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PERIOPERATIVE ANTICOAGULATION IN PRIMARY LAPAROSCOPIC HIATAL HERNIA REPAIR
Ethan Bui
2, Nikhil Erabelli
*2, Connor Fritz
2, Raymar Turangan
2, Sylvestre Pineau
2, Clarissa Hoffman
2, Bashar Alramahi
2, Pavel Levin
3, Andre Miller
3, Farzaneh Banki
11Cardiothoracic 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; 3Memorial Hermann Southeast Hospital, Houston, TX
Aim: To assess the need for perioperative thromboembolic chemical prophylaxis in laparoscopic hiatal hernia repairs
. Methods: Before 02/02/2024, enoxaparin (LMWH), 40 mg subcutaneous, was given routinely to all patients (LMWH-Routine). From 02/02/2024, LMWH was given to a select group with BMI? 35, a history of hypercoagulability/DVT, or LOS ? 1 day (LMWH-Selective).
A simplified DVT Prophylaxis Scoring System (range: 0-15) was devised at our center which divided patients into 4 risk categories: [(0): lowest; no LMWH was given], [(1-3): low; LMWH given in preop and daily in the hospital], [(4-7): moderate; LMWH was given in preop, daily in the hospital, and 10 days post-op], and [(8-15): high; LMWH was given in the preop, daily in the hospital, and 30 days post-op]. The need for LMWH based on the Caprini score was compared to the need for LMWH based on DPSS. All patients received SCDs, and early ambulation was enforced. Values are presented as median (IQR).
Results: From 02/02/23 to 11/19/24 there were 203 laparoscopic hiatal hernia repairs, and 108 /203 (53.2%) primary elective laparoscopic repairs were included. For the entire group, the Caprini score was 5.0 (4.0-6.0), and the DPSS score was 0.0 (0.0-1.0), p<0.001. The Caprini risk categories were lowest in 0/108 (0.0%), low-moderate in 35/108 (32.4%), high in 71/108 (65.7%), and highest in 2/108 (1.9%). The DPSS risk categories were lowest in 79/108 (73.1%), low in 25/108 (23.1%), moderate in 4/108 (3.7%), and high in 0/108 (0.0%). Comparing the need for LMWH based on Caprini vs. DPSS showed: No need in 0/108 (0.0%) vs. 79/108 (73.1%), p<0.001, one dose in 35/108 (32.4%) vs. 25/108 (23.1%), p=0.174, 7-10 days in 71/108 (65.7%) vs. 4/108 (3.7%), p<0.001 and 30 days in 2/108 (1.9%) vs. 0/108 (0.0%), p=0.500. Comparing LMWH-Routine in 54/108 (50.0%) to LMWH-Selective in 54/108 (50.0%) showed age: 62.0 (54.0-70.8) vs. 69.0 (61.2-75.8), p=0.0454 and no difference in sex, BMI, duration of operation, LOS and number of same-day surgery between the two groups. In LMWH-Selective, LMWH was given in 16/54 (29.6%) for transition from SDS to hospitalization in 6/54 (11.1%), BMI ? 35 in 6/54 (11.1%), readmissions in 3/54 (5.6%), and history of DVT in 1/54 (1.9%). None required perioperative transfusion. None had a thromboembolic event at 30 days and at a median of 10.6 months (5.3-15.5) follow-up.
Conclusion: Thromboembolic events are rare complications of primary laparoscopic hiatal hernia repair. Perioperative prophylaxis should be administered selectively. Caprini score overestimates the need for thromboembolic chemical prophylaxis in laparoscopic hiatal hernia repair. A simplified and tailored scoring system will minimize unnecessary use.
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