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Original Investigation
April 29, 2020

Association of the Risk of a Venous Thromboembolic Event in Emergency vs Elective General Surgery

Author Affiliations
  • 1Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
  • 2Division of General and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
JAMA Surg. 2020;155(6):503-511. doi:10.1001/jamasurg.2020.0433
Key Points

Question  Do patients undergoing emergency general surgery have a higher risk of venous thromboembolism than those undergoing elective surgery?

Findings  In this cohort study that included 604 537 adults, the rate of venous thromboembolism within 30 days was 1.9% in emergency general surgery and 0.8% in elective surgery, a statistically significant difference. On multivariable analysis, emergency general surgery was independently associated with venous thromboembolism.

Meaning  Compared with the elective surgery population, the emergency general surgery population had almost twice the risk for venous thromboembolism, and a more aggressive venous thromboembolism chemoprophylaxis regimen should be considered in these patients.

Abstract

Importance  Trauma patients have an increased risk of venous thromboembolism (VTE), partly because of greater inflammation. However, it is unknown if this association is present in patients who undergo emergency general surgery (EGS).

Objectives  To investigate whether emergency case status is independently associated with VTE compared with elective case status and to test the hypothesis that emergency cases would have a higher risk of VTE.

Design, Setting, and Participants  This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, to December 31, 2016, for all cholecystectomies, ventral hernia repairs (VHRs), and partial colectomies (PCs) to obtain a sample of commonly encountered emergency procedures that have elective counterparts. Emergency surgeries were then compared with elective surgeries. The dates of analysis were January 1 to 31, 2019.

Main Outcomes and Measures  The primary outcome was VTE at 30 days. A multivariable analysis controlling for age, sex, body mass index, bleeding disorder, disseminated cancer, laparoscopy approach, and surgery type was performed.

Results  There were 604 537 adults undergoing surgical procedures over 12 years (mean [SD] age, 55.3 [16.6] years; 61.4% women), including 285 847 cholecystectomies, 158 500 VHRs, and 160 190 PCs. The rate of VTE within 30 days was 1.9% for EGS and 0.8% for elective surgery, a statistically significant difference. Overall, 4607 patients (0.8%) had deep vein thrombosis, and 2648 patients (0.4%) had pulmonary embolism. A total of 6624 VTEs (1.1%) occurred in the cohort. As expected, when VTE risk was examined by surgery type, the risk increased with invasiveness (0.5% for cholecystectomy, 0.8% for VHR, and 2.4% for PC; P < .001). On multivariable analysis, EGS was independently associated with VTE (odds ratio [OR], 1.70; 95% CI, 1.61-1.79). Also associated with VTE were open surgery (OR, 3.38; 95% CI, 3.15-3.63) and PC (OR, 1.86; 95% CI, 1.73-1.99).

Conclusions and Relevance  In this cohort study, emergency surgery and increased invasiveness appeared to be independently associated with VTE compared with elective surgery. Further study on methods to improve VTE chemoprophylaxis is highly recommended for emergency and more extensive operations to reduce the risk of potentially lethal VTE.

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