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Venous Thromboembolism in Patients Undergoing Laparoscopic and Arthroscopic Surgery and in Leg Casts
David Bergqvist, MD, PhD;
Gordon Lowe, MD, PhD
Arch Intern Med. 2002;162:2173-2176.
ABSTRACT
The risk of venous thrombosis and need for prophylaxis in patients having
undergone minimally invasive procedures and in patients immobilized in a leg
plaster are poorly defined. We performed a literature search to evaluate the
risk of developing venous thromboembolism after 2 minimally invasive procedures,
laparoscopic surgery and arthroscopy, and in patients with lower limb plaster
casts. Despite problems of "contamination" because some surgeons use prophylaxis
in some of these patients, we were able to determine that (1) laparoscopic
cholecystectomy can be considered a low-risk procedure and therefore routine
use of prophylaxis is probably not justified; (2) patients undergoing arthroscopic
knee surgery are at low to moderate risk and thus prophylaxis is optional;
and (3) patients with plaster cast immobilization because of trauma have a
moderate risk of thrombosis and should receive prophylaxis.
INTRODUCTION
Most surgeons agree in principle that thromboprophylaxis should be used
in moderate- and high-risk patients who undergo surgery or who are exposed
to trauma. Opinions differ, however, on the definition of moderate and high
risk. When developing guidelines for prophylaxis, expert panels usually omit
2 important groups: patients undergoing several new types of minimally invasive
surgical procedures (specifically laprascopic and arthroscopic surgery) and
patients with lower limb plaster casts. Establishing the true incidence of
deep vein thrombosis (DVT) in these groups is problematic for the following
reasons: First, choice of diagnostic technique. For safety reasons, fibrinogen
uptake test cannot be used any longer and its clinical relevance has been
questioned. Duplex ultrasonography lacks sensitivity and has only moderate
specificity as a surveillance method for asymptomatic DVT. Bilateral phlebography
is becoming increasingly difficult to justify in potentially low-risk situations.
The use of clinical end points would require very large population samples.
Second, the true thromboembolic rates in unprotected patients are difficult
to obtain because of "contamination" as a result of use of prophylaxis in
patients who are considered to be at high risk, thereby producing falsely
low estimates of thromboembolic rates.
With these caveats in mind, we sought to summarize contemporary information
about the incidence of venous thromboembolism in patients undergoing laparoscopic
and arthroscopic surgery as well as in patients with lower limb plaster casts.
LAPAROSCOPIC SURGERY
Potential risk factors for thromboembolism during laparoscopic surgery
include the long duration of the procedure and reduced venous emptying when
the abdomen is inflated and the vena cava compressed and from activation of
coagulation related to surgery.1-2 These
risk factors are counterbalanced by the fact that these patients are exposed
to minimal trauma, are mobilized rapidly, and discharged from the hospital
early. Prospective studies on postoperative DVT after laparoscopic cholecystectomy
are summarized in Table 1. As
already stated, these data are limited by the diagnostic method used and the
potential for the random use of prophylaxis. In addition, the accuracy of
the results are questionable because the studies are small, the confidence
intervals around the observed rates are wide, and the variation in rates of
thrombosis are large. A high frequency of thrombosis was reported by Patel
et al.9 In contrast, Lord et al7 reported
no DVT with duplex ultrasound after 27 laparoscopic cholecystectomies; it
is noteworthy that all of the patients received prophylaxis. The same group
of authors found a 1% incidence of DVT after laparoscopic cholecystectomy,
which was the same low frequency as after minilaparotomy cholecystectomy.8 Lindberg et al10 reviewed
the published series on laparoscopic cholecystectomy in which thromboembolic
complications were mentioned. These data, based on 153 832 patients in
60 published series, reveal the following frequency of complications: DVT,
0.02%; pulmonary embolism, 0.06%; fatal pulmonary embolism, 0.02%; and mortality,
0.1%. Accepting the problem of "prophylactic pollution," it appears that the
risk of symptomatic thromboembolic events is very low and the frequency of
fatal pulmonary embolism is extremely low, although pulmonary embolism does
occur.11
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Table 1. Prospective Studies on the Frequency of Deep Vein Thrombosis
(DVT) After Laparoscopic Cholecystectomy
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Data on thromboembolic complications after other types of laparoscopic
procedures are sparse and limited to case reports.12-13 In
one report, no postoperative thrombi were diagnosed with duplex scanning during
unspecified laparoscopic procedures in 61 patients, all of whom did not receive
prophylaxis.14 In another report of 32 patients
undergoing laparoscopic colorectal resections who received low-molecular-weight
heparin combined with intermittent pneumatic compression, no thrombi were
found by duplex ultrasonography, with a 95% confidence interval of 0% to 9%.15
ARTHROSCOPIC SURGERY
As with laparoscopic surgery, only a few studies have focused on the
incidence of venous thromboembolism in this group of patients. Stringer et
al16 performed an incidence study analyzing
various types of knee surgery without prophylaxis. Phlebography of the operated-on
leg was used for diagnosis. The results are summarized in Table 2, with other types of knee surgery shown for comparison.
