[Perioperative thrombosis prophylaxis--where are we going?].
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Anticoagulants↗
Biomedical subjects
Peer Wille-Jørgensen
Publications and source records attributed to Peer Wille-Jørgensen.
Evidence-based guidelines?
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Antineoplastic Combined Chemotherapy Protocols↗
No clear evidence for adjuvant therapy in people with stage II colon cancer.
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Antineoplastic Agents↗
Risk factors for tissue and wound complications in gastrointestinal surgery.
BACKGROUND: Surgical site infections and disruption of sutured tissue are frequent complications following surgery. We aimed to assess risk factors predictive of tissue and wound complications in open gastrointestinal surgery. METHODS: Data from 4855 unselected patients undergoing open gastrointestinal surgery from 1995 through 1998 were recorded in a clinical database and validated. The database embraced variables related to patient history, preoperative clinical condition, operative findings and severity, and the surgeon's training. Variables predictive of surgical site infection and dehiscence of sutured tissue within 30 days after surgery were assessed by multiple logistic regression analysis. RESULTS: Following elective operation, the incidence of tissue and wound complications was 6% compared with 16% in emergency surgery (P < 0.001). These complications resulted in prolonged hospitalization in 50% of the patients and a 3-fold higher risk of reoperation but not increased mortality. Factors associated with complications following elective operations were smoking, comorbidity, and perioperative blood loss. Following emergency operations, male gender, peritonitis, and multiple operations were predictors of complications. Irrespective of elective or emergency surgery, the type of operation was a predictor of complications. CONCLUSION: Factors known to affect the process of tissue and wound healing are independently associated with tissue and wound complications following gastrointestinal surgery.
Adult↗
Systematic review of thromboprophylaxis in colorectal surgery -- an update.
OBJECTIVE: The incidence of thromboembolism after colorectal surgery is higher than after general surgery. The aim of this paper is to update a systematic review addressing thrombosis prophylaxis in connection with colorectal surgery. METHODS: MEDLINE, EMBASE, LILACS, abstract books and reference lists from reviews were searched without language restrictions for randomized controlled trials or clinical controlled trials comparing prophylactic interventions and/or placebo up til August 2003. Five hundred and fifty-eight studies were identified of which 19 fulfilled the inclusion criteria. Data extraction was done by at least two of the authors. Outcome was deep venous thrombosis and/or pulmonary embolism diagnosed by various methods. RESULTS: Any kind of heparin is better than no treatment or placebo (11 studies) with a Peto Odds ratio (POR) at 0.32 (95% CI 0.20-0.53). Unfractionated heparin and low molecular weight heparin (4 studies) were equally effective POR 1.01 (95% CI 0.67-1.52). The combination of graduated compression stockings and LMWH is better than LMWH alone (2 studies) with a POR at 4.17 (95% CI 1.37-12.70). CONCLUSION: The optimal thromboprophylaxis in colorectal surgery is the combination of graduated compression stockings and low-dose unfractionated heparin or low molecular weight heparin.
Anticoagulants↗
Asymptomatic postoperative deep vein thrombosis and the development of postthrombotic syndrome. A systematic review and meta-analysis.
Perioperative antithrombotic clinical regimens have reduced the incidence of postoperative deep venous thrombosis (DVT). Long-term effects of asymptomatic postoperative DVT have been studied in a number of clinical trials and the present review describes the clinical significance of asymptomatic postoperative DVT regarding the possible development of postthrombotic syndrome (PTS). We performed a systematic review of reference databases focusing upon studies including patients suspected of having postoperative DVT and reporting subsequent cases of PTS at the end of a well-defined follow-up period. The included studies were stratified according to type of screening method and applied statistics. Over-all evaluation included meta-analyses based upon the Cochrane software package. The overall relative risk of developing PTS was 1.58 (95% confidence intervals: 1.24-2.02) in patients suffering from asymptomatic DVT as compared to patients without DVT (p<0.0005). In conclusion, asymptomatic postoperative DVT is associated with an increased risk of late development of PTS. The finding emphasizes that postoperative DVT, diagnosed by means of well-defined objective measures, remains the correct scientific endpoint in trials evaluating the efficacy of preoperative antithrombotic treatment regimens.
Data Collection↗
Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center.
