Efficacy of Caprini risk assessment model in predicting venous thromboembolism risks among Asian surgical patients.

INTRODUCTION: Caprini risk assessment model (RAM) has been validated in Caucasians but evidence of its suitability in Asian surgical patients is still unknown. This study aims to determine the efficacy of Caprini model in venous thromboembolism (VTE) risk assessment among Asian surgical patients. MATERIALS AND METHODS: Consecutive surgical patients with Asian ethnicities admitted to a tertiary public hospital between January 2013 and December 2014, were included. Their demographic details, VTE risk factors and scores based on Caprini RAM were recorded. Primary outcome of this study was symptomatic VTE within 90 days of hospitalisation. Fisher's exact test and Lasso regression were performed for statistical analysis. RESULTS: A total of 4206 patients were included in this study. Distribution of this study population by risk level was very low, 14.7%; low, 44.1%; moderate, 25.6% and high, 15.7%. The overall symptomatic VTE incidence within 90 days was 0.5%. The incidence of deep venous thrombosis (DVT), pulmonary embolism (PE) and both was 0.31%, 0.19% and 0.05% respectively. VTE incidence by risk category was very low, 0%; low, 0.16%; moderate, 0.37% and high, 2.12%. Obesity (BMI >25), history of prior major surgery, history of DVT/PE and high-risk category (scores ≥5) were significant VTE factors with odds ratio > 5.0. Following the Caprini RAM with ACCP preventive recommendations, an estimated 85% of surgical patients would need prophylaxis. CONCLUSION: The overall VTE incidence among Asian surgical patients is low. Prophylaxis using Caprini RAM may subject a low incidence patient population to over utilisation of thromboprophylaxis and therefore not cost-effective when applied to Asian patients.

Spontaneous calf haematoma: case report.

Spontaneous calf haematoma is a rare condition and few case reports have been published in the English literature. Common conditions like deep vein thrombosis and traumatic gastrocnemius muscle tear need to be considered when a patient presents with unilateral calf swelling and tenderness. Ultrasound and Magnetic Resonance Imaging are essential for confirmation of diagnosis. The purpose of this paper is to report on a rare case of spontaneous calf hematoma and its diagnosis and management.

A survey of contemporary opinions and practices of surgical and intensive care specialists towards peri-operative venous thromboembolism prophylaxis in Asia.

AIM: This survey was conducted to determine the opinions and practices of peri-operative venous thromboembolism (VTE) prophylaxis among surgical and intensive care specialists in Asia. METHODS: A set of questionnaire was distributed to surgeons and intensivists from different countries in Asia. The specialties included were general surgery and its sub-specialties, orthopaedic surgery, gynaecological surgery and intensive care unit. This survey involved teaching institutions, general hospitals and private hospitals. To gauge if the respondents were from hospitals that would likely encounter VTE cases, the hospital's bed-strength, intensive care facility and sub-specialty services were recorded. Over a period of six months, questionnaires and feedbacks were collected and analyzed. RESULTS: One hundred and ninety-one responses were received from 8 countries throughout Asia. Fifty-six percent of these were from large hospitals (800 bedded or more) and 62% of these hospitals have large intensive care facility (20 or more beds). Only half of the respondents practice routine thromboprophylaxis in moderate and high risk surgeries. Thirty six percent of them practices selective thromboprophylaxis and only 3% do not believe in any thromboprophylaxis. A third prescribed thromboprophylaxis for 3 to 5 days; another third extended it until patient is mobile. About 48.6% of the respondents do not have VTE guidelines in their institutions. Majority of the respondents agreed that more evidence is needed in the form of multi-centre randomized controlled trials to influence their decision on thromboprophylaxis. CONCLUSION: Despite the availability of strong epidemiological data, randomized controlled trials and multicentre case-controlled studies, perioperative VTE prophylactic practices are still suboptimal in Asia.

Asian venous thromboembolism guidelines: prevention of venous thromboembolism.

