Thromboembolism, Bleeding, and Mortality Incidence of Direct Oral Anticoagulants Versus Warfarin Postbariatric Surgery.

BACKGROUND: There is no randomized controlled trial comparing direct oral anticoagulants (DOACs) and warfarin following bariatric surgery to date. The mortality, thromboembolism, and bleeding risk of DOACs in comparison with warfarin following bariatric surgery remains unclear. We aimed to provide a clinical comparison between DOACs and warfarin for these 3 prespecified outcomes. METHODS: A systematic literature search was performed on November 10, 2019, using PubMed, Embase, clinicaltrial.gov, and Cochrane databases. Studies with adult patients who were on either warfarin or DOACs following bariatric surgery and reported the incidence of thromboembolism, bleeding, or mortality were included. Pooled incidence for these prespecified outcomes and its 95% confidence interval (CI) were calculated for each drug separately using the random-effects model, along with a nonadjusted P value comparing the 2 subgroups. RESULTS: A total of 11 studies (805 patients) were included. Comparing DOACs to warfarin, the following pooled incidences were observed for mortality (DOACs: 3.0%; 95% CI 0.4%-18.6% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value comparing the 2 subgroups = .38), thromboembolism (DOACs: 4.9%; 95% CI 1%-21.1% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value = .18), and bleeding (DOACs: 3.9%; 95% CI 0.7%-18.2% versus warfarin: 11.3%; 95% CI 5.7%-21.4%; P value = .23). CONCLUSION: The results of our meta-analysis remain hypothesis-generating, providing rationale for future randomized controlled trial design or well-designed comparative observational studies. Currently, it does not support the change in the current recommendation from warfarin to DOACs following bariatric surgery.

Laparoscopic reversal of mini-gastric bypass to original anatomy for severe postoperative malnutrition.

PURPOSE: Malnutrition after mini-gastric bypass (MGB) is a rare and dreaded complication with few data available regarding its surgical management. We aim to report the feasibility, safety, and results of laparoscopic reversal of MGB to normal anatomy (RMGB) in case of severe and refractory malnutrition syndrome after intensive nutritional support (SRMS). METHODS: A 10-year retrospective chart review was performed on patients who underwent RMGB (video included) for SRMS following MGB. RESULTS: Twenty-six of 2934 patients underwent a RMGB at a mean delay of 20.9 ± 13.4 months post-MGB. At presentation, mean body mass index (BMI), excess weight loss (%EWL), and albumin serum level were 22 ± 4.4 kg/m2, 103.6 ± 22.5%, and 25.5 ± 3.6 gr/L, respectively. Seventeen (63.5%) patients had at least one severe malnutrition related complication including severe edema in 13 (50%), venous ulcers in 2 (7.7%), infectious complications in 7 (27%), deep venous thrombosis in 5 (19.2%), and motor deficit in 5 (19.2%) patients. At surgical exploration, 8 of 12 (66.5%) patients had a biliary limb longer than 200 cm and 9 (34.6%) had bile reflux symptoms. Overall morbidity was 30.8% but lower when resecting the entire previous gastrojejunostomy with creation of a new jejunojejunostomy (8.3 vs 50%, p = 0.03). After a mean follow-up of 8 ± 9.7 months, all patients experienced a complete clinical and biological regression of the SRMS after the RMGB despite a mean 13.9 kg weight regain in 16 (61.5%) patients. CONCLUSIONS: Post-MGB SRMS and its related comorbidities are rare but dreaded conditions. Although burdened by a significant postoperative morbidity and weight regain, RMGB remains an effective option to consider, when intensive nutritional support fails.

