Objectives: Venous thromboembolic (VTE) events remain a leading cause of post-operative morbidity and mortality. It is intuitive that some procedures portend higher VTE risk than others: Prior investigations estimate post-operative VTE rates for hepato-pancreato-biliary surgery of 3.2% and colectomy of 1.9% (Beal 2018), whereas hysterectomy has VTE rate of 0.3% (Kahr 2018). There is, however, a paucity of literature comparing procedures or exploring which procedure types contribute most to the system-wide burden of VTE. Furthermore, many common procedures do not have standardized post-discharge prophylaxis regimens. We thus aimed to identify targets for quality improvement by analyzing which procedures contribute most to the system-wide burden of VTE.
Methods: We analyzed cases of VTE included in the 2020 NSQIP Public User File (PUF), including deep vein thrombosis (DVT) and pulmonary embolism (PE). We counted the prevalence of VTE by CPT code, noting surgical specialty for each procedure, to identify the procedures that contribute most to total VTE burden. We then compared crude VTE counts to total counts of each CPT code in the PUF to quantify a VTE rate for each procedure.
Results: A total of 902,968 patients were included in the PUF, of whom 7385 (0.82%) were diagnosed with pot-operative VTE– 4922 with DVT and 3156 with PE (693 patients were diagnosed with both). Mean time to diagnosis was 11 days (SD 7.8) for DVT and 10 days (SD 7.9) for PE.
The twenty procedures with the most VTE outcomes contributed 39% of the total VTE (see Figure). Most of these twenty were General (12) and Orthopedic (4) Surgery procedures. The rates of VTE of each of these procedures varied dramatically, ranging from high-volume procedures with low VTE rates such as laparoscopic cholecystectomy (0.25%) and laparoscopic hysterectomy (0.32%) to relatively low-volume procedures with high VTE rate such as Hartmann’s procedure (4.32%), Whipple procedure (3.85%), distal pancreatectomy (3.82%), and hemicraniectomy (3.01%). While Urology and Thoracic Surgery are relatively under-represented in the PUF sample and as such not as contributory to the top twenty in crude count, we notably identified high VTE rates in cystectomy (3.44%) and esophagectomy (2.78%).
Conclusion: Our findings agree with prior literature in the VTE rates reported and expand on previous conclusions by placing highly contributory procedures in the context of systemic burden of thromboembolic disease. Procedures with high VTE rate are important targets for quality improvement efforts. Surgeons should aim to standardize protocols for perioperative and post-discharge VTE prophylaxis.
