Aminian Ali, Andalib Amin, Khorgami Zhamak, Cetin Derrick, Burguera Bartolome, Bartholomew John, Brethauer Stacy A, Schauer Philip R
*Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH †Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
Ann Surg. 2017 Jan;265(1):143-150. doi: 10.1097/SLA.0000000000001686.
To determine the risk factors for 30-day postdischarge venous thromboembolism (VTE) after bariatric surgery and to identify potential indications for extended pharmacoprophylaxis.
VTE is among most common causes of death after bariatric surgery. Most VTEs occur after hospital stay; still a few patients receive extended pharmacoprophylaxis postdischarge.
From American College of Surgeons-National Surgical Quality Improvement Program, we identified 91,963 patients, who underwent elective primary and revisional bariatric surgery between 2007 and 2012. Regression-based techniques were used to create a risk assessment tool to predict risk of postdischarge VTE. The model was validated using the 2013 American College of Surgeons-National Surgical Quality Improvement Program dataset (N = 20,575). Significant risk factors were used to create a user-friendly online risk calculator.
The overall 30-day incidence of postdischarge VTE was 0.29% (N = 269). In those experiencing a postdischarge VTE, mortality increased about 28-fold (2.60% vs 0.09%; P < 0.001). Among 45 examined variables, the final risk-assessment model contained 10 categorical variables including congestive heart failure, paraplegia, reoperation, dyspnea at rest, nongastric band surgery, age ≥60 years, male sex, BMI ≥50 kg/m, postoperative hospital stay ≥3 days, and operative time ≥3 hours. The model demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test, P = 0.71) and discrimination (c-statistic = 0.74). Nearly 2.5% of patients had a predicted postdischarge VTE risk >1%.
More than 80% of post-bariatric surgery VTE events occurred post-discharge. Congestive heart failure, paraplegia, dyspnea at rest, and reoperation are associated with the highest risk of post-discharge VTE. Routine post-discharge pharmacoprophylaxis can be considered for high-risk patients (ie, VTE risk >0.4%).
确定减肥手术后30天出院后静脉血栓栓塞症（VTE）的危险因素，并确定延长药物预防的潜在指征。
VTE是减肥手术后最常见的死亡原因之一。大多数VTE发生在住院期间；仍有少数患者在出院后接受延长药物预防。
从美国外科医师学会-国家外科质量改进计划中，我们识别出91963例在2007年至2012年间接受择期初次和翻修减肥手术的患者。基于回归的技术被用于创建一个风险评估工具，以预测出院后VTE的风险。该模型使用2013年美国外科医师学会-国家外科质量改进计划数据集（N = 20575）进行验证。显著的危险因素被用于创建一个用户友好的在线风险计算器。
出院后VTE的总体30天发生率为0.29%（N = 269）。在发生出院后VTE的患者中，死亡率增加约28倍（2.60%对0.09%；P < 0.001）。在45个检查变量中，最终的风险评估模型包含10个分类变量，包括充血性心力衰竭、截瘫、再次手术、静息时呼吸困难、非胃束带手术、年龄≥60岁、男性、BMI≥50kg/m²²、术后住院时间≥3天和手术时间≥3小时。该模型显示出良好的校准（Hosmer-Lemeshow拟合优度检验，P = 0.71）和区分度（c统计量 = 0.74）。近2.5%的患者预测出院后VTE风险>1%。
超过80%的减肥手术后VTE事件发生在出院后。充血性心力衰竭、截瘫、静息时呼吸困难和再次手术与出院后VTE的最高风险相关。对于高危患者（即VTE风险>0.4%），可考虑常规出院后药物预防。
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