Laparoscopic sleeve gastrectomy after failed gastric banding: is it really effective? Six years of follow-up.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a valuable surgical option to rescue laparoscopic adjustable gastric banding (LAGB) failures. OBJECTIVES: The aim of this study was to determine whether conversion to LSG after failed LAGB (CLSG) is a well-tolerated and effective rescue procedure compared with primary LSG (PLSG) in the long term. SETTING: University hospital, France. METHODS: A retrospective review of data concerning consecutive patients receiving a LSG between February 2008 and December 2014 was conducted. Mortality, postoperative complications, and weight loss outcomes were analyzed. RESULTS: Of 701 LSG, 601 (85.7%) were PLSG and 100 (14.3%) were CLSG. The mortality rate was 0%. Overall morbidity was comparable between the primary and conversion group (10% versus 6%, P = .27). The mean percentage of excess weight loss at 3, 36, and 72 months was 34.9%, 72.1%, and 57.2% after PLSG and 22.6%, 51.2% and 29.8% after CLSG (P<.05). The failure rate (mean percentage of excess weight loss<50%) was higher in the CLSG group during the first 5 postoperative years (P < .001) with more than two thirds of the CLSG considered as having failed at 60 months. Patients who underwent band ablation as a result of insufficient weight loss or weight regain presented the worst results after conversion to LSG. CONCLUSION: In this study, the conversion of failed LAGB to LSG in 2 steps indicated a safety profile comparable to that of primary LSG but was significantly less effective from the early postoperative course (3 mo) up to 6 years postoperatively. CLSG may not be the best option because a third operation may be needed as a result of insufficient weight loss.

Long-Term Outcomes of the Laparoscopic Adjustable Gastric Banding: Weight Loss and Removal Rate. A Single Center Experience on 301 Patients with a Minimum Follow-Up of 10 years.

BACKGROUND: Obesity is a chronic disease that requires procedures to enable to maintain good long-term results. Laparoscopic adjustable gastric banding (LAGB) studies with a long-term follow-up are limited and have often given conflicting results. We report our results in terms of banding life span and weight loss in a cohort of 301 patients operated on LAGB with a minimum follow-up of 10 years. METHODS: All patients who underwent LAGB at our university hospital between 1998 and 2004 were included in this study. The main outcome was band survival and complications that led to band removal, and the secondary outcome was weight loss. We present raw data and data after imputation for patients lost at follow-up. RESULTS: Most patients were women (83 %), and the mean body mass index (BMI) baseline was 45.2 ± 6.7. The pars flaccida technique was performed in 50.9 % of the patients. All patients had at least 10 years of follow-up (range 10-16 years). Data were available at 10 years for 79.7 % and at 15 years for 80.6 %. Band survival was 65.8 % at 10 years and 53.3 % at 15 years. Mean excess weight loss (EWL) at 5, 10, and 15 years was 41.4, 38.7, and 35.1 %, respectively. CONCLUSION: Despite the encouraging short-term results, LAGB shows long-term disappointing results in terms of weight loss and complication rates. The removal rate increases with time (about 3-4 % per year), and at 15 years, almost half of the bands had been removed.

Rare Neurological Complications After Sleeve Gastrectomy.

BACKGROUND: Bariatric surgery is considered to be the most effective treatment of morbid obesity and improvement of obesity-related comorbidities, such as type II diabetes. However, both peripheral and central neurological complications can occur after bariatric surgery. Such complications tend to occur more frequently after bypass surgery than after sleeve gastrectomy (SG). The objective of this study was to identify the patients that presented post-operative neurological complications after undergoing SG and describe the incidence, presentation, and management of these complications. METHODS: This was a retrospective study of 592 cases of SG performed between 2009 and 2014 with a special focus on patients who presented neurological complications. RESULTS: Of the 592 SG cases, only seven (1.18 %) patients presented neurological complications. All patients had uneventful post-operative course, but all reported feeding difficulties, accompanied by severe dysphagia, and rapid weight loss, with a mean weight loss of 35 kg (30-40 kg) 3 months after SG. All patients were readmitted owing to neurological symptoms that included paresthesia, abolition of deep tendon reflexes of the lower limbs, muscle pain, and motor and sensitive deficits in some cases. There were two cases of Wernicke's encephalopathy. All patients were treated for neuropathy secondary to vitamin B1 deficiency and had a significant improvement and/or resolution of their symptoms. CONCLUSIONS: Neurological complications after SG are rare and are often preceded by gastrointestinal symptoms, rapid weight loss, and lack of post-operative vitamin supplementation. Re-hospitalization and multidisciplinary team management are crucial to establish the diagnosis and initiate treatment.

