Predicting The Risks Of Venous Thromboembolism Versus Post .

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View metadata, citation and similar papers at core.ac.ukbrought to you byCOREprovided by Elsevier - Publisher ConnectorHPBDOI:10.1111/hpb.12148ORIGINAL ARTICLEPredicting the risks of venous thromboembolism versus postpancreatectomy haemorrhage: analysis of 13 771 NSQIP patientsChing-Wei D. Tzeng, Matthew H. G. Katz, Jeffrey E. Lee, Jason B. Fleming, Peter W. T. Pisters, Jean-Nicolas Vauthey &Thomas A. AloiaDepartment of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USAAbstractBackground: The fear of an early post-pancreatectomy haemorrhage (PPH) may prevent surgeons fromprescribing post-operative venous thromboembolism (VTE) chemoprophylaxis. The primary hypothesis ofthis study was that the national post-pancreatectomy early PPH rate was lower than the rate of VTE. Thesecondary hypothesis was that patients at high risk for post-discharge VTE could be identified, potentiallyfacilitating the selective use of extended chemoprophylaxis.Patients and methods: All elective pancreatectomies were identified in the 2005 to 2010 AmericanCollege of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Factorsassociated with 30-day rates of (pre- versus post-discharge) VTE, early PPH (transfusions 4 units within72 h) and return to the operating room (ROR) with PPH were analysed.Results: Pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) numbered 9140 (66.4%)and 4631 (33.6%) out of 13 771 pancreatectomies, respectively. Event rates included: VTE (3.1%), PPH(1.1%) and ROR PPH (0.7%). PD and DP had similar VTE rates (P 0.05) with 31.9% of VTE occurringpost-discharge. Independent risk factors for late VTE included obesity [odds ratio (OR), 1.5], age ⱖ 75years (OR, 1.8), DP (OR, 2.4) and organ space infection (OR, 2.1) (all P 0.02).Conclusions: Within current practice patterns, post-pancreatectomy VTE outnumber early haemorrhagic complications, which are rare. The fear of PPH should not prevent routine and timely postpancreatectomy VTE chemoprophylaxis. Because one-third of VTE occur post-discharge, high-riskpatients may benefit from post-discharge chemoprophylaxis.Received 20 March 2013; accepted 26 May 2013CorrespondenceThomas A. Aloia, Department of Surgical Oncology, Unit 1484, The University of Texas MD AndersonCancer Center, 1400 Pressler Street, Houston, TX 77030, USA. Tel: 1 713 563 0189. Fax: 1 713 745 1921. E-mail: taaloia@mdanderson.orgIntroductionFor most major abdominal operations, routine post-operativevenous thromboembolism (VTE) chemoprophylaxis has beenproven to be both safe and effective, and is now considered theThis manuscript was presented at the annual AHPBA meeting, Miami,20–24 February 2013.ACS-NSQIP Disclaimer for Participant Use File Research:The AmericanCollege of Surgeons National Surgical Quality Improvement Program andthe hospitals participating in the ACS NSQIP are the source of the data usedherein; they have not verified and are not responsible for the statisticalvalidity of the data analysis or the conclusions derived by the authors.HPB 2014, 16, 373–383international standard of care, especially for cancer surgery.1–7Post-operative VTE chemoprophylaxis in the form of low-doseunfractionated heparin or low-molecular-weight heparin is aGrade 1B recommendation from the most recent AmericanCollege of Chest Physicians (ACCP) guidelines, for all moderateto high-VTE-risk patients undergoing major abdominal surgery,as long as there is no significant bleeding risk.1,2,8 In spite of thisrecommendation, hepatopancreatobiliary (HPB) surgeons havefrequently withheld VTE chemoprophylaxis owing to the perceived risk of peri-operative haemorrhage in liver and pancreaticsurgery. This traditional mentality has placed surgical HPBpatients, most of whom have cancer, at risk for the significantmorbidity and mortality associated with VTE.9,10 2013 International Hepato-Pancreato-Biliary Association

