Detection of Pulmonary Embolism in the Postoperative Orthopedic Patient Using Spiral CT Scans

Orthopedic surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). This study was performed to compare the clinical presentations of a suspected versus a documented PE/DVT and to determine the actual incidence of PE/DVT in the post-operative orthopedic patient in whom CT was ordered. All 695 patients at our institution who had a postoperative spiral CT to rule out PE/DVT from March 2004 to February 2006 were evaluated and information regarding their surgical procedure, risk factors, presenting symptoms, location of PE/DVT, and anticoagulation were assessed. Statistical analysis was performed using an independent samples t test with a two-tailed p value to examine significant associations between the patient variables and CT scans positive for PE. Logistic regression models were used to determine which variables appeared to be significant predictors of a positive chest CT. Of 32,854 patients admitted for same day surgery across all services, 695 (2.1%) had a postoperative spiral CT based on specific clinical guidelines. The incidence of a positive scan was 27.8% (193/695). Of these, 155 (22.3%) scans were positive for PE only, 24 (3.5%) for PE and DVT, and 14 (2.0%) for DVT only. The most common presenting symptoms were tachycardia (56%, 393/695), low oxygen saturation (48%, 336/695), and shortness of breath (19.6%, 136/695). Symptoms significantly associated with DVT were syncope and chest pain. A past medical history of PE/DVT was the only significant predictor of a positive scan. Patients who have a history of thromboembolic disease should be carefully monitored in the postoperative setting.     

Thromboembolic complications after spinal surgery in trauma patients

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

Thromboembolic complications after spinal surgery in trauma patients

Background?Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods?We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results?The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation?We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass.

BACKGROUND: Obesity is a major risk factor for postoperative deep venous thrombosis (DVT) and pulmonary embolism (PE). Identifying those patients at the greatest risk for DVT/PE is essential to prevent thromboembolic events among patients undergoing Roux-en-Y gastric bypass (RYGB) for clinically significant obesity. This aim of the study is to identify factors associated with an increased likelihood of developing DVT/PE after RYGB. METHODS: Prospectively collected data from 660 consecutive patients who underwent RYGB were reviewed. Patients received perioperative prophylaxis with low molecular weight heparin and sequential compression devices. Diagnosis was based on clinical, radiologic, and/or necropsy findings. Patients with and without postoperative DVT/PE were compared using chi(2) and multivariate logistic regression analysis. RESULTS: A total of 23 patients (3.5%) developed postoperative DVT/PE. Age > 50 years (P = .04), previous DVT/PE (P = .02), history of smoking (P < .01), revisional operation (P = .03), open RYGB (P = .02), and anastomotic leak (P < .0001) significantly increased the likelihood of developing DVT/PE. On the other hand, gender, body mass index > 50 kg/m(2) and history of sleep apnea, hypertension, diabetes, or myocardial infarction did not increase the likelihood of DVT/PE. Multivariate analysis revealed that age > 50 years (P = .04), postoperative anastomotic leak (P < .001), smoking (P < .01), and previous DVT/PE (P < .001) increased the likelihood of postoperative DVT/PE. CONCLUSIONS: Age > 50 years, anastomotic leak, smoking, and history of DVT/PE all increase the likelihood of postoperative thromboembolic events in patients undergoing RYGB. Further preoperative screening and/or postoperative prophylaxis may be needed in this subset of high-risk patients.     

Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients

Deep venous thrombosis (DVT) and pulmonary embolism (PE) cause significant morbidity and mortality in orthopaedic surgical practice, although the incidence following surgery to the lumbosacral spine is less than following lower limb surgery. Our objective was to compare our rate of thromboembolic complications with those published elsewhere and investigate whether the adoption of additional pharmacological measures reduced the incidence of clinically evident DVT and PE. This retrospective study was undertaken to investigate the incidence of DVT/PE during the 10 years from 1 January 1985 to 31 December 1994, and then to assess the effectiveness of an anticoagulant policy introduced during 1995 using low dose aspirin or LMH in high risk cases. All records for spinal operations were reviewed for thrombo-embolic complications by reference to the Scottish Morbidity Record form SMR1. To ensure that all patients were compliant with the policy, data for the whole of 1995 was omitted and the period 1 January 1996 to 31 December 2003 was taken to assess its effectiveness. Surgery was done with the patient in the kneeling, seated prone position which leaves the abdomen free and avoids venous kinking in the legs. Records of a total of 1,111 lumbar spine operations were performed from 1 January 1985 to 31 December 2004 were reviewed. The overall incidence of thrombo-embolic complications was 0.29%. A total of 697 operations were performed from 1 January 1985 to 31 December 1994 with two cases of DVT and no cases of PE giving thromboembolic complication rate of 0.29%. During the period 1 January 1996 to 31 December 2003, 414 operations resulted in one case of DVT and no cases of PE, a rate of 0.24%. The incidence of symptomatic thrombo-embolic complications in lumbar spinal surgery is low in the kneeling, seated prone operating position, whether or not anticoagulation is used.     

Thromboembolic complications after arthroscopic knee surgery: Incidence and risk factors in 101 patients

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are less common after knee arthroscopy than after elective hip and knee arthroplasties. There is no consensus on the optimal prophylaxis. In this prospective cohort study, we used ultrasound, phlebography and lung scan pre-and postoperatively to assess the incidence of thromboembolic complications in 101 consecutive patients who underwent knee arthroscopy. Preoperatively, patients were screened for typical risk factors for DVT such as age, obesity, varicose veins, contraceptive pills and nicotine abuse. All patients received a once-daily injection of 5000 IU of low molecular weight heparin, at least 12 hours prior to surgery.

5 weeks after surgery, the same screening tests were repeated. In 12 of the 101 patients either DVT or PE was diagnosed. DVT occurred in 8 cases, 4 of which were silent and 4 symptomatic. The number of PEs was 9, 8 silent and 1 symptomatic. We found no correlation between DVT or PE and individual clinical risk factors, but there was a tendency towards the development of DVT and PE, with a higher number of risk factors. We found no correlation between DVT and intraoperative risk factors such as use of a tourniquet, type of anesthesia or duration of surgery. The relatively high rate of thromboembolic events after knee arthroscopy in our study suggests the need of all patients for routine use of thromboprophylaxis, probably in a higher dose than given.     

Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis

Patients undergoing spinal surgery are at risk of developing thromboembolic complications even though lower incidences have been reported as compared to joint arthroplasty surgery. Deep vein thrombosis (DVT) has been studied extensively in the context of spinal surgery but symptomatic pulmonary embolism (PE) has engaged less attention. We prospectively followed a consecutive cohort of 270 patients undergoing spinal surgery at a single institution. From these patients, only 26 were simple discectomies, while the largest proportion (226) was fusions. All patients received both low molecular weight heparin (LMWH) initiated after surgery and compressive stockings. PE was diagnosed with spiral chest CT. Six patients developed symptomatic PE, five during their hospital stay. In three of the six patients the embolic event occurred during the first 3 postoperative days. They were managed by the temporary insertion of an inferior vena cava (IVC) filter thus allowing for a delay in full-dose anticoagulation until removal of the filter. None of the PE patients suffered any bleeding complication as a result of the introduction of full anticoagulation. Two patients suffered postoperative haematomas, without development of neurological symptoms or signs, requiring emergency evacuation. The overall incidence of PE was 2.2% rising to 2.5% after exclusion of microdiscectomy cases. The incidence of PE was highest in anterior or combined thoracolumbar/lumbar procedures (4.2%). There is a large variation in the reported incidence of PE in the spinal literature. Results from the only study found in the literature specifically monitoring PE suggest an incidence of PE as high as 2.5%. Our study shows a similar incidence despite the use of LMWH. In the absence of randomized controlled trials (RCT) it is uncertain if this type of prophylaxis lowers the incidence of PE. However, other studies show that the morbidity of LMWH is very low. Since PE can be a life-threatening complication, LMWH may be a worthwhile option to consider for prophylaxis. RCTs are necessary in assessing the efficacy of DVT and PE prophylaxis in spinal patients.     

