A SIMPLIFIED DVT PROPHYLAXIS SCORING SYSTEM TAILORED TO LAPAROSCOPIC HIATAL HERNIA REPAIR AIMED TO FACILITATE GUIDELINES APPLICATION AND PREVENT OVERTREATMNT
Raymar Turangan*2, Sylvestre Pineau2, Clarissa Hoffman2, Nada Mustafa2, Bashar Alramahi2, Pavel Levin3, Shinil K. Shah2, Farzaneh Banki1
1Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Southeast Esophageal Disease Center, Houston, TX; 2The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 3Texas Oncology, Houston, TX
Background DVT prophylaxis scoring systems are complex. Guidelines are multiple, not tailored to type of surgery and may result in overtreatment. Our aim was to assess usage/accuracy of calculated Caprini Score (CS), assess the recommended prophylaxis by MDcal and Chest Guidelines (CG) and devise a simplified DVT prophylaxis scoring system (DPSS) with dosage/duration tailored to laparoscopic hiatal hernia repair. Methods Compression device (CD) and 5000 units of Heparin S/Q were ordered in all. DVT/PE % were assessed in all. Usage/accuracy of EMR automated CS and manually calculated CS and prophylaxis recommendations by MDcal (6 risk categories) and CG (5 categories) were assessed in 100 patients. DPSS (range: 0-15) based on age/BMI/history of DVT/PE/smoking/hypercoagulable state/comorbidities/conversion/take back/LOS with prophylactic dose/duration was devised in 3 risk categories (0-3): low, Lovenox 40 mg preop and daily in hospital; (4-7): moderate, Lovenox 40 mg preop, daily in hospital, and 2 weeks post-op; (8-15): high, Lovenox 40 mg in the preop, daily in hospital, and 4 weeks post-op. Values are Median (IQR). Results Total 331 laparoscopic hiatal hernia repairs, 280/331 (84.6%) primary, 234/331 (70.7%) female, 64 (54-71.5) years, BMI 30.0 (26.3-33.7), duration of operation: 113.0 (95.0-137.0) min, LOS 1 (0-2) days. CS was documented in 11/100 (11.0%): 5.0 (3.0-7.5). Manually calculated CS in 11 patients: 7.0 (6.0-7.0). CS was accurate in 1/11 (9.1%) with discrepancy of 2.0 (1.5-3.5) that changed the recommended dose in 5/11 (45.5%) by MDcal and in 4/11 (36.4%) by CG. The CS in 100 patients: 6.0 (5.0-7.0). By MDcal 86/100 (86.0%) were high risk and would get CD and 40 mg Lovenox/day for 7-10 days total, by CG: 90/100 (90.0%) were high risk, would get CD and post-operative prophylaxis, none would get prolonged prophylaxis. DPSS score in 100: 1.5 (1.0-2.0); 95/100 (95.0%): low risk with recommended dose of 40 mg Lovenox preop and daily in hospital. DVT and PE: 1/331 (0.3%): Female/Hx of DVT and PE/BMI of 40 after outpatient type III repair of 103 min, on POD#12. She had no documented CS, got CD and 1 dose of Heparin 5000 units S/Q preop. Her calculated CS was 7, by MDcal would get CD and Lovenox 40 mg S/Q per day for 7-10 days, by CG would get CD and postoperative prophylaxis daily in hospital. Her DPSS score was 5 and would get CD and Lovenox 40 mg S/Q per day for 2 weeks postop. HIT with ischemic complication/death: 1/331 (0.3%). Conclusion CD and 1 dose of DVT prophylaxis seems to be adequate to prevent DVT/PE in the majority of patients who undergo laparoscopic hiatal hernia repair. Prolonged prophylaxis is required in very few high-risk patients. Known DVT prophylaxis guidelines should be simplified and tailored to each type of surgery. Larger population is required to validate DPSS in laparoscopic hiatal hernia repair.
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