We included a total 110 patients with UC in this study. The total number of operations was 143 cases, including 64 cases of TPC with IPAA, 40 cases of TC with ileostomy, 34 cases of proctectomy with IPAA, 4 cases of partial colectomy, and one case of TC with ileorectal anastomosis. Three patients with TC who had preoperative VTE were excluded from the analysis (Fig. 1). Of these 140 cases, postoperative VTE was detected in 24 cases (17.1%) at 7 (5.2–9.7) days after surgery.
Contrast-enhanced CT after surgery was conducted in 91 cases (65%). The most frequent reason for CT examination were suspicion of pelvic abscess or outlet obstruction at the stoma site with elevated fever, abdominal pain, and ileus. Eighteen cases (12.8%) with elevated serum D-dimer levels or transaminase were suspected of VTE prior to CT examination, and VTE was detected in 5 cases of those. All patients with VTE after surgery had no specific symptoms related to VTE, except for one patient who had pulmonary embolism with dyspnea on walking.
Regarding the site of thromboembolism, PMVT occurred most frequently (18 patients, 75%). Of those, 15 patients were detected after TPC + IPAA (Fig. 2). All 17 cases of liver portal vein thrombosis were detected in the right hepatic lobe, and 5 of these cases showed mesenteric venous thrombosis simultaneously. With respect to mesenteric venous thrombosis, five cases were in the inferior mesenteric vein, 2 cases in the superior mesenteric vein, and one case was in the splenic vein. PE occurred in four cases (2.8%, three cases after TPC + IPAA, and one case after TC). One subclavian vein thrombus and one jugular vein thrombus was detected after TC.
The rate of postoperative VTE prophylaxis with anticoagulant was 31.4% in all patients, 41.7% in the VTE (+) group and 29.3% in the VTE (-) group, respectively. The surgical procedure was TPC + IPAA 28 cases (43.7%), TC in 6 cases (16.2%), and proctectomy with IPAA in 10 cases (29.4%).
On univariate analysis, VTE occurred more frequently in patients with neoplasia (cancer or high-grade dysplasia) than refractory to medications (27.2% vs. 12.5%; p < 0.031). There was no difference in age, body mass index, American Society of Anesthesiology-physical status (ASA-PS) score ≥ 3, current smoking, preoperative therapy, and comorbidity between the VTE (+) group and VTE (-) group (Table 1). The perioperative results showed significant differences in the rates of VTE according to surgical procedure. Patients who underwent TPC with IPAA were more likely to develop VTE (28%) than TC (10.5%) or proctectomy (5.9%). Operative time in the VTE (+) group was significantly longer than in the VTE (-) group (340 vs. 291 minutes, p = 0.006). Laboratory data indicated that serum D-dimer levels on the day following surgery were higher in the VTE (+) group (5.6 µg/mL vs. 3.1 µg/mL, p = 0.00218). D-dimer at day 3 after surgery was also higher in the VTE (+) group, but this was not significantly different (Table 2).
Table 1
Patient characteristics according to venous thromboembolism
|
overall
|
VTE +
|
VTE -
|
p value
|
|
N = 140
|
N = 24
|
N = 116
|
|
Gender, n (%)
|
|
|
|
|
Male
|
97 (69.3)
|
15 (62.5)
|
82 (70.6)
|
0.428
|
Female
|
43 (31.7)
|
9 (37.5)
|
34 (29.3)
|
|
Age, median (range)
|
54 (41.2–63)
|
48 (38.2–57.5)
|
55.5 (42-64.7)
|
0.158
|
BMI, median (range)
|
21 (18.7–24.1)
|
21.8 (18.4–24)
|
20.5 (18.7–24.1)
|
0.81
|
ASA-PS ≧ 3, n (%)
|
8 (5.7)
|
1 (4.2)
|
7 (6.0)
|
0.719
|
Current smoking, n (%)
|
13 (9.3)
|
2 (8.3)
|
11 (9.48)
|
0.86
|
Preoperative therapy, n (%)
|
|
|
|
|
Steroid
|
59 (42.1)
|
13 (54.2)
|
46 (39.6)
|
0.19
|
Immunosuppressive agents
|
48 (34.2)
|
9 (37.5)
|
39 (33.6)
|
0.72
|
Biological agents
|
20 (14.2)
|
3 (12.5)
|
17 (14.7)
|
0.78
|
Comorbidity, n (%)
|
|
|
|
|
HT
|
20 (14.2)
|
5 (20.8)
|
15 (8.6)
|
0.31
|
HL
|
11 (7.9)
|
1 (4.2)
|
10 (8.6)
|
0.46
|
DM
|
15 (10.7)
|
0
|
15 (12.9)
|
0.073
|
Indication, n (%)
|
|
|
|
|
cancer/ dysplasia
|
44 (31.4)
|
12 (50)
|
32 (27.5)
|
|
refractory to medication
|
96 (68.5)
|
12 (50)
|
84 (87.5)
|
*0.0313
|
Abbreviations: VTE, venous thromboembolism; BMI, body mass index; ASA-PS, American Society of Anesthesiology-physical status; HT, hypertension; HL, hyperlipidemia; DM, diabetes mellitus.
