Iannuzzi James C, Aquina Christopher T, Rickles Aaron S, Hensley Bradley J, Probst Christian P, Noyes Katia, Monson John R T, Fleming Fergal J
Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
Dis Colon Rectum. 2016 Mar;59(3):224-9. doi: 10.1097/DCR.0000000000000529.
Current guidelines recommend extended-duration thromboprophylaxis for all abdominal oncologic resections. However, other high-risk patients may benefit from extended thromboprophylaxis.
The purpose of this study was to identify risk factors for postdischarge venothromboembolism after colorectal procedures.
This was a retrospective cohort study.
The New York Statewide Planning and Research Cooperative System database (2005-2013) was the data source for this study.
Colon and rectal resections were evaluated. Cases with in-hospital mortality or length of stay ≥30 days were excluded.
Postdischarge venothromboembolism was defined at 30-days after the procedure requiring representation to the emergency department or hospital admission with a new diagnosis of venothromboembolism using International Classification of Diseases, Ninth Revision, codes. Factors associated with postdischarge venothromboembolism were then evaluated using a hierarchical bivariate analysis. A hierarchical mixed-effects model was created using a manual stepwise approach assessing variables meeting p < 0.1 on bivariate analysis.
Among 128,163 patients, postdischarge venothromboembolism occurred in 0.7% (n = 789) of the population. Multiple factors were associated with postdischarge venothromboembolism on bivariate analysis. On multivariable analysis, benign conditions requiring operative intervention remained at high risk, with ulcerative colitis imparting an 93% increased odds when compared with other resections (OR, 1.93 (95% CI: 1.30-2.86); p = 0.001). Advanced malignancies (stages III and IV) were associated with increased postdischarge venothromboembolism risk, whereas stage I and II malignancies were not. The only protective factor was a laparoscopic procedure (OR, 0.80 (95% CI: 0.67-0.95); p = 0.010). There was no significant difference in procedure type after controlling for primary diagnosis.
This was a retrospective analysis of administrative data with inherent limitations. Only patients who presented with postdischarge venothromboembolism to a hospital within New York State were captured.
This study identifies risk factors for postdischarge venothromboembolism and suggests that ulcerative colitis increases risk for postdischarge venothromboembolism whereas Crohn's disease does not. Ulcerative colitis postdischarge venothromboembolism rates exceeded even those of malignancy, suggesting that a future study is necessary to determine the efficacy of extended duration thromboprophylaxis in high-risk benign conditions, such as ulcerative colitis.
当前指南建议对所有腹部肿瘤切除术患者进行延长疗程的血栓预防。然而，其他高危患者可能也会从延长血栓预防中获益。
本研究旨在确定结直肠手术后出院后静脉血栓栓塞的危险因素。
这是一项回顾性队列研究。
纽约州全州规划与研究合作系统数据库（2005 - 2013年）是本研究的数据来源。
对结肠和直肠切除术进行评估。排除院内死亡或住院时间≥30天的病例。
出院后静脉血栓栓塞定义为手术后30天内因新诊断的静脉血栓栓塞需到急诊科就诊或住院，使用国际疾病分类第九版编码。然后使用分层双变量分析评估与出院后静脉血栓栓塞相关的因素。采用手动逐步法创建分层混合效应模型，评估双变量分析中p < 0.1的变量。
在128,163例患者中，0.7%（n = 789）的人群发生了出院后静脉血栓栓塞。双变量分析显示多个因素与出院后静脉血栓栓塞相关。多变量分析显示，需要手术干预的良性疾病仍处于高风险，与其他切除术相比，溃疡性结肠炎的发病几率增加了93%（比值比，1.93（95%可信区间：1.30 - 2.86）；p = 0.001）。晚期恶性肿瘤（III期和IV期）与出院后静脉血栓栓塞风险增加相关，而I期和II期恶性肿瘤则无此关联。唯一的保护因素是腹腔镜手术（比值比，0.80（95%可信区间：0.67 - 0.95）；p = 0.010）。在控制了原发性诊断后，手术类型没有显著差异。
这是对管理数据的回顾性分析，存在固有局限性。仅纳入了纽约州内因出院后静脉血栓栓塞到医院就诊的患者。
本研究确定了出院后静脉血栓栓塞的危险因素，提示溃疡性结肠炎会增加出院后静脉血栓栓塞风险，而克罗恩病则不会。溃疡性结肠炎患者出院后静脉血栓栓塞发生率甚至超过恶性肿瘤患者，这表明有必要进行进一步研究以确定在溃疡性结肠炎等高风险良性疾病中延长疗程血栓预防的疗效。