Pulmonary embolism after spinal surgery: report of two cases

We present two cases of pulmonary embolism (PE) without deep venous thrombosis (DVT) after spinal surgery with an anterior approach. On the seventh day after surgery, the patients’ plasma D-dimer levels were high without symptoms, so computed tomography (CT) was performed from chest to lower limb, revealing PE without lower limb DVT. After the exam, we immediately started anticoagulation therapy with heparin and warfarin. The patients were discharged with no complications. Previous reports have documented that DVT causes most cases of PE; however, our cases had no lower limb DVT. Some reports hypothesize that anterior spinal surgery might have a differential pathogenesis of PE. Simple mechanical prophylaxis for DVT may not protect these patients. On the other hand, the administration of chemical anticoagulants therapy after spinal surgery is controversial because of the risk of epidural hematoma. We should explain the risk of PE to patients undergoing spinal surgery with an anterior approach.     

Pulmonary Embolism and Deep Venous Thrombosis Following Bariatric Surgery

Background

The contribution of obesity to the thromboembolic risks of surgery suggests that patients undergoing bariatric surgery would have a particularly high risk of postoperative pulmonary embolism (PE) and/or deep venous thrombosis (DVT). This study aimed to assess the prevalence of in-hospital PE, DVT, and venous thromboembolism (VTE) following bariatric surgery in the USA from 2007 to 2009.

Methods

We used the database of the Nationwide Inpatient Sample.

Results

The prevalence of PE was 4,500 of 508,230 (0.9 %). The prevalence of DVT not accompanied by PE was 6,480 of 508,230 (1.3 %) and VTE (either PE or DVT) occurred in 10,980 of 508,230 (2.2 %). In-hospital death among patients with PE was 130 of 508,231 (0.03 %). Vena cava filters were inserted in 1,515 of 508,230 (0.3 %) patients who underwent bariatric surgery. Among patients who had VTE, filters were inserted in 1,150 of 10,980 (10.5 %). Among patients who had neither PE nor DVT, prophylactic vena cava filters were inserted in 365 of 497,250 (0.07 %). Among patients with PE, in-hospital mortality was 25 of 635 (3.9 %) with a filter compared with 105 of 3,865 (2.7 %) (NS) without a filter. However, among patients with DVT alone, in-hospital mortality was 0 of 510 (0 %) with a filter compared with 80 of 5,970 (1.3 %) (P?=?0.009) without a filter.

Conclusions

This investigation establishes a baseline for the incidence of venous thromboembolic complications following bariatric surgery in recent years. Determination of the present in-hospital rate of PE and DVT may contribute to antithrombotic prophylactic considerations.     

The incidence of venous thromboembolism after total hip arthroplasty: a specific hypotensive epidural anesthesia protocol.

