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Original Investigation
October 9, 2019

Risk of Pulmonary Embolism More Than 6 Weeks After Surgery Among Cancer-Free Middle-aged Patients

Author Affiliations
  • 1University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
  • 2University Lille, Inserm, CHU Lille, U995, Lille Inflammation Research International Center, Lille, France
  • 3University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011, EGID, Lille, France
  • 4University Lille, CHU Lille, Hematology Transfusion Institute, Lille, France
JAMA Surg. Published online October 9, 2019. doi:10.1001/jamasurg.2019.3742
Key Points

Question  What is the duration and the magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery?

Findings  In this case-crossover analysis of 60 703 patients aged 45 to 64 years without cancer from the French national inpatient database, the postoperative risk of pulmonary embolism extended beyond 6 weeks for 6 types of surgery. The excess risk of postoperative pulmonary embolism remained significantly elevated between 7 and 12 weeks after surgery.

Meaning  Further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define its optimal duration.

Abstract

Importance  The risk of postoperative pulmonary embolism has been reported to be highest during the first 5 weeks after surgery. However, how long the excess risk of postoperative pulmonary embolism persists remains unknown.

Objective  To assess the duration and magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery.

Design, Setting, and Participants  Case-crossover analysis to compute the respective risks of pulmonary embolism after 6 types of surgery using data from a French national inpatient database, which covers a total of 203 million inpatient stays over an 8-year period between 2007 and 2014. Participants were cancer-free middle-aged adult patients (aged 45 to 64) with a diagnosis of a first pulmonary embolism.

Exposures  Hospital admission for surgery. Surgical procedures were classified into 6 types: (1) vascular surgery, (2) gynecological surgery, (3) gastrointestinal surgery, (4) hip or knee replacement, (5) fractures, and (6) other orthopedic operations.

Main Outcomes and Measures  Diagnosis of a first pulmonary embolism.

Results  A total of 60 703 patients were included (35 766 [58.9%] male; mean [SD] age, 56.6 [6.0] years). The risk of postoperative pulmonary embolism was elevated for at least 12 weeks after all types of surgery and was highest during the immediate postoperative period (1 to 6 weeks). The excess risk of postoperative pulmonary embolism ranged from odds ratio (OR), 5.24 (95% CI, 3.91-7.01) for vascular surgery to OR, 8.34 (95% CI, 6.07-11.45) for surgery for fractures. The risk remained elevated from 7 to 12 weeks, with the OR ranging from 2.26 (95% CI, 1.81-2.82) for gastrointestinal operations to 4.23 (95% CI, 3.01-5.92) for surgery for fractures. The risk was not clinically significant beyond 18 weeks postsurgery for all types of procedures.

Conclusions and Relevance  The risk of postoperative pulmonary embolism is elevated beyond 6 weeks postsurgery regardless of the type of procedure. The persistence of this excess risk suggests that further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define the optimal duration of treatment with regard to both the thrombotic and bleeding risks.

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