHODS: This was a retrospective, cohort study that randomly selected VTE patients from 38 academic/teaching, community, and Veterans Administration (VA) hospitals. The study included a physician survey component. The patients selected were those treated between January 2002 and June 2003 who had an ICD-9-CM code for pulmonary embolus (PE), deep vein thrombosis (DVT), or pregnancy-related PE or DVT. RESULTS: The study included 939 patients: 52.7% with DVT, 28.4% with PE, and 18.8% with PE and DVT. Mean age was 59.5 years. Risk factors included obesity (body mass index > 30) in 30.1%, history of VTE in 28.0%, malignancy in 27.4%, surgery in 21.1%, and immobility in 18.5%. Only 56.1% of patients were treated with low-molecular-weight heparin (LMWH). Bridging from LMWH or unfractionated heparin (UFH) to warfarin was completed during hospitalization in 486 (68.6%), but only 246 (50.6%) had an international normalized ratio (INR) > or = 2 for 48 hours before discontinuation of the injectable anticoagulant. Length of stay in patients discharged on bridge therapy was 4.0 +/- 3.7 days vs 8.1 +/- 5.8 days for patients discharged on warfarin therapy (P < .001). Ninety-two (10.1%) patients were discharged with neither oral nor injectable anticoagulation and had a mean duration of treatment of only 10.6 +/- 16.2 days. Of 245 physicians surveyed from participating hospitals, 84% and 53%, respectively, indicated that LMWH was their preferred agent for treatment of DVT and treatment of PE. With regard to warfarin, 30% did not believe it was necessary to have a therapeutic INR for > or = 2 days before discontinuing LMWH or UFH, and 27% responded that it was necessary to keep DVT patients in the hospital until they were therapeutic. CONCLUSIONS: In this cross-section of United States hospitals, lower than anticipated use of LMWH, insufficient bridging from UFH or LMWH to warfarin, and continuation of anticoagulation after hospitalization were all problems discovered with the treatment of VTE. Physician knowledge, attitudes, and beliefs are partially responsible for the gap between actual practice and international guidelines. These results suggest that hospitals should evaluate their adherence to international VTE treatment guidelines and develop strategies to optimize antithrombotic therapy.     

Factors affecting prognosis in patients with gastric trauma

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P < 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs. 87 of 492 or 18%; P < 0.001), required more blood (16+/-16 U vs. 6+/-11 U; P < 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs. 75 of 492 or 15%; P = 0.001), and had an increased length of stay (20+/-30 days vs. 13+/-18 days; P = 0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.     

Do patients with acute deep vein thrombosis have fever?

The purpose of this study was to determine whether those with lower extremity acute venous thrombosis have fever. During a recent 14.5-month period, 1847 patients undergoing lower extremity venous duplex scanning also had their oral temperature measured using a digital thermometer at the time of duplex examination. Patients were 57.8 +/- 17.3 years of age (range, 14 to 99). Temperature was 98.5 +/- 1.1 degrees F. Twenty-three patients had acute inferior vena cava thrombosis, 60 had acute iliac vein thrombosis, 138 had acute femoral venous thrombosis, and 131 had acute popliteal venous thrombosis. Calf vein thromboses were present in 102 patients, and 43 patients had superficial venous thrombosis. A total of 228 patients had acute lower extremity venous thrombosis in one or more of these venous segments. Temperature with acute lower extremity venous thrombosis was 98.7 +/- 1.05 degrees F versus 98.5 +/- 1.10 degrees F in those with no acute thrombosis. Although small, this temperature difference was statistically significant (P < 0.02). Acute deep venous thrombosis (DVT) was defined as acute popliteal or more proximal femoral, iliac, or vena cava thrombosis. The temperature for the 175 patients with acute DVT was 98.7 +/- 1.10 degrees F versus 98.5 +/- 1.10 degrees F for those without DVT (P < or = 0.035). There was no temperature that served to accurately differentiate those who did from those who did not have DVT. The frequency that patients with DVT had fever, defined as a temperature > or = 100 degrees F, was 9.1 per cent (16 of 175) with DVT versus 7.5 per cent (126 of 1678) without DVT (not significant). In the subgroup with a temperature > or = 101 degrees F, 4.6 per cent (8 of 175) with DVT had such a fever versus 3.4 per cent (57 of 1672) without DVT (not significant). Those undergoing venous duplex who were found to have acute lower extremity venous thrombosis, including acute DVT, had statistically higher temperatures, but such temperature differences were minimal. The incidence of fever, defined as a temperature > or = 100 degrees F or > or = 101 degrees F, was not different between those with and those without acute DVT. It appears that the presence of fever may not be a sensitive or specific indicator for the presence of underlying acute DVT.     