374As with all major abdominal surgery, pancreatic surgeons mustmaintain a balance between the risk of intra- or post-operativebleeding and the risk of VTE. In addition, pancreatic cancerpatients, who make up the majority of patients undergoing pancreatic surgery, have an intrinsically high risk of VTE.11,12 Withregard to bleeding risk, the true incidence of an early postpancreatectomy haemorrhage (PPH)13 has not been delineatedexcept in institutional studies.14 Nor has it been compared withVTE event rates. In the absence of large-scale comparative dataregarding the incidence of bleeding and thrombosis,14 pancreaticsurgery patients have been treated based on the surgeon’s discretion, with a variety of approaches to the initiation, timing andduration of post-operative VTE chemoprophylaxis. We recentlyreported that in liver surgery patients, the risk of VTE outweighedthe risk of early post-hepatectomy bleeding events.15 In thepresent study, we sought to determine whether this paradigm heldtrue for pancreatectomies as well.A second set of issues to address is the timing of postpancreatectomy VTE and the potential benefit of extended,post-discharge, chemoprophylaxis.16 Several previous studies ofabdominal surgery patients have shown the value of extendedchemoprophylaxis in high-risk patients.8,17,18 Thus, in high-VTErisk cancer patients undergoing abdominal surgery, the ACCPcurrently recommends 4 weeks of extended duration chemoprophylaxis if the risk of bleeding is not high (Grade 1B recommendation).1 However, longer-term prescriptions of extendedchemoprophylaxis are associated with problems related to patientquality of life, financial costs and potential bleeding risk. The mosttailored strategy would, therefore, be to focus extended chemoprophylaxis on only patients who are truly high risk and thus wouldbenefit most from the prescription. Before developing postdischarge VTE prophylaxis recommendations, there is a need todemonstrate that post-discharge VTE is a separate entity frompre-discharge VTE and that post-discharge VTE comprises a clinically relevant proportion of all post-operative VTE. Then theremust be identifiable risk factors (and a large enough studycohort with sufficient events) to stratify patients into a high-riskgroup who would potentially benefit the most from extendedchemoprophylaxis.The primary hypothesis of the present study was that thenational post-pancreatectomy VTE rate was greater than the ratesof early PPH events. The secondary hypothesis was that a certainsubset of pancreatectomy patients was at high risk for postdischarge VTE and that there were clinical factors that could beused to select patients for extended chemoprophylaxis. To test thesehypotheses, this study was designed to evaluate the rates, timingand risk factors for pre- and post-discharge VTE after a pancreaticoduodenectomy (PD) and a distal pancreatectomy (DP).Patients and methodsData acquisition, patients, and definitionsFrom the American College of Surgeons-National SurgicalQuality Improvement Program (ACS-NSQIP) participant use fileHPB 2014, 16, 373–383HPBfor 2005 to 2010, all pancreatectomy procedures were selected.After excluding emergency cases, enucleations, necrosectomies,pancreatic biopsies, hyperthermic intraperitoneal chemotherapycases, islet