Inguinal Hernia Repair Using Self-adhering Sutureless Mesh: Adhesix™: A 3-Year Follow-up with Low Chronic Pain and Recurrence Rate.

To review our experience and outcomes after inguinal hernia repair using the lightweight self-adhering sutureless mesh "Adhesix™" and demonstrate the safety and efficacy of this mesh. This is a 3-year retrospective study that included 143 consecutive patients who underwent 149 inguinal hernia repairs at our department of surgery. All hernias were repaired using a modified Lichtenstein technique. Preoperative, perioperative, and postoperative data were prospectively collected. Incidence of chronic pain, postoperative complications, recurrence, and patient satisfaction were assessed three years postoperatively by conducting a telephone survey. We had 143 patients with a mean age of 58 years (17-84), who underwent 149 hernia repairs using the Adhesix™ mesh. Ninety-two per cent (131 patients) were males. Only 10 patients (7%) had a postoperative pain for more than three years. In our series, neither age nor gender was predictive of postoperative pain. Only one patient had a hematoma lasting for more than one month and only four patients (2.8%) had a recurrence of their hernia within three years of their initial surgery. Ninety per cent of the patient expressed their satisfaction when surveyed three years after their surgery. In conclusion, the use of the self-adhering sutureless mesh for inguinal hernia repair has been proving itself as effective as the traditional mesh. Adhesix™ is associated with low chronic pain rate, recurrence rate, and postoperative complications rate, and can be safely adopted as the sole technique for inguinal hernia repair.

Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity.

BACKGROUND: Few data exist about the characteristics and management of enteric leaks after mini-gastric bypass (MGB). OBJECTIVES: We aimed to describe the incidence, presentation, and surgical management of enteric leaks in patients who underwent laparoscopic MGB for morbid obesity. SETTING: Private practice. METHODS: An 8-year, 9-month retrospective chart review was performed on patients who had enteric leak requiring reoperation after MGB at a single institution. RESULTS: Thirty-five of 2321 patients were included. Ninety-seven percent had symptoms. Arterial hypertension and heavy smoking were predicting factors of leaks occurrence post-MGB (P<.01). Enteric leak was diagnosed by systematic upper gastrointestinal series in 4 pts (11.4%) and by computed tomography with oral water soluble contrast in 4 of 31 pts (13%). In the other 27 patients, diagnosis of the leak was made intraoperatively. Eleven patients (32%) had leak arising from the gastric stapler line (type 1), 4 (11%) from the gastrojejunal anastomosis (type 2), and 20 (57%) from undetermined origin. The most common presentation was intra-abdominal abscess in type 1 and leaks of undetermined origin and generalized peritonitis in type 2. One third of the patients who underwent reoperation developed well-drained chronic fistula into the irrigation-drainage system, with complete healing in all patients without any further procedure. The mean hospital stay was 19 days with no mortality reported. CONCLUSION: Enteric leak leading to intra-abdominal sepsis post-MGB is rare (1.5%) An operative aggressive management based on clinical symptoms is the treatment of choice allowing no postoperative leak-related mortality and complete healing.

Two stages conversion of failed laparoscopic adjustable gastric banding to laparoscopic roux-en-y gastric bypass. A study of one hundred patients.

INTRODUCTION: Conversion to laparoscopic gastric bypass (LRYGB) appears to be the treatment of choice after failed LAGB. To reduce the risk of postoperative complications, some surgeons routinely adopt a two-stage strategy. The purpose of this study was to analyze our institution's experience with the two-stage procedure for LAGB conversion to LRYGB MATERIALS AND METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of LAGB to LRYGB from November 2007 to June 2012. RESULTS: One hundred patients were included. Of these, 62 (62%) required conversion to LRYGB for inadequate weight loss or weight regain and 38 for band-related complications. All the procedures were performed in two stages and laparoscopically. The average time between band removal and LRYGB was 17.3 months. The mean follow-up after LRYGB was 31 ± 18.7 months. The mean BMI prior to LRYGB conversion was 45.3 ± 5.2. Early complications occurred in 15 patients (15%), while late complications occurred in only 3 patients (3%). The average %EWL at 24 months and 48 months after conversion was 70.1 and 69.4%, respectively. CONCLUSION: Although a two-stage conversion strategy increases the number of operations and hospital stay without decreasing the rate of early complications compared to one-stage conversion; it has shown to be associated with low rates of GJA stenosis and excellent %EWL.

