Predicting the risks of venous thromboembolism versus post-pancreatectomy haemorrhage: analysis of 13,771 NSQIP patients

Abstract

Background: The fear of an early post-pancreatectomy haemorrhage (PPH) may prevent surgeons from prescribing post-operative venous thromboembolism (VTE) chemoprophylaxis. The primary hypothesis of this study was that the national post-pancreatectomy early PPH rate was lower than the rate of VTE. The secondary hypothesis was that patients at high risk for post-discharge VTE could be identified, potentially facilitating the selective use of extended chemoprophylaxis.

Patients and methods: All elective pancreatectomies were identified in the 2005 to 2010 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Factors associated with 30-day rates of (pre- versus post-discharge) VTE, early PPH (transfusions > 4 units within 72 h) and return to the operating room (ROR) with PPH were analysed.

Results: Pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) numbered 9140 (66.4%) and 4631 (33.6%) out of 13 771 pancreatectomies, respectively. Event rates included: VTE (3.1%), PPH (1.1%) and ROR+PPH (0.7%). PD and DP had similar VTE rates (P > 0.05) with 31.9% of VTE occurring post-discharge. Independent risk factors for late VTE included obesity [odds ratio (OR), 1.5], age ≥ 75 years (OR, 1.8), DP (OR, 2.4) and organ space infection (OR, 2.1) (all P < 0.02).

Conclusions: Within current practice patterns, post-pancreatectomy VTE outnumber early haemorrhagic complications, which are rare. The fear of PPH should not prevent routine and timely post-pancreatectomy VTE chemoprophylaxis. Because one-third of VTE occur post-discharge, high-risk patients may benefit from post-discharge chemoprophylaxis.

Figure 1

Venous thromboembolism (VTE) events outnumber post-operative bleeding transfusions (post-pancreatectomy haemorrhage > 4 units in first 72 h after surgery) and returns to the operating room (ROR) with bleeding transfusions. There is no difference in the rates of bleeding or thrombotic events between a pancreaticoduodenectomy and a distal pancreatectomy

Figure 2

Approximately 1 in 3 post-pancreatectomy VTE events are recognized post-discharge. (PE, pulmonary embolus; DVT, deep venous thrombosis; VTE, venous thromboembolism)