Rate of venous thromboembolism in gynecologic patients on an ERAS pathway.

214 Background: Venous thromboembolism (VTE) is a serious and potentially life-threatening complication of surgery. An Enhanced Recovery After Surgery (ERAS) program is a multimodal care pathway meant to facilitate faster recovery from surgery. ERAS protocols include mechanical and pharmacologic VTE prophylaxis and rapid return to ambulation. Our objective was to evaluate the rate of symptomatic VTE on an ERAS pathway among patients undergoing open and minimally invasive gynecologic surgery (MIS). Methods: Data was collected prospectively on patients undergoing gynecologic surgery on the ERAS pathway at a single academic institution between November 1, 2014 and March 31, 2021. For patients undergoing MIS data were collected from February 1, 2016 to March 31, 2021. Patients undergoing emergency surgery or requiring therapeutic anticoagulation prior to surgery were excluded. For planned open surgery, patients received heparin prophylaxis prior to surgery, sequential compression device (SCD) during surgery and goal directed fluid management. If also diagnosed with malignancy, patients received extended VTE prophylaxis with low molecular weight heparin for 28 days after surgery starting postoperative day 1. For planned MIS, patients received SCD and goal directed fluid management. Descriptive statistics, univariate and multivariate statistical analyses were performed. Results: Of the 3,932 patients, 2,016 (51%) underwent laparotomy, 1,541 (39%) laparoscopy and 375 (10%) robotic approach. The incidence of thromboembolism was 0.5% (N = 21) overall, 0.8% (N = 17) with open approach and 0.2% (N = 4) with MIS approach. Among laparotomy patients, there was 88% compliance with preoperative heparin prophylaxis. Characteristics associated with developing a VTE were black race, malignancy, open surgical approach, surgical time, surgical complexity, and receipt of intraoperative blood transfusion. On multivariate analysis, black race and transfusion remained associated with VTE. Among laparotomy patients, the rate of intraoperative blood transfusion was 5.9% (N = 120), reoperation for bleeding 0.3% (N = 5) and reoperation for hematoma 0.2% (N = 3). Conclusions: We found a low rate of VTE among patients undergoing laparotomy and MIS under an ERAS pathway. The rate of VTE following MIS surgery was low without use of extended pharmacologic VTE prophylaxis or receipt of preoperative prophylactic heparin. Receipt of preoperative heparin prophylaxis prior to open surgery is safe with a low complication rate. This establishes a benchmark for the expected rate of VTE following gynecologic surgery on an ERAS pathway.

Heparin prophylaxis in major sclerotherapy (the Prosclep study)

Objective To study the incidence and the possibility of preventing thrombotic complications during major sclerotherapy for venous insufficiency of lower limbs. Methods A total of 2489 sclerotherapy sessions were performed on 2010 patients. 1087 sessions (43.7%) were carried out without heparin prophylaxis while in 1402 sessions (56.3%) a prophylaxis with low molecular weight (LMWH) was used. Thrombotic complications were divided into a) post sclerotherapy transient extension (POSTE) if they consisted of a simple extension of sclerotherapy, and b) deep venous thrombosis (DVT) when the complication occurred in a location separate from that of sclerosis. Results The overall incidence of a thrombotic complication was 0.52%. Out of 2489 sessions, 8 cases of POSTE (0.32%) and 5 thromboses of a gastrocnemius vein (0.2%) were diagnosed The most significant figures were reached in the great saphenous vein (GSV) subgroup, where the incidence of complications was 1.91% without prophylaxis and 0.31% (p = 0.009) with prophylactic heparin. Conclusions In this study prophylaxis with LMWH significantly reduced the incidence of thrombotic complications when sclerotherapy of the great saphenous vein was performed.