cell transplants and ampullectomies, all remaining pancreatectomies were included for analysis. For PD, this includedcurrent procedural terminology (CPT) codes 48150, 48152, 48153and 48154. For the purposes of the analysis, total pancreatectomies (CPT 48155) were grouped with PD. A distal pancreatectomyincluded CPT codes 48140, 48145 and 48146. CPT codes wereanalysed from the primary CPT column as well as from any of theconcurrent procedure columns. CPT coding did not differentiatebetween open and laparoscopic cases.For thrombotic events within 30 days of a pancreatectomy, theanalysis focused on three post-operative NSQIP variables: deepvein thrombosis (DVT), pulmonary embolism (PE) or a combination of the two. VTE was defined as a clinically detected DVT orPE. When both DVT and PE occurred, the first instance of eitherwas considered the presenting VTE. The timing of VTE was compared with discharge date and labelled as ‘early’ (pre-discharge)versus ‘late’ (post-discharge).For post-operative haemorrhagic events, the analysis focusedon two post-operative variables: post-operative ‘bleeding transfusion’ which was defined by NSQIP as a transfusion of 4 unitspacked red blood cells (PRBC) within 72 h of surgery (early PPH)and unplanned return to the operating room (ROR) combinedwith bleeding transfusion (ROR with PPH). Risk factors for preand post-discharge VTE were derived from analysis of all NSQIPcollected clinical factors.The pre-operative NSQIP risk factors that were assessedincluded race, age, gender, performance status, weight/body massindex, haematocrit, platelets, blood urea nitrogen, creatinine,albumin, partial thrombin time, international normalized ratio,bilirubin, white blood cell count, alkaline phosphatase, aspartateaminotransferase, American Society of Anesthesiologists (ASA)class, smoking, chronic obstructive pulmonary disease (COPD),pneumonia, ascites, sepsis, disseminated cancer, diabetes, bleedingdisorder, pre-operative radiation therapy, pre-operative chemotherapy, pre-operative transfusion, pre-operative hospitalizationand a previous operation within 30 days.Intra-operative variables included operative time, intraoperative transfusion, type of pancreatectomy and concurrentmajor operation. Concurrent major operations were defined asadrenalectomy, gastrectomy, oesophagectomy, intestinal resection,colorectal resection, retroperitoneal tumor resection, nephrectomy and/or hepatectomy. The definition of major concurrentoperations did not include splenectomy, cholecystectomy, liverwedge resection/biopsy, radiofrequency ablation, feeding tubeplacement and abdominal wall hernia repair.Thirty-day post-operative outcomes included a post-operativetransfusion, bleeding transfusion (early PPH), ROR, renal insufficiency or failure, respiratory failure, myocardial infarction,cardiac arrest, surgical site infection, organ space infection(OSI, including abscess or pancreatic leak), fascial dehiscence, 2013 International Hepato-Pancreato-Biliary Association

HPBpost-operative sepsis or septic shock, length of stay and mortality.As a result of the defined limitations of NSQIP data, postpancreatectomy mortality was defined as death within 30 postoperative days or death at a later date if the patient had a continuoushospitalization from surgery to the death date.Statistical analysisThe association of clinical factors with VTE, bleeding complications and mortality, was analysed using the chi-squared test orFisher’s exact test for non-parametric categorical data and theMann–Whitney U-test for non-parametric continuous data. Significant univariate risk factors were entered into a