Thromboemboli in laparascopy By: Dr behnamreza makhsousi

1Thromboembolic complications of laparoscopic cholecystectomy

Thromboemboli in laparascopy The incidence of deep venous thrombosis and pulmonary embolism in diagnostic laparoscopy is low. It was reported as 0-2 cases/1000 procedures in a confidential inquiry into 50427 gynaecological laparoscopies. In a single report of 100 laparoscopic salpingectomies deep venous thrombosis occurred in one patient. Concern has been raised, however, about the increased potential for thromboembolism in patients undergoing laparoscopic cholecystectomy. The true incidence of thromboembolism in this procedure is not known.

Thromboemboli in laparascopy In the laboratory we have shown hypertension in the common femoral vein in a pig undergoing laparoscopic Nissen fundoplication. When pneumoperitoneum was established, the femoral venous pressure rose from 4 mmHg to 9 mmHg. With duplex Doppler scanning of the common femoral vein in humans we have shown a considerable reduction in peak blood flow velocity and shortening of the flow cycle during the respiratory phase on two occasions, with a return to normal venous blood flow characteristics on removal of the intraperitoneal gas.

Thromboemboli in laparascopy These cases highlight the potential for thromboembolism with laparoscopic cholecystectomy. Our early experimental work suggests that the aetiology may be increased venous stasis caused by the raised intra-abdominal pressure associated with pneumoperitoneum. Also, these procedures, in contrast to gynaecological laparoscopy, are performed in the reverse Trendelenberg position, which would compound any venous stasis already present.

Thromboemboli in laparascopy Further work must be performed to document the incidence and aetiology of deep venous thrombosis and effective prophylaxis during prolonged therapeutic laparoscopy. Until these issues have been resolved all patients undergoing laparoscopic cholecystectomy should be regarded as at risk of deep venous thrombosis and pulmonary embolism. They should have some intraoperative measure to reduce venous stasis of the lower limbs as well as routine preoperative and postoperative prophylaxis against deep venous thrombosis.

2An Approach to Venous Thromboembolism Prophylaxis in Laparoscopic Roux-en-Y Gastric Bypass Surgery

Thromboemboli in laparascopy Venous thromboembolism (VTE) prophylaxis regimens for laparoscopic Roux-en-Y gastric bypass (LRYGBP) have not been adequately addressed in the literature. This study presents the results of our prophylactic regimen in LRYGBP at a tertiary care hospital.

Thromboemboli in laparascopy A retrospective review of 255 morbidly obese patients undergoing LRYGBP between March 2000 and February 2003 was conducted. Patients received preoperative subcutaneous heparin (SQH) (5000u or 7500u) and every 8 hours thereafter during hospitalization . Sequential compression devices (SCD) were utilized during and after surgery unless ambulating. Early ambulation was enforced.

Thromboemboli in laparascopy Results: 255 patients underwent LRYGBP, with 5 (1.9%) conv e rted to open. Average preoperative weight and body mass index (BMI) were 138 kg and 50, respectively. Operative time averaged 174 minutes. Average length of stay was 2.2 days. 9 patients (3.6%) had a prior history of deep venous thrombosis/pulmonary embolism (DVT/PE), one of whom had a DVT/PE postoperatively. 2 patients developed DVT/PE within 30 days. Overall DVT/PE incidence was 1.2%. There were 6 postoperative bleeding episodes (2.4%)

3A randomized study on 1- week versus 4-week prophylaxis for venous thromboembolism after laparoscopic surgery for colorectal cancer

Thromboemboli in laparascopy To compare the efficacy and safety of antithrombotic prophylaxis given for 1 week or 4 weeks in patients undergoing laparoscopic surgery for colorectal cancer. Extending antithrombotic prophylaxis beyond 1 week reduces the incidence of venous thromboembolism (VTE) after open abdominal surgery for cancer.