Demers et al17 found a DVT frequency of 17.9%
when unilateral phlebography was performed 1 week after arthroscopy in 184
patients. Of the 33 DVTs, 20 were symptomatic (9 [49%] of which were proximal).
The risk was significantly increased if a tourniquet had been applied for
60 minutes or longer. In another study, a frequency of 3.5% was reported using
compression ultrasonography (3 of 85, all asymptomatic18).
Based on these data, arthroscopy can be considered as a moderate risk if the
tourniquet is applied for an extended duration and low risk under other circumstatnces.
The low risk of this procedure is further supported by a recent publication
by Dahl et al,19 in which the frequency of
clinically symptomatic thrombosis diagnosed by means of compression ultrasonography
or phlebography was analyzed during a 10-year period (1989-1998). Of 1335
arthroscopies in which prophylaxis was not used, there were 8 patients with
thromboses (0.6%), 7 of which were in the calf veins and 1 extending to the
popliteal vein. The clinical symptoms appeared at a median of 1 day after
arthroscopy (range, 1-6 days). A similar low incidence was reported by Jaureguito
et al.20 Using clinical symptoms with thrombosis
confirmed by duplex ultrasound as the end point, the incidence of thrombosis
was 0.24% in a retrospective study of 2050 arthroscopies and 2.9% in a prospective
study of 239 patients. An even lower incidence of clinically suspected thromboembolic
disease was reported by Small21; 6.9% after
10 262 arthroscopies. Schippinger et al22 performed
a clinical follow-up 14 days after arthroscopic knee surgery and a follow-up
by duplex ultrasonography and ventilation-perfusion scan after 5 weeks. Of
the 101 consecutive patients, 8 developed DVT (4 symptomatic) and 9 developed
pulmonary embolism (1 symptomatic). The overall frequency of thromboembolism
was 12%. All patients received prophylaxis with dalteparin but this was limited
to the time of discharge which, on average, occurred on the second day. In
a randomized study of 239 patients, Wirth et al23 found
a 4.1% rate of DVT with compression ultrasonography with no prophylaxis vs
0.85% when reviparin was used.
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Table 2. Frequency of Deep Vein Thrombosis (DVT) After Elective Knee
Surgery*
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PLASTER CAST
The indications for plaster casts vary. Here, we discuss casts used
to immobilize the lower leg because of a traumatic fracture or soft tissue
injury. Three factors contribute to the risk of thrombosis after a fracture:
the trauma causing the fracture, treatment with surgical fixation of the fracture,
and immobilization in the cast. In a series of 200 patients followed up clinically
for 3 months, 9 (4.5%) developed symptomatic venous thromboembolism, which
was objectively verified with phlebography or lung scintigraphy.24 The
frequency of venous thrombosis detected by phlebography, after crural fractures,
usually tibial fractures, is summarized in Table 3. This is a high-risk group and although most of the thrombi
are localized to the calf veins, they can be complicated by pulmonary embolism,
including fatal embolism. The risk of thrombosis appears to be low when there
is no fracture. Table 4 shows
results of studies in which patients with fractures or soft tissue injuries
wore a plaster cast. In a recent study, the low-molecular-weight heparin reviparin
was compared with placebo in 440 patients with lower extremity fracture or
rupture of the Achilles tendon who were immobilized for 42 days in a cast
or brace.34 Phlebography at cast removal showed
thrombosis in 34 (18%) of the patients who received placebo, 10 of which were
proximal. In the reviparin group the frequency of DVT was 9% (P = .014).
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Table 3. Frequency of Deep Vein Thrombosis (DVT) (Phlebographic Diagnosis)
After Lower Limb Fracture (Tibial)
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Table 4. Frequency of Deep Vein Thrombosis (DVT) in Patients Wearing
Lower Limb Plaster Casts
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CONCLUSIONS
Laparoscopic cholecystectomy and simple knee arthroscopic surgery can
be considered low-risk situations for venous thromboembolism. Knee arthroscopic
surgery that requires prolonged tourniquet time is a moderate-risk procedure.
Data on the risk of thrombosis with other laparoscopic procedures are too
sparse to allow comment. The routine use of prophylaxis is probably not justified
in these groups of patients, but should be considered in higher-risk patients
who have knee arthroplasty. Patients requiring immobilization in a plaster
cast because of trauma have a moderate risk of thrombosis and probably should
receive prophylaxis.
AUTHOR INFORMATION
Accepted for publication February 27, 2002.
This study was supported by the Swedish Medical Research Council (grant
00759), Swedish Heart and Lung Foundation.
Drs Bergqvist and Lowe made equal contributions in collecting articles
and extracting the information for this article.
Corresponding author and reprints: David Bergqvist, MD, PhD, Department
of Surgical Sciences, University Hospital, SE-751 85 Uppsala, Sweden (e-mail: david.bergqvist{at}kirurgi.uu.se).
From the Department of Surgical Sciences, University Hospital, Uppsala,
Sweden (Dr Bergqvist); and University Department of Medicine, Royal Infirmary,
Glasgow, Scotland (Dr Lowe).
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