multivariatelogistic regression model to determine independent associations.Analyses were performed using SPSS Statistics 19 (IBM, Armonk,NY, USA). All tests were two-sided. Statistical significance wasdefined as P 0.05.ResultsPatients and pancreatectomies analysedFrom 2005 to 2010, 13 771 patients met the inclusion criteria witha median age 64 years (range 16–90), 51.7% female gender and78.6% Caucasian race. Rates of common pre-operative risk factorsincluded 66.5% with ASA class ⱖ3, 19.7% with age ⱖ 75 years and26.9% with obesity [body mass index (BMI) ⱖ 30 kg/m2]. Thecase distribution included 9140 (66.4%) PD (including 306(2.2%) total pancreatectomies) and 4631 (33.6%) DP. Indicationsfor surgery included malignant diagnoses in 81.7% of patientswith no difference in VTE rates between malignant and benignindications (3.2% versus 2.9%, P 0.451). Other clinically relevant pre-, intra- and post-operative factors are described inTable 1.VTE, bleeding, and transfusions in relation totype of pancreatectomyOverall complication rates included the following: DVT (2.2%),PE (1.2%), VTE (3.1%), PPH (1.1%) and ROR with PPH (0.6%).There were only 5 (0.04%) patients who experienced both VTEand PPH after a pancreatectomy. VTE event rates were more frequent than PPH rates and/or ROR with PPH rates for both PD(3.0%, 1.1%, 0.7%) and DP (3.3%, 1.0%, 0.5%, P 0.001, Fig. 1).Analysis of the association between the type of pancreatectomyand complication rates showed no differences in bleeding or VTEevents, P 0.362, Fig. 1. Intra-operative transfusions ⱖ 1 unitPRBC were common (28.7%), as were intra-operative transfusions ⱖ 2 units PRBC (21.6%), with PD transfusion rates (31.5%,23.4%) higher than for DP (23.5%, 18.2%, respectively, P 0.001).Factors associated with early PPHThe univariate analysis of peri-operative factors associated withearly PPH, or bleeding transfusion, is detailed in Table 1. Onmultivariate analysis, independent pre- and intra-operativefactors associated with early PPH included the following: ASAclass ⱖ 3 [odds ratio (OR) 1.74, 95% confidence interval (CI)HPB 2014, 16, 373–3833751.08–2.79, P 0.023], a lack of independent functional status (OR2.10, 95% CI, 1.11–3.95, P 0.023) and an intra-operative transfusion ⱖ 4 units PRBC (OR 6.16, 95% CI, 4.12–9.21, P 0.001,Table 2).Factors associated with ROR with early PPHThe univariate analysis of peri-operative factors associated withROR with early PPH is detailed in Table 3. On multivariate analysis, independent pre- and intra-operative predictors of ROR withearly PPH included the following: pre-operative sepsis (OR 2.77,95% CI, 1.23–6.25, P 0.014), a pre-operative bleeding disorder(OR 2.83, 95% CI, 1.25–6.44, P 0.013) and an intra-operativetransfusion ⱖ 4 units PRBC (OR 6.09, 95% CI, 3.64–10.21, P 0.001, Table 2).Factors associated with 30-day mortalityThe 30-day postoperative mortality rate was 2.6%. Comparisonsof risk factors for 30-day mortality are provided in Table 4. Independent risk factors for 30-day mortality included age ⱖ 80 years(OR 2.56, 95% CI 1.723–3.79), pre-operative dyspnoea (OR 1.57,95% CI 1.03–2.40), a lack of independent function (OR 2.14, 95%CI 1.28–3.57), albumin 3.5 g/dl (OR 1.47, 95% CI 1.07–2.03), anintra-operative transfusion ⱖ 4 units PRBC (OR 2.65, 95% CI1.81–3.88), PD (vs. DP, OR 1.87, 95% CI 1.26–2.77), unplannedROR (OR 4.35, 95% CI 3.00–6.29), post-operative acute renalinsufficiency/failure (OR 6.33, 95% CI 3.86–10.40), postoperative pneumonia (OR 2.35, 95% CI 1.56–3.54), ventilatorneed/failure to wean 48 h (OR 2.13, 95% CI 1.38–3.28) and earlyPPH (OR 2.05, 95% CI 1.11–3.81). VTE was not an independentfactor for