We retrospectively reviewed all consecutive unilateral primary total hip arthroplasty (THA) procedures performed by 3 attending surgeons on the Arthroplasty Service at our institution from January 1, 1990, to December 31, 1993. All surgery was performed under a specific hypotensive epidural anesthesia protocol. Hypotensive epidural anesthesia at our institution provides a lower level of hypotension (mean arterial pressure of 50-60 mmHg) as compared to hypotensive anesthesia used more generally around the world (mean arterial pressure >70 mmHg). For each patient, hospital and postdischarge office records for a minimum of 3 months after surgery were reviewed for the type of postoperative screening test, the incidence of deep venous thrombosis (DVT), and the incidence of symptomatic pulmonary embolism (PE). Overall, 2,592 primary unilateral THAs were performed with 78.6% (2,037 of 2,592) of patients receiving a venogram. Our protocol for thromboembolic disease prophylaxis in these patients included aspirin postoperatively as well as antithromboembolic disease stockings and early ambulation (24-48 hours postoperatively). The 555 patients who did not receive venography were managed with a different protocol that included warfarin postoperatively as well as antithromboembolic disease stockings and early ambulation. This high-risk group consisted of patients who received warfarin preoperatively (ie, cardiac valve) or patients with a history of DVT who were to receive warfarin postoperatively, regardless of venography result. Overall, DVT was diagnosed in 10.3% (210 of 2,037) of patients who had a venogram. Of these patients who had venography, 2.3% (46 of 2,037) had an isolated proximal DVT; 6.0% (123 of 2,037), a distal DVT; and 2.0% (41 of 2,037), both a proximal and a distal DVT. Of the 87 cases of proximal DVT identified, 60.9% (53 of 87) were femoral DVT; 18.4% (16 of 87), popliteal DVT; and 20.7% (18 of 87), both femoral and popliteal DVT. Of the 164 distal DVT, 68.3% (112 of 164) were major calf DVT and 31.7% (52 of 164) were minor calf DVT. The overall incidence of major venous thrombosis (sum of proximal and major calf thrombi) was 9.8% (199 of 2,037) in patients who had venography. Ventilation-perfusion scanning was used selectively in patients symptomatic for PE. Overall, symptomatic PE was diagnosed by ventilation-perfusion scan in 1.0% (26 of 2,592) of patients, with 0.58% (15 of 2,592) of patients having an in-hospital PE. Of the 15 patients who had an in-hospital PE, 11 patients had a venogram, and only 3 of 11 were positive. Late symptomatic PE was defined from discharge (mean, 7 +/- 2 days) to 3 months after discharge from the hospital and occurred in 0.42% (11 of 2,592) of patients. One of the 11 late symptomatic PEs was fatal. In the overall study, this represents 0.04% (1 of 2,592) fatal PE. Of the 11 patients with a late symptomatic PE, 10 had venograms in the hospital, and all 10 were negative for DVT. Overall, in the patients with a positive venogram, the incidence of symptomatic PE was 1.4% (3 of 210), whereas in the patients with a negative venogram, the incidence of symptomatic PE was 0.44% (8 of 1,827). At our institution, patients who undergo primary THA performed with hypotensive epidural anesthesia, postoperative aspirin, antithromboembolic disease stockings, and early ambulation have a low risk for thromboembolic disease.     

The incidence of deep vein thrombosis and pulmonary embolism with the elective use of external fixators

Little evidence exists about the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with the use of external fixators. We investigated this in a cohort of 207 consecutive patients undergoing 258 elective frame applications by case note review. Case notes were obtained for 84 % of the sample population. The type of surgery, demographic data, thromboembolic risk factors and the incidence of DVT/PE were recorded. One patient experienced DVT (0.39 %) and one a PE (0.39 %). Both were of high risk and had received mechanical and chemical thromboprophylaxis during their inpatient stay. These complications were identified at least 3 months post-operatively. These findings help to more accurately counsel patients undergoing elective frame surgery on the risks of DVT/PE and also contribute to the discussion between surgeons about whether or not extended course chemical thromboprophylaxis would be of overall benefit.     

The Rate and Mortality of Postoperative Venous Thromboembolism of Moderate Risk Surgery in Asian Patients without Thrombo-prophylaxis: Systematic Review with Meta-analysis

Background

The general gynecologic and neurologic surgeries are regard as carrying moderate risk for postoperative venous thromboembolism (VTE). This review analyzed the postoperative VTE rate of these surgeries in Asia.

Methods

Inclusion criteria were: prospective study; deep vein thrombosis (DVT) diagnosed by venography, ultrasonography, or radionucleotide scan; and no thromboprophylaxis. The pooled proportion was back calculated from Freeman–Tukey variant transformation, using a random effect model.

Results

Medline, EMBASE, Cochrane Library, and KoreaMed were searched. Fourteen studies (total population of 1,625) published from 1974 to 2008 were included. In general surgery, the pooled rate of all-sites proximal, isolated distal DVT was 13.4, 2.1, and 11.8 % (radionucleotide scan). The cancer patients carried a higher all-sites DVT rate (19.7 % radionucleotide scan and 17.4 % ultrasound). Gynecologic and neurologic surgery had 3.1 % (ultrasound) and 3.8 % (radionucleotide scan) all-sites DVT rate. For general, gynecologic, and neurologic patients, the pooled rates of symptomatic DVT were 1.5, 0.2, and 1.0 % respectively. The pooled rate of symptomatic pulmonary embolism (PE) was 0.4 % for general surgery. No patients died from PE (pooled rate 0.2 %); however, a single PE death was reported in the excluded study.

Conclusions

Postoperative symptomatic VTE was relatively low in Asia. Further study is required to stratify VTE risk and the need for thromboprophylaxis in individual patients.     

