Surgical Duration and Risk of Venous Thromboembolism | Health Care Safety | JAMA Surgery | JAMA Network
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Turrentine  FE, Wang  H, Simpson  VB, Jones  RS.  Surgical risk factors, morbidity, and mortality in elderly patients.  J Am Coll Surg. 2006;203(6):865-877.PubMedGoogle ScholarCrossref
Ramanan  B, Gupta  PK, Sundaram  A,  et al.  In-hospital and postdischarge venous thromboembolism after vascular surgery.  J Vasc Surg. 2013;57(6):1589-1596.PubMedGoogle ScholarCrossref
Tzeng  CW, Fleming  JB, Pisters  PW,  et al.  Risk of venous thromboembolism outweighs post-hepatectomy bleeding complications: analysis of 5651 National Surgical Quality Improvement Program patients.  HPB (Oxford). 2012;14(8):506-513.PubMedGoogle ScholarCrossref
Rambachan  A, Mioton  L, Saha  S, Fine  N, Kim  J.  The impact of surgical duration on plastic surgery outcomes.  Eur J Plast Surg. 2013;36(11):707-714.Google ScholarCrossref
Pannucci  CJ, Shanks  A, Moote  MJ,  et al.  Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery.  Ann Surg. 2012;255(6):1093-1099.PubMedGoogle ScholarCrossref
Chan  MM, Hamza  N, Ammori  BJ.  Duration of surgery independently influences risk of venous thromboembolism after laparoscopic bariatric surgery.  Surg Obes Relat Dis. 2013;9(1):88-93.PubMedGoogle ScholarCrossref
Rogers  SO  Jr, Kilaru  RK, Hosokawa  P, Henderson  WG, Zinner  MJ, Khuri  SF.  Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study.  J Am Coll Surg. 2007;204(6):1211-1221.PubMedGoogle ScholarCrossref
White  RH, Zhou  H, Romano  PS.  Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures.  Thromb Haemost. 2003;90(3):446-455.PubMedGoogle Scholar
Khaldi  A, Helo  N, Schneck  MJ, Origitano  TC.  Venous thromboembolism: deep venous thrombosis and pulmonary embolism in a neurosurgical population.  J Neurosurg. 2011;114(1):40-46.PubMedGoogle ScholarCrossref
Stamou  KM, Toutouzas  KG, Kekis  PB,  et al.  Prospective study of the incidence and risk factors of postsplenectomy thrombosis of the portal, mesenteric, and splenic veins.  Arch Surg. 2006;141(7):663-669.PubMedGoogle ScholarCrossref
Iannuzzi  JC, Young  KC, Kim  MJ, Gillespie  DL, Monson  JRT, Fleming  FJ.  Prediction of postdischarge venous thromboembolism using a risk assessment model.  J Vasc Surg. 2013;58(4):1014-20.e1.PubMedGoogle ScholarCrossref
Ghaferi  AA, Birkmeyer  JD, Dimick  JB.  Variation in hospital mortality associated with inpatient surgery.  N Engl J Med. 2009;361(14):1368-1375.PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention (CDC).  Venous thromboembolism in adult hospitalizations—United States, 2007-2009.  MMWR Morb Mortal Wkly Rep. 2012;61(22):401-404.PubMedGoogle Scholar
White  RH.  The epidemiology of venous thromboembolism.  Circulation. 2003;107(23)(suppl 1):I4-I8.PubMedGoogle Scholar
Beckman  MG, Hooper  WC, Critchley  SE, Ortel  TL.  Venous thromboembolism: a public health concern.  Am J Prev Med. 2010;38(4)(suppl):S495-S501.PubMedGoogle ScholarCrossref
Bainbridge  D, Martin  J, Arango  M, Cheng  D; Evidence-Based Peri-operative Clinical Outcomes Research (Epicor) Group.  Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis.  Lancet. 2012;380(9847):1075-1081.PubMedGoogle ScholarCrossref
Institute of Medicine.  Crossing the quality chasm: a new health system for the 21st century. Published March 1, 2001. Accessed January 8, 2013.
 Joint Commission. Improving America’s hospitals: a report on quality and safety 2012. Published September 18, 2012. Accessed January 11, 2013.
Khuri  SF, Henderson  WG, Daley  J,  et al; Principal Investigators of the Patient Safety in Surgery Study.  Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.  Ann Surg. 2008;248(2):329-336.PubMedGoogle ScholarCrossref
American College of Surgeons, National Surgical Quality Improvement Program.  User guide for the 2011 participant use data file. Published October 2012. Accessed January 16, 2013.
Shiloach  M, Frencher  SK  Jr, Steeger  JE,  et al.  Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program.  J Am Coll Surg. 2010;210(1):6-16.PubMedGoogle ScholarCrossref
Schneeweiss  S.  Sensitivity analysis and external adjustment for unmeasured confounders in epidemiologic database studies of therapeutics.  Pharmacoepidemiol Drug Saf. 2006;15(5):291-303.PubMedGoogle ScholarCrossref
Peterson  CW.  Venous thrombosis: an overview.  Pharmacotherapy. 1986;6(4, pt 2):12S-17S.PubMedGoogle Scholar
Xenos  ES, Vargas  HD, Davenport  DL.  Association of blood transfusion and venous thromboembolism after colorectal cancer resection.  Thromb Res. 2012;129(5):568-572.PubMedGoogle ScholarCrossref
Jaffer  AK, Barsoum  WK, Krebs  V, Hurbanek  JG, Morra  N, Brotman  DJ.  Duration of anesthesia and venous thromboembolism after hip and knee arthroplasty.  Mayo Clin Proc. 2005;80(6):732-738.PubMedGoogle ScholarCrossref
Turpie  AGG, Chin  BSP, Lip  GYH.  Venous thromboembolism: pathophysiology, clinical features, and prevention.  BMJ. 2002;325(7369):887-890.PubMedGoogle ScholarCrossref
Kroegel  C, Reissig  A.  Principle mechanisms underlying venous thromboembolism: epidemiology, risk factors, pathophysiology and pathogenesis.  Respiration. 2003;70(1):7-30.PubMedGoogle ScholarCrossref
Eppihimer  MJ, Schaub  RG.  P-selectin–dependent inhibition of thrombosis during venous stasis.  Arterioscler Thromb Vasc Biol. 2000;20(11):2483-2488.PubMedGoogle ScholarCrossref
Khuri  SF, Hermanides  J, DeVries  JH,  et al.  The NSQIP: a new frontier in surgery.  Surgery. 2005;138(5):837-843.PubMedGoogle ScholarCrossref
Wakefield  TW, Myers  DD, Henke  PK.  Mechanisms of venous thrombosis and resolution.   Arterioscler Thromb Vasc Biol. 2008;28:387-391.PubMedGoogle ScholarCrossref
Bahl  V, Hu  HM, Henke  PK, Wakefield  TW, Campbell  DA  Jr, Caprini  JA.  A validation study of a retrospective venous thromboembolism risk scoring method.  Ann Surg. 2010;251(2):344-350.PubMedGoogle ScholarCrossref
Joint Commission.  Venous thromboembolism; 2013. Accessed May 18, 2013
Sweetland  S, Green  J, Liu  B,  et al; Million Women Study collaborators.  Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study.  BMJ. 2009;339:b4583.PubMedGoogle ScholarCrossref
Amin  AN, Lenhart  G, Princic  N, Lin  J, Thompson  S, Johnston  S.  Retrospective administration database study of the time period of VTE risk during and following hospitalization for major orthopedic or abdominal surgery in real-world US patients.  Hosp Pract. 2011;39(2):7-17.Google ScholarCrossref
Falck-Ytter  T, Francis  CW, Johanson  NA.  Prevention of CTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.  Chest. 2012;141(2)(suppl):e278S-e325s. doi:10.1378/chest.11-2404. PubMedGoogle Scholar
American Society for Metabolic and Bariatric Surgery Clinical Issues Committee.  ASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients.  Surg Obes Relat Dis. 2013;9(4):493-497.PubMedGoogle ScholarCrossref
Koch  CG, Li  L, Hixson  E, Tang  A, Phillips  S, Henderson  JM.  What are the real rates of postoperative complications: elucidating inconsistencies between administrative and clinical data sources.  J Am Coll Surg. 2012;214(5):798-805.PubMedGoogle ScholarCrossref
De Martino  RR, Beck  AW, Edwards  MS,  et al.  Impact of screening versus symptomatic measurement of deep vein thrombosis in a national quality improvement registry.  J Vasc Surg. 2012;56(4):1045-1051, e1.PubMedGoogle ScholarCrossref
Original Investigation
February 2015