Thromboemboli in laparascopy In consecutive patients who underwent laparoscopic surgery for colorectal cancer, complete compression ultrasonography of the lower limbs was performed after 8 ± 2 days of antithrombotic prophylaxis. Patients with no evidence of VTE were randomized to short (heparin withdrawal) or to extended (heparin continued for 3 additional weeks) prophylaxis. Complete compression ultrasonography was repeated at day 28 ± 2 after surgery by investigators blinded to treatment allocation. The primary outcome of the study was the composite of symptomatic and ultrasonography-detected VTE at day 28 ± 2 after surgery.

Thromboemboli in laparascopy RESULTS: Overall, 301 patients were evaluated for inclusion in the study and 225 were randomized. VTE occurred in 11 of 113 patients randomized to short (9.7%) and in none of the 112 patients randomized to extended heparin prophylaxis (P = 0.001). The incidence of VTE at 3 months was 9.7% and 0.9% in patients randomized to short or to extended heparin prophylaxis, respectively (relative risk reduction: 91%, 95% confidence interval: 30%-99%; P = 0.005). The rate of bleeding was similar in the 2 treatment groups. Two patients died during the study period, 1 in each treatment group.

4 Risk of postoperative venous thromboembolism after laparoscopic and open colorectal surgery: an additional benefit of the minimally invasive approach?

Thromboemboli in laparascopy Venous thromboembolism constitutes a major cause of morbidity associated with surgical procedures. Colorectal surgical patients are at an elevated risk for postoperative venous thromboembolism. Whether the laparoscopic approach influences this risk is not well defined.

Thromboemboli in laparascopy This study aimed to assess the risk of venous thromboembolism following major colorectal procedures. The influences of laparoscopic and open approaches on venous thromboembolism were compared while controlling for other potential confounders.

Thromboemboli in laparascopy Patients who underwent major colorectal procedures were identified. Association between patient, disease, operation-related factors, and venous thromboembolism within 30 days of surgery was determined by the use of a logistic regression analysis.

Thromboemboli in laparascopy SETTINGS: Patients were identified from the National Surgical Quality Improvement Program database PATIENTS: According to the National Surgical Quality Improvement Program database, 31,109 patients underwent colorectal surgery (open, 71%; laparoscopic, 29%) for cancer (48.3%), IBD (10.1%), diverticular disease (24.2%), and other benign conditions (17.4%). MAIN OUTCOME MEASURES: The primary outcomes measured were deep venous thrombosis and pulmonary embolism

Thromboemboli in laparascopy RESULTS: The venous thromboembolism rate was 2.4% (laparoscopic 1.2% vs open 2.9%, P < .001). Patients who developed venous thromboembolism were older (age 65.4 vs 61.5, P < .001), more often male (52.5% vs 47.5%, P = .023), with worse functional status (P < .001), and more comorbidities (P < .001). - Venous thromboembolism was associated with sepsis (7.9% vs 1.8%, P < .001), steroid use (5.4% vs 2.2%, P < .001), surgical site infection (4.8% vs 2%, P < .001), and reoperation (7% vs 2.1%, P < .001). On multivariate analysis, open surgery, older age, steroid use, sepsis, surgical site infection, reoperation, prolonged ventilation, and low albumin were independently associated with a higher venous thromboembolism rate.

Thromboemboli in laparascopy With the increased intra abdominal pressure Compressing the inferior vena cava, there is diminished venous return from the lower extremities. This has been well documented in the patient placed in the revers terendelenburg position for upper abdominal operations. Venous engogement and decreased venous return promote venous thrombosis. Many series of advanced laparascopic procedures in which DVT prophylaxis was not use demonstrate the frequency of pulmonary embolus.

Thromboemboli in laparascopy This usually is an avoidable complication with the use of sequential compression stockings,subcotaneous heparin,or low molecular weight heparin. In short duration laparascopic procedures, such as appendectomy, hernia repair,or cholecystectomy,the risk of DVT may not be sufficient to warrant extensive DVT prophylaxis.