Meta-analysis of trials comparing ximelagatran with low molecular weight heparin for prevention of venous thromboembolism after major orthopaedic surgery

BACKGROUND: Use of low molecular weight heparin (LMWH) is standard practice for preventing postoperative venous thromboembolism (VTE). Ximelagatran is a new direct thrombin inhibitor for this indication. METHODS: A systematic review was conducted to compare the efficacy and safety of LMWH with ximelagatran in orthopaedic surgery. RESULTS: Six eligible, well conducted clinical trials (10 051 patients) were identified. Overall, the risk of VTE (OR (odds ratio) 1.22 (95 per cent confidence interval (c.i.) 0.89 to 1.67)) and serious bleeding (OR 0.70 (95 per cent c.i. 0.42 to 1.18)) was not significantly different for LMWH compared with ximelagatran. Exploratory analyses to investigate statistical heterogeneity found that results varied by surgical subtype and treatment regimen. Compared with postoperative ximelagatran, LMWH had a significantly lower rate of VTE (OR 0.68 (95 per cent c.i. 0.56 to 0.82); P < 0.001), with no significant difference in bleeding rate (OR 1.09 (95 per cent c.i. 0.62 to 1.94); P = 0.76), in hip surgery, and no significant differences in knee surgery. When ximelagatran was started immediately before surgery, LMWH had a significantly higher rate of VTE in both hip (OR 1.87 (95 per cent c.i. 1.20 to 2.92); P = 0.006) and knee (OR 1.49 (95 per cent c.i. 1.14 to 1.93); P = 0.003) surgery, but less bleeding: hip OR 0.30 (95 per cent c.i. 0.17 to 0.53; P < 0.001); knee OR 0.71 (95 per cent c.i. 0.30 to 1.67; P = 0.43). CONCLUSION: This review demonstrated no overall advantage for either LMWH or ximelagatran in thromboprophylaxis following orthopaedic surgery. Benefits in VTE prevention with ximelagatran were gained at the expense of an increased risk of serious bleeding.     

Indicators of depressed fibrinolytic activity in pre-operative prediction of deep venous thrombosis

Euglobulin lysis time (ELT), tissue plasminogen activator (tPA), and the fast-acting inhibitor of tPA, were measured pre-operatively in 128 patients who underwent elective major abdominal surgery. Deep venous thrombosis (DVT) was detected by 125I-labelled fibrinogen scan in 37 patients (29 per cent) after operation. Pre-operatively, there was diminished euglobulin lysis activity (332 +/- 197 versus 255 +/- 156 min, mean +/- s.d.; P less than 0.025), and tissue plasminogen activator activity (4.2 +/- 9.9 versus 7.7 +/- 14.3 milliunits/ml, mean +/- s.d.; P = 0.094) in patients who subsequently developed postoperative DVT compared with those who did not. There was no significant difference between the two groups in the level of inhibition of tissue plasminogen activator (160.6 +/- 75.4 per cent versus 152.5 +/- 77.5 per cent, mean +/- s.d.; n = 47). Stepwise logistic discriminant analysis of the data obtained preoperatively showed that tissue plasminogen activator, a more specific measure of fibrinolytic activity, was a weaker predictor of DVT than euglobulin lysis time. The results confirm other observations which indicate that lowered fibrinolytic activity is a risk factor for postoperative DVT. In addition, they suggest that this is not due entirely to low levels of activity of tissue plasminogen activator in plasma.     

Screening for major deep vein thrombosis in seriously injured patients: A prospective study

The purpose of the study is to determine the prevalence of acute deep venous thrombosis (DVT) in severely injured trauma patients, to investigate the cost effectiveness of a noninvasive surveillance program, and to assess the merit of current methods of prophylaxis against DVT. One hundred and forty-eight patients (295 limbs) with a mean age of 36.5 years, mean trauma score of 13.3, mean injury severity score of 22.4 with predominantly blunt injuries (88.5%), were part of the study. The mean length of stay was 17.6 days. Venous duplex scans (VDS) were performed on inpatients on days 2-5, day 11, and day 30 following admission. Sequential compression device and/or subcutaneous heparin was used in 99% of patients with compliance being monitored by trauma nurse clinicians. A total of 272 VDS were performed with total charges of $111,520. DVT was found by VDS or venography in eight limbs (2.7%) of six patients (4%), four of the limbs being symptomatic. Two additional patients had pulmonary embolism, both with normal VDS. Routine serial VDS in severely injured patients who undergo aggressive prophylaxis against DVT is not cost effective and therefore not justified. (Ann Vasc Surg 1997; 11:626-629.)     