Thermally injured patients are at significant risk for thromboembolic complications

BACKGROUND: The incidence of thromboembolic complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE) in thermally injured patients is considered sufficiently uncommon that routine prophylactic measures are not warranted. Nevertheless, the incidence of DVT/PE may be increasing. METHODS: The records of 1,300 patients admitted to our unit from January 1990 to June 1995 were reviewed. RESULTS: Twenty-three patients developed a clinically significant DVT, eight patients developed a PE, and two patients developed both a DVT and a PE, for an overall DVT/PE incidence of 2.9%. Four of 10 PEs were felt to be fatal. The DVT/PE patients were older (mean age, 42.6 vs. 28.7; p < 0.001) and had larger burns (37% vs. 18%, p < 0.001) than patients without evidence of DVT/PE. Body weight appeared to also influence DVT/PE rates, with obese patients (>30% over ideal body weight) having a higher incidence than patients with low or normal body weight (7.2 vs. 2.7%, p < 0.015). Age and total body surface area (TBSA) burn had a synergistic effect on DVT/PE risk, with the sum of age and TBSA burn exerting the strongest independent effect when discriminant function analysis was performed (p < 0.001). CONCLUSION: One can identify a population at increased risk of DVT/PE on the basis of the sum of age and TBSA burn, but prospective screening trials that assess all risk factors for DVT/PE should be performed before routine prophylaxis is used in thermally injured patients.     

Prolonged thromboprophylaxis with Dalteparin during immobilization after ankle fracture surgery: a randomized placebo-controlled, double-blind study

Background Skeletal trauma and immobilization are well-known risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE). While prophylaxis against thromboembolic complications has become routine after major orthopedic surgery, whether or not prophylaxis after minor surgery and lower limb immobilization is necessary is still under debate.

Methods In a double-blind, placebo-controlled study, 272 consecutive patients were randomized to receive either thromboprophylaxis with Dalteparin (n = 136) or placebo (n = 136) for 5 weeks after ankle fracture surgery. All patients received 1 week of initial treatment with Dalteparin before randomization. A unilateral phlebography was performed when the cast was removed.

Results The overall incidence of DVT was 21% (95% CI: 13-29%) in the Dalteparin group and 28% (CI: 19- 37%) in the placebo group (risk ratio = 0.8, CI: 0.6-1.1; p = 0.3). The incidence of proximal DVTs was 4% and 3%, respectively. No major bleeding occurred.

Interpretation We found no significant difference in the incidence of DVT between the 2 treatment groups and our results do not support prolonged thromboprophylaxis. The overall incidence of DVT was high, reflecting the potential risk of PE and post-thrombotic syndrome after ankle fracture surgery. Most of the DVTs were asymptomatic, however, and were located in distal veins.     

Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage

ABSTRACT: INTRODUCTION: Therapeutic anticoagulation is an important treatment of thromboembolic complications, such as DVT, PE, and blunt cerebrovascular injury. Traumatic intracranial hemorrhage has traditionally been considered to be a contraindication to anticoagulation. Hypothesis Therapeutic anticoagulation can be safely accomplished in select patients with traumatic intracranial hemorrhage. METHODS: Patients who developed thromboembolic complications of DVT, PE, or blunt cerebrovascular injury were stratified according to mode of treatment. Patients who underwent therapeutic anticoagulation with a heparin infusion or enoxaparin (1 mg/kg BID) were evaluated for neurologic deterioration or hemorrhage extension by CT scan. RESULTS: There were 42 patients with a traumatic intracranial hemorrhage that subsequently developed a thrombotic complication. Thirty-five patients developed a DVT or PE. Blunt cerebrovascular injury was diagnosed in four patients. 26 patients received therapeutic anticoagulation, which was initiated an average of 13 days after injury. 96% of patients had no extension of the hemorrhage after anticoagulation was started. The degree of hemorrhagic extension in the remaining patient was minimal and was not felt to affect the clinical course. CONCLUSION: Therapeutic anticoagulation can be accomplished in select patients with intracranial hemorrhage, although close monitoring with serial CT scans is necessary to demonstrate stability of the hemorrhagic focus.     

