Risk for VTE is higher in emergency surgery than elective procedures

More invasive surgery is associated with a higher rate of VTE.

In the GAPS non-inferiority randomized controlled trial (RCT) in elective surgical inpatients at moderate or high risk of venous thromboembolism (VTE), administration of pharmacological thromboprophylaxis alone was non-inferior to a combination of pharmacological thromboprophylaxis plus graduated compression stockings (GCS).

Main Takeaway

• The risk for venous thromboembolism (VTE) is significantly higher with emergency general surgery than elective surgery.
• Emergency surgery and procedures with increased invasiveness are associated with significant risk for VTE.

Why This Matters 

• This is the first study to compare the rate of VTE in the emergency surgery compared with the same operations performed electively.
• Surgeons and hospitals should promote research and quality improvement processes aimed at patients undergoing elective surgery to prevent and mitigate VTE.
• A more aggressive VTE chemoprophylaxis regimen may be considered for emergency and more invasive surgery. 

Study Design

• A retrospective cohort study of 604,537 patients from the American College of Surgeons National Surgical Quality Improvement Program database.
• Patients underwent cholecystectomies (n=285,847), ventral hernia repairs (VHRs; n=158,500) and partial colectomies (PCs; 160,190) during 2005-2016.
• Primary outcome was VTE at 30 days
• Funding: None disclosed.

Key Results

• Mean age was 55.3 years.
• Of the procedures, 57.3% were performed laparoscopically.
• Overall rate of VTE within 30 days was 1.1% (deep vein thrombosis [DVT], 0.8% and pulmonary embolism [PE], 0.4%).
• The rate of VTE within 30 days was 1.9% for emergency surgery and 0.8% for elective surgery (P<0.001).
• At 30 days, emergency vs. elective showed significantly higher rate of:
  • DVT: 1.4% vs. 0.5% (P<0.001)
  • PE: 0.6% vs. 0.3% (P<0.001).
• The rate of VTE was 0.4% for laparoscopic surgery and 2.0% for open surgery.
• The rate of VTE increased with increasing invasiveness of surgery (0.5% for cholecystectomy, 0.8% for VHR and 2.4% for PC; P<0.001).
• The 30-day mortality rate was 9 times higher in patients undergoing emergency vs. elective surgery (3.6% vs. 0.4%; P<0.001).
• On multivariable analysis, independent risk factors for VTE were:
  • Emergency general surgery (OR, 1.70; 95% CI, 1.61-1.79; P<0.001);
  • Open surgery (OR, 3.38; 95% CI, 3.15-3.63; P<0.001); and
  • PC (OR, 1.86; 95% CI, 1.73-1.99; P<0.001).

Limitations

• Retrospective design.
• The database represents only a sample of procedures performed and therefore, the findings may not be generalisable.
• VTE chemoprophylaxis adherence, dosing or the type of anticoagulants used were not known.
• Information on specific practice locations or facility types was not available