death.Risk factors and timing of post-pancreatectomy VTEComparisons of risk factors for VTE are provided in Table 5.Independent risk factors for any (either pre- or post-discharge)VTE within 30 days of surgery are listed in Table 2. Major postoperative complications associated with any VTE included OSI(OR 1.72, 95% CI, 1.26–2.34, P 0.001) and post-operative ventilator requirement 48 h (OR 3.55, 95% CI 2.57–4.91). For PD,the median date of diagnosis of OSI was post-operative day(POD) 11, whereas for DP, it was POD 14. Relative to the mediandischarge dates of POD 9 for PD and POD 7 for DP, the mediandate of any VTE was POD 11, whereas it was POD13 for DP. Latethromboembolic events accounted for 33.7%, 35.7% and 31.9%of all observed DVT, PE, and VTE, respectively (Fig. 2). Amongpatients with early VTE, the median date of VTE was POD 8 witha median discharge date of POD 20. Among patients with lateVTE, the median date of VTE was POD 19 with a median discharge date of POD 8.Post-pancreatectomy VTE pre-discharge risk factorsUnivariate factors associated with early VTE are detailed inTable 6. Independent risk factors included a lack of independentfunctional status (OR 1.78, 95% CI 1.05–2.99, P 0.031), 2013 International Hepato-Pancreato-Biliary Association

HPB376Table 1 Factors associated with early post-pancreatectomy haemorrhage (PPH, 4 units blood in first 72 h after surgery)Clinical CharacteristicNAll patients (n 13771)No early PPH 4 unitsEarly PPH 4 unitsn ormediann ormediann ormedian% orrange13771% orrange13623P% orrange148Pre-operative factorsBMI ⱖ 40 .0283802.8%3662.7%149.5% 0.001Lack of independent functionAlcohol 0.007AST 46 IU/l306625.4%302325.3%4334.1%0.023Albumin 3.5 g/dl312926.5%308226.4%4738.2%0.003ASA class ⱖ 3916166.5%904566.4%11678.4%0.002Disseminated cancer4953.6%4793.5%1610.8% 0.001Bleeding ocrit 39%Intra-operativeOperative time, min24612–89231312–11460.004Operative time ⱖ 360 min506936.8%500036.7%6946.6%0.013Any intra-operative transfusion300228.7%291028.3%9262.6% 0.001RBC ⱖ47186.9%6696.5%4933.3% 0.001Concurrent Major GI/GU9907.2%9697.1%2114.2%0.001PD/total versus distal turn to ORSepsis/septic shock9216.7%8326.1%8960.1% 0.001189913.8%183813.5%6141.2% 0.001Acute renal insufficiency/failure2381.7%2171.6%2114.2% 0.001Failure to wean ventilator 48 h6945.0%6334.6%6141.2% 0.0017065.1%6744.9%3221.6% 0.001Any SSI or organ space infection275920.0%271519.9%4429.7%0.003Organ space infection145110.5%142110.4%3020.3% 0.0011511.1%1371.0%149.5% 0.001343625.0%331324.3%12383.1% 0.001Post-operative pneumoniaCardiac arrestSevere complicationsPost-operative LOSDeath within 30 days83571–2152.6%83231–215142.4%341–11923.0% 0.001 0.001ASA, American Society of Anesthesiologists; AST, aspartate aminotransferase; BMI, body mass index; LOS, length of stay; OR, operating room;RBC, (units) red blood cells; SSI, surgical site infection. Not significant: age, gender, race, platelets, sodium, blood urea nitrogen, creatinine, partial thrombin time, international normalized ratio, totalbilirubin, alkaline phosphatase, white blood cells, steroid use; chronic obstructive pulmonary disease; previous coronary stent; previous cardiacsurgery; medical hypertension; pre-operative sepsis; surgical peripheral vascular disease; smoking, pre-operative stroke, pre-operative radiationtherapy, operation in the preceding 30 days; pre-operative chemotherapy within 30 days; pre-operative weight loss ⱖ 10%; dehiscence; superficialSSI, deep SSI, venous thromboembolism. Not evaluated with 1%: pre-operative pneumonia; ascites; varices; congestive heart failure; recent myocardial infarction; angina; rest pain,pre-operative acute renal failure or dialysis; altered mental status; pre-operative open wound; pre-operative transfusion 4 units; post-operativeMI, post-operative coma, post-operative stroke.Severe complications include: pneumonia, reintubation, ventilator 48 h, renal insufficiency/failure, cardiac arrest, myocardial infarction, coma, stroke,sepsis, septic shock, return to OR, wound dehiscence and organ space infection.HPB 2014, 16, 373–383 2013 International Hepato-Pancreato-Biliary Association

