Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
Surgery. 2012 Oct;152(4):528-34; discussion 534-6. doi: 10.1016/j.surg.2012.07.012.
Colectomy patients are at high-risk for venous thromboembolism (VTE), but associated risk factors and best prophylaxis in this defined population are only generalized.
Fifteen hospitals prospectively collected pre-, peri-, and postoperative variables related to VTE and prophylaxis, in addition to the variables defined by the National Surgical Quality Improvement Program between 2008 and 2009 concerning open and laparoscopic colectomy patients with 30-day outcomes. Symptomatic VTE was the primary outcome, and risk factors were tested for association with VTE using multiple logistic regression.
The cohort included 3,464 patients with a mean age of 65; 53% were female. Overall, the 30d incidence of VTE was 2.2%. VTE prophylaxis included sequential compression devices (SCDs, 11%) alone; pharmacologic prophylaxis alone (15%); and both SCDs and pharmacologic prophylaxis (combined prophylaxis, 74%). VTE was associated with each additional year of age (OR, 1.05; 95% CI 1.02-1.06, P < .001); increased body mass index (OR 1.03; CI 1.01-1.05; P = .02); preoperative anemia (OR 2.4; CI 1.2-4.8; P = .011); contaminated wound (OR 3.4; CI 1.6-7.3; P < .01); postoperative surgical site infection (OR 2.5; CI 1.2-5.2; P < .011); and postoperative sepsis/pneumonia (OR 3.6;CI 1.9-6.7; P < .01). Postoperative factors alone accounted for 32% of VTE risk. When controlling for all other factors, only combination prophylaxis was protective against VTE (OR 0.48; CI 0.27-0.9; P = .02). Operative time, presence of disseminated malignancy, anastomotic leak, transfusion, urinary tract infection, and laparoscopic procedure were not significantly associated with VTE. Propensity matching showed that unfractionated heparin was equivalent to low molecular weight heparin, and the transfusion rate was not increased with pharmacologic prophylaxis compared to SCDs alone.
Regardless of preoperative factors, VTE prophylaxis using a combination of SCDs and chemoprophylaxis was associated with significant reduction in VTE and should be standard care for patients after colectomy.
结肠切除术患者存在发生静脉血栓栓塞症（VTE）的高风险，但该特定人群中的相关风险因素和最佳预防措施仅为一般性结论。
2008 年至 2009 年期间，15 家医院前瞻性收集了与 VTE 和预防措施相关的术前、术中和术后变量，此外还收集了国家外科质量改进计划中与 30 天结局相关的开放和腹腔镜结肠切除术患者的变量。症状性 VTE 是主要结局，使用多因素逻辑回归检验危险因素与 VTE 的关联。
队列包括 3464 例平均年龄 65 岁的患者；53%为女性。总体而言，30d 内 VTE 的发生率为 2.2%。VTE 预防措施包括单独使用序贯压迫装置（SCDs，11%）；单独使用药物预防（15%）；以及同时使用 SCDs 和药物预防（联合预防，74%）。VTE 与每增加 1 岁相关（OR，1.05；95%CI 1.02-1.06，P <.001）；体重指数增加（OR，1.03；CI 1.01-1.05；P =.02）；术前贫血（OR，2.4；CI 1.2-4.8；P =.011）；污染伤口（OR，3.4；CI 1.6-7.3；P <.01）；术后手术部位感染（OR，2.5；CI 1.2-5.2；P <.011）；术后脓毒症/肺炎（OR，3.6；CI 1.9-6.7；P <.01）。术后因素单独占 VTE 风险的 32%。当控制所有其他因素时，只有联合预防措施对 VTE 具有保护作用（OR，0.48；CI 0.27-0.9；P =.02）。手术时间、弥漫性恶性肿瘤、吻合口漏、输血、尿路感染和腹腔镜手术与 VTE 无显著相关性。倾向匹配显示普通肝素与低分子肝素等效，与单独使用 SCDs 相比，药物预防并未增加输血率。
无论术前因素如何，使用 SCDs 和化学预防联合的 VTE 预防措施与 VTE 发生率显著降低相关，应为结肠切除术后患者的标准治疗措施。