Deep venous thrombosis after laparoscopic cholecystectomy and prevention with nadroparin

Background: Postoperative thromboembolic disease has been suggested to occur with higher frequency during laparoscopic cholecystectomy than during other laparoscopic procedures or conventional cholecystectomy. The aim of this prospective study was to evaluate the occurrence of deep vein thrombosis (DVT) in laparoscopic cholecystectomy patients, whether they were treated with low-molecular-weight heparins or not. Methods: All 238 laparoscopic cholecystectomy patients included in the study underwent pre- and postoperative venous duplex scanning of both legs. Subcutaneous Nadroparin was administred to 105 patients. The remaining 133 patients did not receive pharmacologic prophylaxis. The different risk factors for thromboembolic disease were distributed evenly between the two groups, except for the duration of general anesthesia. Results: No patient had postoperative clinical manifestations of DVT or pulmonary embolism. In five patients, DVT was detected at duplex scan approximately 10 days after surgery. Four DVTs were found among the 133 patients who did not receive Nadroparin (1.68%). In the group with pharmacologic prevention, one patient manifested a DVT (0.42%), giving a total DVT incidence of 2.10% after laparoscopic cholecystectomy. The difference between the two groups was not significant (p = 0.27), but the results seem to indicate a tendency toward a lower incidence in the Nadroparine group. Conclusions: In the light of the study results, it seems advisable to use thromboembolic prophylaxis during laparoscopic cholecystectomy.     

Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions

OBJECTIVE: Low-dose heparin (LDH) regimens reduce the frequency of deep venous thrombosis (DVT) and pulmonary embolism (PE) in spinal surgery but pose a risk of postoperative hemorrhage threatening neurologic function. Pneumatic compression stocking (CS) could provide an alternative means of mechanical prophylaxis alone against DVT and PE and would possibly avoid its hemorrhagic complications. METHODS: The efficacy of CS alone in preventing DVT and PE was evaluated in 139 patients undergoing multilevel lumbar laminectomies (average 3.8 levels) with instrumented fusions (average 1.4 levels). All patients received CS stocking prophylaxis intraoperatively and throughout the average 5-day postoperative course including following ambulation. Doppler screening for DVT was routinely performed 2 days postoperatively. Subsequent Doppler studies or computed tomography angiograms were selectively performed in symptomatic patients with potential DVT/PE. RESULTS: Four (2.8%) patients developed DVT 2-6 days postoperatively and required inferior vena cava (IVC) filters. One of the four had a positive routine screening Doppler study performed the second postoperative day. Two developed DVT the fourth postoperative day. The fourth patient developed DVT 6 days postoperatively but 3 weeks later embolized around the IVC filter. This patient, the only one to develop a PE, tested positive for Factor V Leiden mutation (hypercoagulable syndrome) and remains on long-term warfarin. CONCLUSIONS: Pneumatic compression stocking prophylaxis effectively reduced the incidence of DVT (2.8%) and PE (0.7%) in 139 patients undergoing multilevel lumbar laminectomies with instrumented fusions. These rates compared favorably with those reported in spinal series employing LDH prophylaxis.     

Risk of postoperative venous thromboembolism in Indian patients sustaining pelvi-acetabular injury

Most surgeons believe that Asians have a low risk of developing venous thromboembolism (VTE) and routine thromboprophylaxis therapy is not required after major orthopaedic trauma. This study evaluates the postoperative risk of VTE in Indian patients sustaining pelvi-acetabular injury. Fifty-six patients with pelvi-acetabular injury, who underwent open reduction and internal fixation, were prospectively evaluated for VTE in the postoperative period. They were evaluated, both clinically and radiologically (pulmonary CT angiography and indirect venography of lower limb and pelvis veins), until six weeks after surgery. A total of 16 patients developed VTE, of which 12 had proximal deep vein thrombosis (DVT), ten had pulmonary embolism (PE) and only two had distal DVT. Six patients with proximal DVT had associated PE. The risk of development of VTE among Indian patients after pelvi-acetabular injury is high (28.6%) with increasing chances of proximal DVT and PE; hence, administration of routine thromboprophylaxis is fully justified in them.