HPB377Figure 1 Venous thromboembolism (VTE) events outnumber post-operative bleeding transfusions (post-pancreatectomy haemorrhage 4units in first 72 h after surgery) and returns to the operating room (ROR) with bleeding transfusions. There is no difference in the rates ofbleeding or thrombotic events between a pancreaticoduodenectomy and a distal pancreatectomyTable 2 Independent factors associated with venous thromboembolism (VTE) and bleeding events after a pancreatectomyRisk factorEarly PPH 4 unitsVTEOR95% CIPOR95% CIROR with early PPHpOR95% CIPPre-operativeHaematocrit 39%1.461.13–1.880.003Age ⱖ 70 years1.471.15–1.880.002BMI ⱖ 30 kg/m21.471.14–1.900.003Bleeding 831.25–6.440.0136.093.64–10.21 0.001Pre-operative sepsis1.981.19–3.290.008Disseminated cancer2.121.36–3.320.001ASA class ⱖ 31.741.08–2.790.023Lack independent function2.101.11–3.950.0236.164.12–9.21 0.001Intra-operativeOperative time ⱖ 360 min1.301.02–1.650.048Transfusion ⱖ 4 unitsPost-operativeOrgan space infection1.721.26–2.340.001Ventilator 48 h3.552.57–4.91 0.001ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; OR, odds ratio; PPH, post-pancreatectomyhaemorrhage; ROR, return to operating room; VTE, venous thromboembolism.pre-operative haematocrit 39% (OR 1.69, 95% CI 1.17–2.43, P 0.005), chronic obstructive lung disease (OR 1.74, 95% CI 1.01–2.99, P 0.046), pre-operative leukocytosis (OR 2.12, 95% CI1.43–3.16, P 0.001), disseminated cancer (OR 2.50, 95% CI1.02–3.32, P 0.040), bleeding disorder (OR 2.56, 95% CI 1.47–4.44, P 0.001), an intra-operative transfusion ⱖ 2 units (OR1.53, 95% CI 1.09–2.16, P 0.014), operative time ⱖ300 min (OR1.44, 95% CI 1.02–2.03, P 0.039), ventilator need/failure to wean 48 h (OR 3.74, 95% CI 2.42–5.77, P 0.001) and OSI (OR1.64,HPB 2014, 16, 373–38395% CI 1.10–2.45, P 0.016). Patients with early VTE experienceda 30-day mortality rate of 9.0% (versus 2.6% overall baselinemortality rate, P 0.001).Post-pancreatectomy post-discharge VTE risk factorsUnivariate factors associated with late VTE are detailed in Table 6.Multivariate analysis identified the following independent riskfactors associated with post-discharge VTE: obesity (OR 1.53,95% CI, 1.08–2.19, P 0.018) and age ⱖ 75 years (OR 1.76, 95% 2013 International Hepato-Pancreato-Biliary Association

HPB378Table 3 Factors associated with return to the operating room (ROR) and a post-pancreatectomy haemorrhage (PPH) 4 units blood in thefirst 72 h after surgeryClinical characteristicAll patients(n 13771)n ormediann% orrange13771No ROR with PPH 4 unitsROR with PPH 4 unitsn ormediann ormedian% orrange13682P% orrange89Pre-operative factorsLack of independent functionAST 46 .7%0.003Alkaline phosphatase ⱖ 126 IU/l441136.6%437636.6%3548.6%0.035Albumin 3.5 g/dl312926.5%309726.4%3242.7%0.002ASA class ⱖ 3916166.5%909166.4%7078.7%0.015Disseminated cancer4953.6%4873.6%89.0%0.006Pre-operative sepsis4673.4%4593.4%89.0%0.003Bleeding 48.3%0.024Intra-operativeOperative time, min31412–114631312–1146Operative time ⱖ 360 min506936.8%502636.7%Any intra-operative transfusion300228.7%294928.5%5359.6% 0.001RBC ⱖ 47186.9%6896.7%2932.6% 0.001Concurrent major