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve.

BACKGROUND: Despite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20-60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG). METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012. RESULTS: A total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion. CONCLUSION: In this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.

New Freedom through Medical Devices Based on the Global System for Mobile Communications: A Prospective Survey of 620 Users of the Swiss Limmex Emergency Wristwatch-An Original Study from Switzerland.

About 500,000 elderly people in Switzerland suffer a fall each year. Thus medical attention and help are essential for these people, who mostly live alone without a caregiver. Only 3% of people aged over 65 in Switzerland use an emergency system. Personal telehealth devices allow patients to receive enough information about the appropriate treatment, as well as followup with their doctors and reports of any emergency, in the absence of any caregiver. This increases their quality of life in a cost-effective fashion. "Limmex"-a new medical emergency watch-was launched in Switzerland in 2011 and has been a great commercial success. In this paper, we give a brief review of this watch technology, along with the results of a survey of 620 users conducted by the Department of Emergency Medicine in Bern.

Do we need new personalized emergency telehealth solutions? A survey of 100 emergency department patients and a first report of the swiss limmex emergency wristwatch: an original study.

Development of new personal mobile and wireless devices for healthcare has become essential due to our aging population characterized by constant rise in chronic diseases that consequently require a complex treatment and close monitoring. Personal telehealth devices allow patients to adequately receive their appropriate treatment, followup with their doctors, and report any emergency without the need of the presence of any caregivers with them thus increasing their quality of life in a cost-effective fashion. This paper includes a brief overview of personal telehealth systems, a survey of 100 consecutive ED patients aged >65 years, and introduces "Limmex" a new GSM based technology packaged in a wristwatch. Limmex can by a push of a button initiate multiple emergency call and establish mobile communication between the patient and a preselected person, institution, or a search and rescue service. To the best of our knowledge, Limmex is the first of its kind worldwide.

Acute health problems in African refugees: ten years' experience in a Swiss emergency department.

BACKGROUND: Over the last two decades, the total number of applications from Africans for asylum in the countries of the European Union has increased from 578,000 to more than 2.9 million. About 20 % (7,196/36,100) of the asylum seekers in Switzerland originate from Africa. The disease profile of African asylum seekers is remarkably different from that of the native population in the country of application. We have therefore conducted an analysis of African asylum seekers presenting themselves to our emergency department. METHODS: In a retrospective analysis, the central patient registry database was searched for patients originating from Africa admitted from 1 January 2000 to 30 November 2011 and labelled as "Asylbewerber" (asylum seeker) or "Flüchtling" (refugee). RESULTS: Three thousand six hundred and seventy-five African asylum seekers were admitted to our emergency department between 2000 and 2010. Thirty-four percent (n = 1,247) were female and 66 % (n = 2,426) male. Eighty percent (n = 1,940) of the men and 70 % (n = 823) of the women were younger than 40 years. Most of our patients originated from Algeria (n = 612). Forty-five percent (n = 1,628) of all patients presented with internal medical problems, 40 % (n = 1,487) with injuries. 3.5 % (n = 130) of all patients presented with psychiatric problems. Admission for psychiatric problems increased steadily from 2 % (n = 4) in 2001 to 10 % (n = 35) in 2011. CONCLUSION: The causes of presentation are manifold, including internal medical problems and injuries. Admissions for psychiatric problems are increasing. Establishing simple screening scores for somatization should be a key priority in providing more focused treatment in emergency departments.

Transvaginal ultrasound in fertile patients with suspected appendicitis: an experience report of current practice.