|
Table 2
Peri-operative results according to venous thromboembolism
|
overall
|
VTE +
|
VTE -
|
p value
|
|
N = 140
|
N = 24
|
N = 116
|
|
Procedure
|
|
|
|
|
TPC་IPAA, n (%)
|
64 (45.7)
|
18(75)
|
46 (39.7)
|
|
TC, n (%)
|
38 (27.1)
|
4 (16.7)
|
34 (29.3)
|
|
Proctectomy + IPAA, n (%)
|
34 (24.2)
|
2 (8.3)
|
32 (27.6)
|
|
Other, n (%)
|
4 (2.8)
|
0
|
4 (3.4)
|
*0.0144
|
IPAA
|
96 (68.6)
|
20 (83.3)
|
76 (65.5)
|
0.087
|
Operative time, min.(range)
|
291 (203–383)
|
340 (255–476)
|
277 (181–355)
|
*0.006
|
Blood loss, ml (range)
|
300 (155–522)
|
326 (230–528)
|
275 (12–520)
|
0.1775
|
Complications
|
|
|
|
|
Ileus, n (%)
|
28 (20)
|
6 (25)
|
22 (19)
|
0.57
|
Anastomosis leakage, n (%)
|
9 (6.4)
|
1 (4.2)
|
8 (6.9)
|
0.629
|
Pelvic abscess, n (%)
|
24 (17)
|
3 (12.5)
|
21 (18)
|
0.497
|
Emergency operation
|
36 (27.6)
|
5 (20.8)
|
31 (26.7)
|
0.5478
|
Prophylaxis with anticoagulant, n (%)
|
44 (31.4)
|
10 (41.7)
|
34 (29.3%)
|
0.2956
|
D-dimer, µg/ml (range)
|
|
|
|
|
POD1 D-dimer,
|
3.1 (2.2–5.8)
|
5.6 (2.7–8.9)
|
3 (2.2–4.7)
|
*0.0218
|
POD3 D-dimer
|
4.4 (3.1–8.25)
|
7 (3.5–10.6)
|
4.1 (3.1–7.7)
|
0.083
|
Peak D-dimer
|
8.85 (5.9–13)
|
10.1 (7.4–15.3)
|
8.7 (5.7–12)
|
0.072
|
Abbreviations: VTE, venous thromboembolism; TPC, total proctocolectomy; IPAA, ileal pouch–anal anastomosis; TC, total colectomy; POD, post-operative day.
|
In logistic regression analysis, we identified that TPC with IPAA, TC, longer operative time (> 4 hours), and serum D-dimer level > 5.3 mg/dL on the day following surgery were predictive risk factors for postoperative VTE in patients with UC (Table 3).
Table 3
Predictive risk factors in logistic regression analysis
|
|
OR
|
95% CI
|
p value
|
Procedure
|
Proctectomy + IPAA
|
reference
|
-
|
-
|
|
TC
|
45.88
|
1.44–2863
|
*0.0304
|
|
TPC + IPAA
|
17.12
|
1.675–433.7
|
*0.015
|
Indication
|
cancer/dysplasia
|
0.45
|
0.06–2.89
|
0.405
|
Operative time
|
(> 4 h)
|
28.84
|
1.23–1260
|
*0.0358
|
D-dimer at Day1
|
(> 5.3 µg/dl )
|
3.69
|
1.02–14.78
|
*0.0452
|
Abbreviations: OR, odds ratio; CI, confidence interval; TPC, total proctocolectomy; IPAA, ileal pouch–anal anastomosis; TC, total colectomy.
|