Nonoperative management of blunt renal trauma: a prospective study

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (Match 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3-5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score > or = 15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 +/- 1.72 vs 1.87 +/- 1.4 liters, P = 0.003) and blood transfusions (2.40 +/- 2 vs 0.42 +/- 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.     

Stress ulceration requiring definitive surgery after severe trauma

Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 +/- 1.2 days after admission, 7.2 +/- 1.2 days before definitive operative therapy, and requiring 7.1 +/- 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 +/- 41 vs 158 +/- 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.     

Prospective evaluation of a screening protocol to exclude deep vein thrombosis on the basis of a combination of quantitative D-dimer testing and pretest clinical probability score

BACKGROUND: Clinical signs and symptoms such as swelling, pain, and redness are unreliable markers of deep vein thrombosis (DVT). Because of this venous duplex scanning (VDS) has been heavily used in DVT detection. The purpose of this study was to determine if a combination of D-dimer testing and pretest clinical score could reduce the use of VDS in symptomatic patients with suspected DVT. STUDY DESIGN: One hundred seventy-four consecutive patients with suspected DVT were prospectively evaluated using pretest clinical probability (PCP) score and D-dimer testing before VDS. After calculating clinical probability scores developed by Wells and associates, patients were divided into low risk (or=3 points) PCP. RESULTS: One hundred fifty-eight patients were enrolled. The prevalence of DVT in this study was 37%. Thirty-eight patients (24%) were classified as low risk, 64 (41%) as moderate risk, and 56 (35%) as high risk PCP. DVT was identified in only one patient (2.6%) with low risk PCP. In contrast, DVT was found in 22 (34%) with moderate risk, and 35 (63%) with high risk PCP. In the high and moderate risk PCP groups, positive scan patients had a markedly higher value of D-dimer assay than negative scan patients (p=0.0001 and p=0.0057, respectively). In the low risk PCP patients, D-dimer testing provided 100% sensitivity, 46% specificity, 4.8% positive predictive value, and 100% negative predictive value in the diagnosis of DVT. Similarly, in the moderate risk PCP, the D-dimer testing showed 100% sensitivity, 45% specificity, 49% positive predictive value, and 100% negative predictive value. In the high risk group, D-dimer testing achieved 100% sensitivity, 57% specificity, 80% positive predictive value, and 100% negative predictive value in the diagnosis of DVT. These results suggested that 36 of 158 patients who had a non-high PCP (low and moderate PCP) and a normal D-dimer concentration were considered to have no additional investigation, so VDS could have been reduced by 23% (36/158). CONCLUSIONS: A combination of D-dimer testing and clinical probability score may be effective in avoiding unnecessary VDS in suspected symptomatic DVT in the low and moderate PCP patients. The need for VDS could be reduced by 23% despite a relatively high prevalence of DVT.     

Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity?

We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984-2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs. 77%, P = 0.05) and radiation therapy (86% vs. 52%, P < 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours +/- 2.5 hours vs. 5.6 hours +/- 1.8 hours, P = 0.03), but lengths of stay were similar (13 +/- 5.9 days vs. 12 +/- 7.6 days, P = 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs. 40%, P = 0.1) and major wound-healing complications (32% vs. 26%, P = 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs. 28%, P = 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group (P = 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.     

Factors predictive of venous thromboembolism in bariatric surgery

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in bariatric surgery. The aim of this study was to evaluate the effect of patient characteristics, payer type, comorbidities, and surgical techniques on development of VTE in bariatric surgery. Using the National Inpatient Sample (NIS) database from 2006 to 2008, clinical data of 304,515 morbidly obese patients who underwent bariatric surgery were examined. Multiple regression analysis was performed to identify factors predictive of VTE. The overall rate of in-hospital VTE was 0.17 per cent, with the highest rate of VTE observed in open gastric bypass (0.45%). The VTE rate was significantly lower in laparoscopic compared with open gastric bypass (0.13% vs 0.45%, respectively, P < 0.01) and in nongastric bypass compared with gastric bypass procedures (0.06% vs 0.21%, respectively, P < 0.01). Alcohol abuse [odds ratio (OR): 8.7], open operation (OR: 2.5), gastric bypass procedures (OR: 2.4), renal failure (OR: 2.3), congestive heart failure (OR: 2.0), male gender (OR: 1.5), and chronic lung disease (OR: 1.4) were associated with a higher rate of VTE. This study identified several significant risk factors for development of VTE in bariatric surgery. To minimize the risk of VTE, surgeons may consider these factors in selection of appropriate prophylaxis and bariatric surgical options.     

Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries

This is a retrospective review of 731 patients sustaining diaphragmatic trauma over a 22 year period (1980-2002) at an urban level I trauma center. Patients had an average injury severity score (ISS) of 22 +/- 12. The mortality rate (MR) was 23 per cent (168/731). There were a total of 460 left-sided diaphragmatic injuries (L-TDR), 263 right-sided diaphragmatic injuries (R-TDR), and 8 bilateral diaphragmatic injuries (B-TDR). There were no significant differences in mortality with L-TDR versus R-TDR. Shotgun wounds had the highest MR (42%) (P = 0.0028). Emergency thoracotomies were performed in 31 per cent (225) with a 62 per cent (140) MR. Bilateral thoracotomies had a significantly higher MR of 85 per cent (33/39) compared to the 58 per cent (107/186) for unilateral thoracotomies (P = 0.0028). Multivariate analysis revealed the most significant independent predictors of mortality to be the revised trauma score, transfusion of pRBCs > 10 units, and need for thoracotomy (P < 0.0001). The infection rate was 41 per cent. Multivariate analysis revealed blunt trauma, blood transfusions, ISS, and pancreatic injury as the most significant independent predictors of infection (P < 0.001). The initial physiologic presentation of the patient and the severity of hemorrhagic shock are the primary determinants for survival. Prompt identification of associated injuries with rapid control of bleeding is paramount to survival.     

Complications digestives sévères après chirurgie cardiaque sous circulation extracorporelle

PURPOSE: To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC). METHODS: Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997. RESULTS: Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9). CONCLUSION: Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.     

Prognostic determinants in duodenal injuries

A retrospective review of 222 consecutive patients with duodenal injuries admitted to an urban Level 1 Trauma Center who subsequently underwent laparotomy during the period July 1980 to April 2002 was performed in an effort to elucidate factors associated with mortality, infectious morbidity, and length of stay in these patients. Predictably, the patients were predominantly male (92.7%) and young (mean age, 31.6 years). The overall mortality rate was 22.5 per cent, with a mortality rate of 18 per cent seen in the first 48 hours. Penetrating trauma was suffered by 88.3 per cent of the patients. Multivariate analysis revealed the performance of a thoracotomy, initial emergency department (ED) systolic blood pressure (SBP) <90 mm Hg, final operating room (OR) core body temperature less than 35 degrees C, and presence of a splenic injury to be the most important predictors of mortality (all P < 0.05). Mortality in the patients undergoing a resuscitative thoracotomy was 88.9 per cent versus 13.3 per cent in those patients not requiring thoracotomy. An initial SBP in the ED <90 was associated with a 46 per cent mortality rate, as compared with 4 per cent in those patients not in shock. A final OR core body temperature of less than 35 degrees C led to a 60 per cent mortality rate versus 8.3 per cent for warmer patients. Patients with a concomitant splenic injury were noted to have a 62.5 per cent mortality rate; those without had a 19.4 per cent mortality rate. The mean length of stay among survivors greater than 48 hours was 16.0 +/- 24.7 days. Univariate analyses revealed lowest OR core body temperature below 35 degrees C, initial OR SBP <90, presence of infection, >5 transfusions, initial ED SBP <90, final OR core temperature <35 degrees C, colon injury, spleen injury, and an injury severity score (ISS) >25 all to be significantly associated with increased length of stay. Multivariate analysis revealed an initial operating room blood pressure of less than 90 mm Hg systolic, the presence of an infection, and greater than 5 blood transfusions to be the factors most significantly correlated with increased length of stay (all P < 0.02). Of 182 patients surviving 48 hours, 98 (54%) developed an infection. Fifty-seven (31%) patients were noted to have wound-related infections, 92 (51%) patients had nosocomial infections, and 50 (27%) patients had both types. The presence of an abdominal arterial injury, an ISS >25, pancreatic injury, and lowest OR core body temperature <35 degrees C were the factors identified on multivariate analysis most significantly correlated with infectious morbidity (all P < 0.05). This data suggests that early efforts to prevent shock and rapidly control bleeding are the most likely efforts to reduce mortality rates in these patients. Those patients with duodenal injury presenting in shock or requiring a thoracotomy for resuscitation did poorly. Splenic injury was the associated injury found on multivariate analysis to be most closely associated with increased mortality. Early control of bleeding and the prevention of infection provide the most significant opportunity for decreasing length of stay. Infections are common with duodenal injuries, and aggressive surveillance should especially be performed in those patients with an abdominal arterial injury, an ISS >25, pancreatic injury, or lowest OR core body temperature <35 degrees C.     

Behavioral factors associated with successful weight loss after gastric bypass

Patients undergoing bariatric surgery lose substantial weight (> or = 50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as > or =50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 +/- 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.