Background. Transvaginal ultrasound (TVU) in female patients with acute right lower quadrant (RLQ) abdominal pain is time and infrastructure intensive and not always available. This study aims to evaluate the role of TVU in these patients. Methods. Retrospective analysis identified 224 female patients with RLQ pain and TVU. Results. TVU revealed an underlying pathology in 34 (15%) patients, necessitating a diagnostic laparoscopy in 12 patients. Six patients (2%) had a true gynaecological emergency. The remaining 23 patients did not require surgery. The other 190 patients with RLQ pain had a bland TVU; 127 (67%) were discharged, while 63 patients (33%) received a diagnostic laparoscopy. Conclusion. The incidence of true gynaecological emergencies requiring urgent surgical intervention is very low in our patient cohort. TVU is a helpful tool if performed by a physician who is well trained in TVU.

Human bite wounds: a swiss emergency department experience.

UNLABELLED:  Human bites (HB) are the third most common bite wound diagnosed in emergency departments, after dog and cat bites. Management of HB can be challenging, given the high risk of infection associated with multiorganism-rich oral flora. Recognition and early aggressive treatment are essential steps in preventing infections and other associated complications. METHODS: A retrospective, 10-year electronic chart review was performed, which identified 104 HB. Diagnosis, treatment, and outcome were noted for each case. RESULTS: Most of the patients were male, with a male:female ratio of 4:1. A majority of patients (n = 53, 51%) presented with finger and hand injuries. Only 13.8% were bitten on the head or neck, and 25% on the upper limbs. The remainder (35.2%) of patients sustained injuries to other body parts. Twelve operations were necessary and performed by plastic and hand surgeons. More than half of the patients (60.5%) received antibiotic therapy, and 84.6% of the patients had their tetanus prophylaxis administered or received a booster by the time of treatment. Only 40.4% of patients had a post-bite serology test to rule out bloodborne viral infections, none of whom tested positive. The viral status of the biter was known in two cases. CONCLUSION: The goals of HB management are to minimize infection risk and its complications, and to prevent the transmission of systemic infections, such as hepatitis B/C and HIV. Accurate documentation and a management algorithm should be instituted in emergency departments in order to achieve these goals. .

Full body low radiation radiography using Lodox Statscan.

Lodox Statscan provides high-speed, high-quality, low radiation, full body imaging in a single scan, combined with three-dimensional reconstructive and zooming functionality. Several trauma centres have incorporated it into their advanced trauma life support protocol. This review gives a brief overview of the system.

Missed opportunities for primary repair in complicated acute diverticulitis.

BACKGROUND: Complicated acute diverticulitis (CAD) requiring an urgent operation is usually managed by fecal diversion (FD) despite reports suggesting that primary repair (PR) is safe. We aim to identify patient characteristics predicting successful PR and explore if patients are managed by FD despite the presence of such characteristics. METHODS: We reviewed the medical records of 194 patients with CAD, requiring colectomy within 48 hr of admission from January 1996 to January 2006. Exclusion criteria included: admission for elective repair, treatment with antibiotics and/or percutaneous abscess drainage prior to operation (semi-elective), concurrent inflammatory disease, cancer, and inadequate documentation. Univariate and multivariate analysis identified independent predictors of PR. Patients who despite having these independent predictors underwent FD, were compared with the PR group. RESULTS: Eighteen patients (9%) received PR. They were younger than FD patients, had a lower incidence of left-sided disease, were less frequently operated on within 4 hr of hospital arrival, and had less severe disease (Hinchey I or II). They also had shorter postoperative hospital stays (6.2 ± 2.3 vs 14.6 ±16.1; P = .002) and a trend towards a lower mortality (0% vs 6.8%; P = .38). The independent predictors of performing PR included: age less than 55 years, interval between admission and operation longer than 4 hr, and a Hinchey score I or II. There were 71 patients who had 2 (64) or all 3 (7) independent predictors of PR but still received FD. These patients were not different in any characteristic from the PR patients but had worse outcomes. CONCLUSION: FD remains the prevailing operative method of choice of CAD. Despite the presence of factors favoring PR, many patients still receive FD and have worse outcomes. PR can be used more liberally in CAD.