PURPOSE: In the past, colonic obstruction caused by malignancy most often resulted in high-risk operations, usually involving two-step procedures or leaving the patient with a stoma in case of disseminated disease. METHODS: Between May 1997 and January 2003, 104 procedures with self-expanding metal stents have been performed in 96 patients at our institution. The goals of the procedure were either postponement of emergency operation or definitive palliative treatment. Surgeons with combined endoscopic and fluoroscopic technique performed all procedures. In most cases no analgesia or only slight sedation was used. Seven types of stents were used, CHOO stents and Wallstents accounting for the majority. RESULTS: A total of 96 patients were included, 44 men and 52 women, with a mean age of 78 (range, 41-100) years. Technical success was achieved in 92 percent; clinical success, in 82 percent. Thirty-eight patients presented with an acute obstruction and were treated with self-expanding metal stents. Seventeen patients later underwent an elective resection, 9 patients were not decompressed, and 12 patients had disseminated disease and were not treated further. Eight patients had benign strictures. These eight patients accounted for several of the reinterventions, and only three patients truly gained benefit from stenting. In the remaining patients disseminated disease was diagnosed and the acute stenting served as the definitive palliative treatment. Procedure-related complications were few: perforation occurred in three patients during stenting and in one instance 6 to 7 hours after. Other technical problems could mainly be overcome by introducing an additional stent. Complications seen in the group treated with self-expanding metal stents and subsequent resection [mortality N = 3 (18 percent)], anastomotic leakage [N = 3 (18 percent)], do not differ from the number of complications we usually see in our patients who undergo elective colorectal resection. CONCLUSIONS: The use of self-expanding metal stents in malignant colonic obstruction is a safe and effective procedure with a low mortality and morbidity. In our experience the stenting of benign strictures is ineffective and combined with a high rate of complications.
Adult↗
Thromboembolic prophylaxis as a risk factor for postoperative complications after breast cancer surgery.
Hematoma and bruising (sugillation) are frequent problems after operations for primary breast cancer. In the present study we evaluated the influence of various methods of perioperative thromboembolic prophylaxis on the postoperative incidence of hematoma and suggilation. From June 1994 through August 1996, a series of 425 patients consecutively operated on for primary breast cancer were included. Thromboembolic prophylaxis was low-molecular-weight heparin (LMWH) in 310 patients and thigh-long graded compression (TED) stockings in 102 patients. Postoperative complications including deep vein thrombosis, pulmonary embolism, wound hematoma, and sugillation were recorded, and 17 variables with a potential influence on complications were analyzed by logistic regression analysis. Heparin prophylaxis compared to prophylaxis with TED stockings was significantly and independently associated with postoperative hematoma [odds ratio (OR) 3, 13; 95% confidence interval (CI) 1.38-7.13] or sugillation (OR 3.34; 95% CI 1.93-5.78). No clinically overt thromboembolic complications were diagnosed. After operations for breast cancer we found that LMWH was significantly associated with postoperative hematoma and sugillation compared to TED stockings for perioperative thromboembolic prophylaxis.
Anticoagulants↗
Delayed ischemic cecal perforation despite optimal decompression after placement of a self-expanding metal stent: report of a case.
Endoscopic deployment of self-expanding metal stents offers an alternative to surgical intervention in rectocolonic obstructions. Reported clinical failures in the literature are all related to the site of stent placement. We report a case of serious intra-abdominal disease after technically and clinically successful stent deployment: a potentially dangerous situation of which the surgeon should be aware. A previously healthy 72-year-old female was referred to our department with symptoms of an obstructing colorectal tumor. Successful stent placement resulted in resolution of the obstructive condition. Three days after stent deployment, x-ray examinations revealed a small-bowel obstruction and emergency surgery was performed. Intraoperative findings demonstrated a segment of ileum fixated to the tumor in the small pelvis, resulting in the obstructive condition. Furthermore, a cecal perforation, probably caused by ischemic conditions developed before stent-decompression of the colon was revealed during the operation. The patient died in the postoperative course. We discuss the observation of patients treated with self-expanding metal stents based on the selection-strategy used to allocate patients to this specific treatment. We conclude that although a patient is eligible for treatment with self-expanding metal stents, large-bowel obstruction can be too "old" for stent-decompression, causing ischemic perforation of the colon. Furthermore, we underline the need to focus on the possibility of obstructions other than those being treated.
Aged↗
Clinical value of preoperative mechanical bowel cleansing in elective colorectal surgery: a systematic review.
PURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1). Overall anastomotic leakage-six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2). Peritonitis-three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3). Wound infection-six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.
Colorectal Surgery↗
Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study.
INTRODUCTION: The aim of this study was to investigate the incidence of deep vein thrombosis (DVT) in patients immobilized in plaster cast and the possible efficacy of prophylaxis with low molecular weight heparin (LMWH). MATERIAL AND METHODS: The study was a randomized, assessor-blinded, open multicenter (three centers) study. All patients over 18 years of age with planned plaster cast on a lower extremity of at least 3 weeks were eligible for participation. Written informed consent was obtained from 300 patients and they were randomized to either 3.500 IU anti-Xa of tinzaparin (Innohep) subcutaneously once daily or no prophylaxis. On the day the cast was removed, ascending unilateral venography was performed. Two experienced radiologists, unaware of treatment, assessed the pictures independently. The radiologist had to obtain consensus as to whether DVT was present or not. RESULTS: 300 patients were included (148 in the treatment group and 152 in the control group). Ninety-five were subsequently withdrawn. DVT was diagnosed in 10/99 patients in the treatment group and in 18/106 patients in the control group. This difference is not significant (P=.15, chi(2) test) and the odds ratio was 0.55 (95% confidence interval=0.34-1.26). CONCLUSION: DVT in legs after plaster casting is a big problem, with an incidence of almost 20%. An effective prophylactic regime is required. Once-daily dose of 3.500 IU anti-Xa of tinzaparin was not sufficient.
Adolescent↗