Venous thromboembolism (VTE) prophylaxis is under-utilized in Asia because of the misconception that its incidence is lower in Asians as compared to the Caucasians. The available data on VTE in Asia is limited due to the lack of well-designed multicenter randomized controlled trials as well as non-standardized research designs, making data comparison difficult. Emerging data indicates that the VTE incidence is not low in Asia, and is comparable to that reported in the Western literature in some instances. There is also a trend towards increasing incidence of VTE, as demonstrated by a number of hospital-based studies in Asia. This could be attributed to lifestyle changes, ageing population, increasing awareness of VTE and wider availability of Duplex ultrasound. The risk of VTE in hospitalized patients remain the same in Asians and Caucasians, even though there may be factors that are inherent to patients in Asia that influence the slight variation in incidence. The utilization rate of VTE prophylaxis remains suboptimal in Asia. The Asian Venous Thrombosis Forum (AVTF) comprises participants from various countries such as China, Hong Kong, India, Indonesia, Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand and experts from Australia and Europe. The forum evaluated the available data on VTE from the Asian region and formulated guidelines tailored to meet the needs of the region. We recommend that serious considerations are given to VTE prophylaxis especially in the at-risk group and a formal hospital policy be established to facilitate the implementation. On admission to the hospital, we recommend assessing the patients for both VTE and bleeding risk. We recommend mechanical prophylaxis for patients at increased risk of bleeding and utilizing it as an adjunctive measure in combination with pharmacological prophylaxis in patients with high risk of VTE. For patients undergoing general or gynecological surgery and with moderate risk for VTE, we recommend prophylaxis with one of the following: low dose unfractionated heparin (LDUH), low molecular weight heparin (LMWH), fondaparinux or intermittent pneumatic compression (IPC). For the same group of patients at high risk of VTE, we recommend pharmacological or combination of pharmacological and mechanical prophylaxis. For patients undergoing major orthopedic surgeries like total hip replacement, total knee replacement and proximal hip fracture surgery, we recommend using one of the following: LMWH, fondaparinux, rivaroxaban, apixaban, edoxaban, dabigatran, warfarin or aspirin with IPC. For patients admitted to the hospital with acute medical illness and has moderate risk of VTE, we recommend prophylaxis with LDUH, LMWH or Fondaparinux. For the same group at high risk of VTE, we recommend combination of pharmacological and mechanical prophylaxis.

New oral anticoagulants for venous thromboembolism (VTE) prophylaxis.

Venous thromboembolism is a rising concern in Asia especially among patients after surgery where this complication is readily preventable. Despite the availability of several treatment options, the acceptance of prophylaxis and usage of these methods remain low. A possible explanation to this behavior is the limitations attached to the available treatment options: narrow therapeutic window of warfarin and parenteral administration of low molecular weight as well as unfractionated heparins. Newer agents have been researched and introduced to overcome these limitations in the hope of improving the adaptation towards post surgical thromboprophylaxis. Dabigatran and rivaroxaban are two such new agents that are promising in view of efficacy and ease of administration.

Perforation of duodeno-jejunal junction in an 8-month-old infant: a management challenge to a general surgeon.

We report a case of perforation over duodeno-jejunal junction (DJ) in a healthy 8-month-old baby. The difficulty in diagnosis, management dilemma and probable etiology is discussed.

Update on the management of peripheral arterial disease (PAD).

There has been much progress made in the management of peripheral arterial disease (PAD) in the past two decades. Progress in the understanding of the endothelial-platelet interaction during health and disease state have resulted in better antiplatelet drugs that can prevent platelet aggregation, activation and thrombosis during angioplasty and stenting. Collaborative effort by different international societies has resulted in a consensus guideline that recommends the modality of intervention in certain disease states. Progress in perioperative care has reduced the morbidity and mortality associated with peripheral vascular reconstruction surgery. Nevertheless, the advances in percutaneous peripheral intervention (PPI) have made a paradigm shift in the current management of patients. The procedure is safe and effective and is emerging as the first choice revascularization procedure.

Duodenal intussusception of Brunner's gland adenoma mimicking a pancreatic tumour.

Brunner's gland adenoma is a rare benign tumour of the duodenum. It is usually asymptomatic but may occasionally present with gastrointestinal haemorrhage and obstruction. We report a 40-year old lady, presenting with upper gastrointestinal bleeding and was found to have prolapsed and intussuscepted Brunner's gland adenoma of the duodenum, which mimicked the appearance of a tumour in the head of pancreas.

Barium peritonitis--following barium enema of the proximal colon through a colostomy.

Perforation with extravasation of barium is a rare complication of contrast enema examination of the large bowel with a high associated mortality rate. The experience of performing a re-laparotomy in a patient previously exposed to barium peritonitis is even less common. We describe an elderly male patient with a Hartmann's procedure performed a year previously, presenting with peritonitis following barium enema evaluation of the proximal colon via an end descending colon stoma. Emergency laparotomy, segmental bowel resection and liberal peritoneal toilet resulted in a satisfactory outcome. The patient had a subsequent successful reversal of his Hartmann's procedure nine months later despite the presence of dense barium induced adhesions. This potentially preventable iatrogenic complication is discussed in this report, which is supplemented by a brief review of the English literature.

Revascularization for foot salvage in diabetic critical foot ischaemia.

A consecutive series of 32 diabetic patients, 16 male and 16 female, who presented to the authors with critical limb ischaemia was reviewed over a two-year period. Atherosclerotic risk factors and co-morbidities were present in 56% of these patients. Diagnostic angiography was performed in all patients. Revascularization was achieved in 91% of the cases with three perioperative deaths. Ten bypasses were anastomosed distally to one of the crural or ankle arteries at the foot. Major amputations were required in five patients who had had revascularization and in 4 of these gross sepsis was the main factor responsible for limb loss despite patent grafts. The primary graft patency rates at one month and one year were 96% and 90% respectively. Surgical reconstruction was possible in the majority of diabetic patients with critical ischaemia and should be offered to patients preferably before the establishment of gross sepsis to improve limb salvage.