From the Journals

VTE risk after gynecologic surgery lower with laparoscopic procedures

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Individualize VTE prophylaxis

The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.

Dr. David M. Jaspan

Dr. David M. Jaspan

The study was completed at Beth Israel Deaconess Medical Center and Massachusetts Memorial Health Care. ICD-9 procedure codes were used to abstract the type of surgery. The laparoscopic group included conventional laparoscopy, robotic-assisted laparoscopy, and combined laparoscopic-assisted vaginal surgery. The vaginal group included hysteroscopic cases as well as vaginal hysterectomies. A manual chart review was completed for those cases that required additional classification.

Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.

The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.

Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.

Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.

Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.

It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.

The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.

This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.

David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.


 

FROM OBSTETRICS & GYNECOLOGY

Laparoscopic gynecologic surgery is associated with a significantly lower risk of postoperative venous thromboembolism (VTE) than laparotomy, according to a study published in Obstetrics & Gynecology.

U.S. Air Force Maj. Arthur Greenwood and Capt. Stuart Winkler, 633rd Surgical Operations Squadron obstetricians, use a 3-D scope and glasses while performing a laparoscopic hysterectomy at Langley Air Force Base, Va., June 14, 2016 U.S. Air Force photo by Staff Sgt. Ciara Gosier

The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.

Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.

The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).

“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.

Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.

Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.

However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.

U.S. Air Force Maj. Arthur Greenwood and Capt. Stuart Winkler, 633rd Surgical Operations Squadron obstetricians, stitch up an incision after performing a laparoscopic hysterectomy at Langley Air Force Bae, Va., June 14, 2016. U.S. Air Force photo by Staff Sgt. Ciara Gosier

“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.

Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.

More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.

“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.

Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.

No conflicts of interest were declared.

SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.

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