GI/GU9907.2%3767.1%1415.7%0.002PD/total versus distal %4146.1% 0.001Acute renal insufficiency/failure2381.7%2221.6%1618.0% 0.001Failure to wean ventilator 48 h6945.0%6494.7%4550.6% 0.001Post-operative pneumonia7065.1%6825.0%2427.0% 0.001145110.5%143110.5%2022.5% 0.0011.1%141Post-operativeSepsis/septic shockOrgan space infectionCardiac arrestPost-operative LOSDeath within 30 days15183571–2152.6%83341.0%1011.2% 0.0011–215131–73 0.0012.4%2325.8% 0.001ASA, American Society of Anesthesiologists; AST, aspartate aminotransferase; GI, gastrointestinal; GU, genitourinary; LOS, length of stay;PD, pancreaticoduodenectomy; RBC, (units) red blood cells. Not significant: age, gender, race, body mass index, platelets, sodium, blood urea nitrogen, creatinine, partial thrombin time, internationalnormalized ratio, total bilirubin, white blood cells, steroid use; lung disease, dyspnoea, diabetes, previous coronary stent; previous cardiac surgery;medical hypertension, alcohol use, smoking, pre-operative stroke, pre-operative radiation therapy, operation in preceding 30 days, pre-operativechemotherapy, pre-operative weight loss ⱖ 10%, dehiscence; superficial or deep surgical site infection, venous thromboembolism.CI 1.20–2.58, P 0.004), distal pancreatectomy (OR 2.41, 95% CI1.71–3.39) and OSI (OR 2.14, 95% CI 1.39–3.28, P 0.001). Ofthe 136 patients with late VTE, 89 (65.4%) had at least one of these4 risk factors. Patients with late VTE experienced a 30-daymortality rate of 2.9% (versus 2.6% overall baseline mortalityrate, P 0.579).DiscussionThe primary aims of this study were to compare the postoperative rates of thromboembolic and bleeding events afterHPB 2014, 16, 373–383pancreatectomy and to identify risk factors for VTE, early PPHand ROR with PPH, in patients undergoing PD and DP. Based onstandardized definitions and the presence of trained reviewers fordata collection, the ACS-NSQIP database was well-suited toaddress each of these aims.15,19,20 This analysis determined that,within the context of current national practice patterns, the risk ofVTE outweighs the risk of haemorrhagic events for both PD andDP. In addition, the study identified unique risk factors for bothpre- and post-discharge VTE after pancreatic surgery. These datasuggest that late VTE is a clinically relevant complication after apancreatectomy with one-third of post-operative VTE occurring 2013 International Hepato-Pancreato-Biliary Association

HPB379Table 4 Factors associated with 30-day mortality after a pancreatectomyClinical characteristicNAll patients (n 13771)No deathn ormediann ormedian% orrange13771Death% orrange13414n ormedianP% orrange357Pre-operative factorsAge ⱖ 80 19153.5% 0.0010.046Dyspnoea12108.8%11508.6%6016.8% 0.001Diabetes306322.2%295322.0%11030.8% 0.001COPD5984.3%5694.2%298.1% 0.001Previous coronary stent8526.2%8096.0%4312.0% 0.001714551.9%688851.3%25772.0% 0.0013802.8%3422.5%3810.6% 0.001 10% weight loss218615.9%210315.7%8323.2% 0.001Haematocrit 39%718953.6%697253.4%21762.7%0.001Alkaline phosphatase ⱖ126 IU/l441136.6%427036.4%14143.9%0.006AST 46 IU/l306625.4%295225.1%11435.4% 0.001PTT 27 s680667.5%660667.4%20073.5%0.032BUN ⱖ 20 mg/dl242618.6%233918.4%8725.1%0.002Creatinine ⱖ 1.3 mg/dl11298.5%10688.2%6117.7% 0.001Albumin 3.5 g/dl312926.5%298226.0%14746.4% 0.001Bilirubin 1.0 133.6%0.020ASA class ⱖ 3916166.5%884866.0%31387.7% 0.001INR ⱖ 1.1 0.001Medical hypertensionLack of independent functionSteroid use392034.0%377633.7%14446.9%Platelets 150 000/ml8046.0%7725.9%329.2%0.012Pre-operative sepsis4673.4%4363.3%318.7% 0.001Disseminated cancer4953.6%4723.5%236.4%0.003Bleeding disorder3822.8%3662.7%164.5%0.046Pre-operative radiation