title: Identifying Esophagectomy Patients at Risk for Predischarge Versus Postdischarge Venous Thromboembolism.
abstract: BACKGROUND
  Current guidelines recommend postoperative venous thromboembolism (VTE) chemoprophylaxis for moderate-risk patients (3% rate or greater) and extended-duration chemoprophylaxis for high-risk patients (6% or greater). Large-scale studies of and recommendations for esophagectomy patients are lacking. This study was designed to evaluate the timing, rates, and predictors of postesophagectomy VTE.
  
  
  METHODS
  Patients undergoing esophagectomies for cancer were identified from the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement database. Timing and rates of VTE (deep venous thrombosis or pulmonary embolism, or both) were calculated. Events were stratified as predischarge or postdischarge. Perioperative factors associated with 30-day rates of predischarge and postdischarge VTE were analyzed.
  
  
  RESULTS
  Of 3,208 patients analyzed, the surgical approach was Ivor-Lewis (n = 1,131, 35.3%), transhiatal (n = 945, 29.5%), three-field (n = 587, 18.3%), thoracoabdominal (n = 364, 11.3%), and nongastric conduit reconstruction (n = 181, 5.6%). Rates were 2.0% pulmonary embolism, 3.7% deep venous thrombosis, and 5.1% VTE. Overall median length of stay was 11 days (versus 19 days, p < 0.001, if predischarge VTE). Predischarge VTE occurred on median day 9, whereas postdischarge VTE occurred on day 19 (p < 0.001). Only 17% of VTE occurred after discharge. Multivariate analysis identified being male (odds ratio [OR] 2.09, p = 0.018), white race (OR 1.93, p = 0.004), prolonged ventilation (OR 3.24, p < 0.001), and other major complications (OR 1.90, p = 0.005) as independent predictors of predischarge VTE. Older age (OR 1.06 per year, p = 0.006) and major complications (OR 3.14, p = 0.004) were independently associated with postdischarge VTE.
  
  
  CONCLUSIONS
  Postesophagectomy VTE occurs in a clinically significant proportion of esophageal cancer patients with identifiable risk factors for predischarge and postdischarge events. Elderly patients and patients with major complications are most likely to benefit from extended-duration chemoprophylaxis.
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky. Electronic address: j.martin@uky.edu.
authors.forename: Jeremiah T
authors.initials: JT
authors.lastname: Martin
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Angela L
authors.initials: AL
authors.lastname: Mahan
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Victor A
authors.initials: VA
authors.lastname: Ferraris
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Sibu P
authors.initials: SP
authors.lastname: Saha
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Timothy W
authors.initials: TW
authors.lastname: Mullett
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Zwischenberger
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky.
authors.forename: Ching-Wei D
authors.initials: CW
authors.lastname: Tzeng
mesh_terms: D000368:Aged; D016629:Esophagectomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D054556:Venous Thromboembolism / Q000453:epidemiology*