Emanuele Chisari, Graham S. Goh, Javad Parvizi.
Response/Recommendation: Surgical duration is directly associated with an increased risk of venous thrombosis (VTE). When intraoperative complications or surgical complexity affect the length of surgery, VTE risk should be reevaluated.
Strength of Recommendation: Moderate.
Rationale: Understanding the relationship between VTE risk and surgical duration is important for surgical planning and management. Risk stratification could help refine chemoprophylaxis strategies for surgeons, perioperative care physicians, and anesthesiologists, and better inform patients of the potential hazards associated with prolonged surgery.
Multiple studies in general1–3, plastic4,5, vascular6, gynecological7, and neurosurgical8 literature have found an increased risk of VTE with longer operative time. This association has been shown even in patients undergoing outpatient procedures9. In the context of orthopaedic surgery, conflicting evidence has been reported. While the majority of studies have identified increased operative time as a risk factor for VTE10–17, some studies did not18–23. It is also possible that this risk may not apply to all orthopaedic procedures24,25. In a systematic review of Level-I and Level-II studies, Zhang et al., concluded that surgery time >2 hours increased the risk of VTE14. A separate systematic review of randomized control trials also found that the incidence of deep venous thrombosis (DVT) in patients undergoing elective total knee arthroplasty (TKA) declined with the average duration of surgery (124.3 minutes in 1996 to 97.3 minutes in 2003)26. Using routine venography to assess for DVT on the third to ninth postoperative day, Zhang et al., found that 173 of 963 patients with a venography-confirmed DVT had a greater operative duration compared to those who did not13. This association has also been reported in the Asian population15,27. Won et al., found that the relative risk was 1.6 times higher in the group with ≥105-minute surgery time compared to those with <105-minute surgery time16. Using a national database in Japan, Nagase et al., found that patients who underwent a longer period of anesthesia (≥180 minutes) had more than twice the risk (odds ratio [OR] 2.13) of postoperative pulmonary embolism (PE) compared to patients with a shorter period of anesthesia (<180 minutes)28. Consistent with these findings, Jaffar et al., analyzed institutional data of 4,075 postmenopausal women undergoing primary major joint replacement and found that a threshold of 3.5 hours (210 minutes) increased the odds of VTE substantially (OR 3.83)17. This relationship was shown after controlling for multiple confounders and persisted even when patients with distal DVT were excluded.
In spite of the abundant literature on the topic, few studies were sufficiently powered or utilized multi-institutional data. To overcome these shortcomings, Kim et al., performed a comprehensive analysis across surgical specialties and institutions using a generalizable database29. Using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2011, the authors studied 1’432,855 patients who underwent surgery under general anaesthesia across 9 surgical disciplines, performing the analysis at the specialty and procedural level while adjusting for differing surgical and patient complexity. Compared with a procedure of average duration, patients who underwent the longest procedures experienced a 1.27-fold increase in the odds of developing a VTE, whereas the shortest procedures demonstrated an OR of 0.86. Importantly, the incidence of VTE increased with increasing quintiles of surgical duration in all 9 surgical specialties in the subgroup analyses.
Despite the broad consensus on the association between VTE risk and operative time, an exact cutoff time that significantly increased the risk of this complication could not be identified. While some studies examined a threshold of 120 minutes or more9,27, different cutoffs such as 80 mins11, 105 mins16, 180 mins28, and even up to 3.5 hours17 have been identified. Due to the heterogeneity in procedure type, anaesthesia techniques, follow-up duration, and method for calculating operative time, a precise cutoff would be extremely difficult to ascertain.
The explanation for the relationship between surgical duration and VTE risk is likely multifactorial. In accordance with the pathophysiologic basis of VTE (also known as “Virchow’s triad”30(p198)), immobility resulting from long surgical procedures can result in blood stasis, hypercoagulability, and endothelial damage caused by vessel wall distension17,31–34, thus increasing the risk of VTE development. Venous stasis and ischemia can promote DVT formation via the upregulation of P-selectin and local prothrombotic microparticles34,35. The hypercoagulable state as well as the inflammation and endothelial damage that occurs during surgery can similarly initiate the clotting cascade and increase the risk of thrombus formation.
With such a large volume of surgeries performed annually, the adjusted risk difference of -0.12% to 0.23% as suggested by Kim et al., could translate into a substantial burden of VTE attributable to surgical duration29. Consequently, the relationship between operative time and the incidence of VTE should be strongly considered in the postoperative assessment of VTE risk. Widely used risk stratification tools such as the Rogers score do not take surgical duration into account36, whereas the Caprini score distinguishes only between operations shorter or longer than 45 minutes for the sake of defining “major surgery”37. In view of these limitations, future development of risk assessment scoring systems should also factor in the length of surgery to guide prophylactic measures. Overall, a greater understanding of the relationship between VTE and surgical duration will help direct surgical planning, target chemoprophylaxis strategies, and better inform patients and clinicians when deciding to proceed with combined or longer operations.
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