therapy3042.2%2892.2%154.2%0.009Operative time ⱖ 360 min506936.8%488636.4%18351.3% 0.001Any intra-operative transfusion300228.7%286328.1%13955.6% 0.001RBC ⱖ 47186.9%6456.3%7329.2% 0.001Concurrent major GI/GU9907.2%9467.1%4412.3% 0.001463233.6%456634.0%6618.5%Early VTE2902.1%2642.0%267.3%Late VTE1361.0%1321.0%41.1%0.782Any VTE4263.1%3963.0%308.4% 0.001Bleeding transfusion1481.1%1140.8%349.5% 0.001Any post-operative transfusion9166.7%8356.2%8122.7% 0.001Return to OR9216.7%7695.7%15242.6% 0.001189913.8%171412.8%18551.8% 0.001Acute renal insufficiency/failure2381.7%1581.2%8022.4% 0.001Failure to wean ventilator 48 h6945.0%5444.1%15042.0% 0.001Post-operative pneumonia7065.1%6164.6%9025.2% 37610.3%7521.0% 0.001Intra-operative 0.001PD/total versus distal pancreatectomyDistalPost-operativeSepsis/septic shockOrgan space infectionCardiac arrestSevere complications (not VTE) 0.0011511.1%360.3%11532.2% 0.001343625.0%313023.3%30685.7% 0.001ASA, American Society of Anesthesiologists; AST, aspartate aminotransferase; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; GI, gastrointestinal;GU, genitourinary; INR, international normalized ratio; OR, operating room; PD, pancreaticoduodenectomy; PTT, partial thrombin time; RBC, (units) red blood cells;VTE, venous thromboembolism. Not significant: body mass index; race, alcohol use; white blood cells, smoking, pre-operative stroke, operation in preceding 30 days; pre-operative chemotherapy within30 days; superficial and deep surgical site infections.HPB 2014, 16, 373–383 2013 International Hepato-Pancreato-Biliary Association

HPB380Table 5 Factors associated with no venous thromboembolism (VTE) compared with VTEClinical characteristicNAll patients (n 13771)No VTE (DVT or PE)VTE (DVT or PE)n ormediann ormediann ormedian% orrange13771% orrange13345P% orrange426Preoperative factorsMedian age (range), years6416–906416–906620–900.004Age ⱖ70 years457233.2%440733.0%16538.7%0.014BMI ⱖ 30 3Steroid 9.4%0.0023802.8%3492.6%317.3% 0.001Medical hypertensionLack of independent functionPre-operative sepsisINR .6%0.005Haematocrit 39%718953.6%692853.3%26162.7% 0.001WBC 11 000/ml10607.9%10057.7%5513.2% 0.001Albumin 3.5 g/dl312926.5%298926.2%14038.3% 0.001Disseminated cancer4953.6%4593.4%368.5% 0.001Bleeding disorder3822.8%3542.7%286.6% 0.001861881.7%833981.7%27983.3%0.451 0.001Neoplasm (versus e time ⱖ 360 minOperative time, min506931436.8%12–1146487231336.5%19746.2% 0.001Any intra-operative transfusion300228.7%286428.3%13841.1% 0.001RBC ⱖ 47186.9%6716.6%4714.0% 0.001Concurrent major operation9907.2%9457.1%4510.6%PD/total versus distal tiveAny post-operative transfusion ( 72 h)9166.7%8736.5%4310.1%0.004Return to OR (ROR)9216.7%8546.4%6715.7% 0.001Sepsis/septic shock 0.001189913.8%174713.1%15235.7%Acute renal ure to wean ventilator 48 h6945.0%6134.6%8119.0% 0.001 0.001Post-operative pneumonia7065.1%6444.8%6214.6%Deep SSI2681.9%2531.9%153.5%0.017Any SSI or organ space infection275920.0%260619.5%15335.9% 0.001Organ space infection145110.5%135710.2%9422.1% 0.0012241.6%2081.6%163.8% 0.001343625.0%320924.0%Fascial dehiscenceSevere complicationsPost-operative LOSDeath within 30 days83571–2152.6%832722753.3% 0.0011–215141–98 0.0012.5%307.0% 0.001BMI, body mass index; COPD, c

mies (CPT 48155) were grouped with PD.A distal pancreatectomy included CPT codes 48140, 48145 and 48146. CPT codes were analysed from the primary CPT column as well as from any of the concurrent procedure columns. CPT coding did not differentiate between open and laparoscopic cases. For thrombotic events within 30 days of a pancreatectomy, the

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