Surgical Duration and Risk of Venous Thromboembolism

Author Affiliations
  • 1Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Surg. 2015;150(2):110-117. doi:10.1001/jamasurg.2014.1841

Importance  There is a paucity of data assessing the effect of increased surgical duration on the incidence of venous thromboembolism (VTE).

Objective  To examine the association between surgical duration and the incidence of VTE.

Design, Settings, and Participants  Retrospective cohort of 1 432 855 patients undergoing surgery under general anesthesia at 315 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011.

Exposure  Duration of surgery.

Main Outcomes and Measures  The rates of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE within 30 days of the index operation. Surgical duration was standardized across Current Procedural Terminology codes using a z score. Outcomes were compared across quintiles of the z score. Multiple logistic regression models were developed to examine the association while adjusting for patient demographics, clinical characteristics, and comorbidities.

Results  The overall VTE rate was 0.96% (n = 13 809); the rates of DVT and PE were 0.71% (n = 10 198) and 0.33% (n = 4772), respectively. The association between surgical duration and VTE increased in a stepwise fashion. Compared with a procedure of average duration, patients undergoing the longest procedures experienced a 1.27-fold (95% CI, 1.21-1.34; adjusted risk difference [ARD], 0.23%) increase in the odds of developing a VTE; the shortest procedures demonstrated an odds ratio of 0.86 (95% CI, 0.83-0.88; ARD, −0.12%). The robustness of these results was substantiated with several sensitivity analyses attempting to minimize the effect of outliers, concurrent complications, procedural differences, and unmeasured confounding variables.

Conclusions and Relevance  Among patients undergoing surgery, an increase in surgical duration was directly associated with an increase in the risk for VTE. These findings may help inform preoperative and postoperative decision making related to surgery.