Testing of blood products in a polytrauma model: results of a multi-institutional randomized preclinical trial.

INTRODUCTION: Trauma-induced coagulopathy, acidosis, and hypothermia form a "lethal triad" that is difficult to treat and is associated with extremely high mortality. This study was performed at three academic centers to evaluate whether resuscitation with blood components could reverse the coagulopathy in a complex polytrauma model. METHODS: Yorkshire swine (40 +/- 5 kg) were subjected to a three-phase protocol: (a) "Prehospital" phase = femur fracture, hemorrhage (60% blood volume), and 30 minutes shock + infusion of saline (3x shed blood) + induction of hypothermia (33 degrees C); (b) "Early hospital" phase = grade V liver injury; and (c) "Operative" phase= liver packing. After liver packing, the animals (n = 60) were randomized to the following groups: (1) Sham-instrumentation and anesthesia without hemorrhage/injuries, (2) fresh whole blood (FWB), (3) 6% hetastarch (Hextend), (4) fresh frozen plasma/packed RBCs in 1:1 ratio (1:1 FFP/PRBC), and (5) FFP alone. Treatment volumes were equal to the volume of shed blood. Hemodynamic and physiologic parameters and coagulation profile (thrombelastography, prothrombin time, activated partial thromboplastin time, international normalized ratio, and platelets) were monitored during the experiment and for 4 hours posttreatment. RESULTS: At the end of prehospital phase, animals had developed significant acidosis (lactate >5 mmol/L and base deficit >9 mmol/L) and coagulopathy. Posttreatment mortality rates were 85% and 0% for the Hextend and blood component treated groups, respectively (p < 0.05). Hemodynamic parameters and survival rates were similar in groups that were treated with blood products (FWB, FFP, and FFP:PRBC). Animals treated with FFP and Hextend had significant anemia compared with the groups that received red blood cells (FWB and FFP:PRBC). Treatment with FFP and FFP:PRBC corrected the coagulopathy as effectively as FWB, whereas Hextend treatment worsened coagulopathy. CONCLUSIONS: In this reproducible model, we have shown that trauma-associated coagulopathy is made worse by hetastarch, but it can be rapidly reversed with the administration of blood components. Impressively, infusion of FFP, even without any red blood cells, can correct the coagulopathy and result in excellent early survival.

Pulmonary embolism and deep venous thrombosis in trauma: are they related?

HYPOTHESIS: Pulmonary embolism (PE) and deep venous thrombosis (DVT) in trauma are related. DESIGN: Retrospective review of medical records. SETTING: Academic level I trauma center. PATIENTS: Trauma patients who underwent computed tomographic pulmonary angiography (CTPA) with computed tomographic venography (CTV) of the pelvic and proximal lower extremity veins over a 3-year period (January 1, 2004, to December 31, 2006) were reviewed. Data on demographics, injury type and severity, imaging findings, hospital length of stay, and mortality were collected. MAIN OUTCOME MEASURES: Pulmonary embolism and DVT. RESULTS: Among 247 trauma patients undergoing CTPA/CTV, PE was diagnosed in 46 (19%) and DVT in 18 (7%). Eighteen PEs were central (main or lobar pulmonary arteries), and 28 PEs were peripheral (segmental or subsegmental branches). Pulmonary embolism occurred within the first week of injury in two-thirds of patients. Seven patients with PE (4 femoral, 2 popliteal, and 1 iliac) had DVT. Pulmonary embolism was central in 5 patients and peripheral in 2 patients. No significant differences were noted in any of the examined variables between patients with PE having DVT and those not having DVT. CONCLUSIONS: Few patients with PE have DVT of the pelvic or proximal lower extremity veins. Pulmonary embolism may not originate from these veins, as commonly believed, but instead may occur de novo in the lungs. These findings have implications for thromboprophylaxis and, particularly, the value of vena cava filters.