Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study.

BACKGROUND: Abdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. METHODS: Retrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. RESULTS: A total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7-27) versus 7 (5-11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05-1.93, p = 0.038) and independently predicted its occurrence. CONCLUSIONS: The risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

Efficacy of patient selection criteria for obesity surgery in a non-high-dependency unit/intensive care unit facility.

BACKGROUNDS: Publicly funded obesity surgery remains underfunded in Australia. One barrier to expansion is the perception that perioperative care requires critical care facilities. This study evaluates the effectiveness of patient selection criteria in avoiding unplanned patient transfer and adverse outcomes in obesity surgery performed at a facility without a high-dependency unit/intensive care unit (HDU/ICU). METHODS: Retrospective analysis was performed on patients undergoing obesity surgery between January 2017 and March 2020 in a centre with specific screening criteria. Criteria included: body mass index <48 for males and <52 for females with up to three stable comorbidities from a selected list. Revision sleeve or bypass procedures were contraindicated. Primary outcome was patient transfer to our main campus. Secondary outcomes included return to theatre (RTT), readmission and death. Outcomes were compared to laparoscopic cholecystectomies (LC) performed at the same centre. RESULTS: A total of 387 obesity surgery procedures were performed; 372 patients (96%) were discharged without complication. Fifteen (3.9%) were transferred to the main campus, eight were admitted to ICU and two required re-operation. Twelve (3.1%) were readmitted within 30 days of discharge, five required re-operation. Transfer, 30-day readmission and 30-day emergency department presentation rates were similar in comparison to LC. RTT during index admission (0.5% vs. 3.0%; p = 0.006) and during 30-day post-operative period (1.8% vs. 4.4%; p = 0.025) was lower in the obesity surgery group. CONCLUSION: Carefully selected screening criteria allow obesity surgery to be performed at a well-supported non-HDU/ICU facility with few complications and acceptable rates of unplanned patient transfer.

Effect of the acute general surgical unit: a regional perspective.

BACKGROUND: Acute surgical units have gained favour in Australia and New Zealand. However, there is a lack of evidence regarding their effectiveness in regional centres. We aim to investigate the effect of the introduction of the Acute General Surgical Unit (AGSU) on the outcomes for patients undergoing emergency appendicectomies or cholecystectomies in a regional hospital. METHODS: AGSU was introduced in March 2012. We conducted a retrospective comparison analysis of patients admitted 2 years prior to and 2 years after the introduction of AGSU. Primary outcomes included length of stay, time to theatre, after hours and overnight operating. Secondary outcomes included negative appendicectomy rate, conversion to open cholecystectomy and bile duct injuries. RESULTS: No difference was seen between pre and post-AGSU introduction in median time to theatre in the appendicectomy group (8.00 h versus 9.24 h) or cholecystectomy group (17.63 h versus 17.75 h). Additionally, there was no difference between median length of stay in the appendicectomy group (47.52 h versus 48.00 h) or the cholecystectomy group (71.50 h versus 70.67 h). Night operating was significantly reduced in the positive appendicectomy group (4.4% versus 9.1%, P = 0.027) and the overall cholecystectomy group (0.43% versus 3.4%, P = 0.035), however overall after hours operating remained equivalent. CONCLUSIONS: The introduction of the AGSU unit led to a significant reduction in overnight operating, which may improve patient outcomes and surgeon satisfaction. Length of stay and time to theatre did not change. Future directions include further research into the impact of theatre access on emergency surgery outcomes.