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Review Article |

Venous Thromboembolism in Patients Undergoing Laparoscopic and Arthroscopic Surgery and in Leg Casts FREE

David Bergqvist, MD, PhD; Gordon Lowe, MD, PhD
[+] Author Affiliations

From the Department of Surgical Sciences, University Hospital, Uppsala, Sweden (Dr Bergqvist); and University Department of Medicine, Royal Infirmary, Glasgow, Scotland (Dr Lowe).


Arch Intern Med. 2002;162(19):2173-2176. doi:10.1001/archinte.162.19.2173.
Text Size: A A A
Published online

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.

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.

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

Table Graphic Jump LocationTable 1. Prospective Studies on the Frequency of Deep Vein Thrombosis (DVT) After Laparoscopic Cholecystectomy

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

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.

Table Graphic Jump LocationTable 2. Frequency of Deep Vein Thrombosis (DVT) After Elective Knee Surgery*

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).

Table Graphic Jump LocationTable 3. Frequency of Deep Vein Thrombosis (DVT) (Phlebographic Diagnosis) After Lower Limb Fracture (Tibial)
Table Graphic Jump LocationTable 4. Frequency of Deep Vein Thrombosis (DVT) in Patients Wearing Lower Limb Plaster Casts

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.

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@kirurgi.uu.se).

Lindberg  FRasmussen  ISiegbahn  ABergqvist  D Coagulation activation after laparoscopic cholecystectomy in spite of thromboembolism prophylaxis. Surg Endosc. 2000;14858- 861
Link to Article
Rahr  HBFabrin  KLarsen  JFThorlacius-Ussing  O Coagulation and fibrinolysis during laparoscopic cholecystectomy. Thromb Res. 1999;93121- 127
Link to Article
Bounameaux  HHicklin  LDesmarais  S Seasonal variation in deep vein thrombosis. BMJ. 1996;312284- 285
Link to Article
Caprini  JAArcelus  JILaubach  M  et al.  Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. Surg Endosc. 1995;9304- 309
Kopanski  ZCienciala  AUlatowski  ZMicherdzinski  J Comparison of thrombosis rate after laparoscopic and conventional interventions with the I(125) fibrinogen test [in German]. Wien Klin Wochenschr. 1996;108105- 110
Krasinski  ZGabriel  MOszkinis  GDzieciuchowicz  LBegier-Krasinska  B Thrombophlebitis profunda in patients after conventional and laparoscopic cholecystectomy [in German]. Langenbecks Arch Chir Suppl Kongressbd. 1998;1151105- 1106
Lord  RVHugh  TBColeman  MJDoust  BD The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust. 1996;165402discussion 402-403
Lord  RVLing  JJHugh  TBColeman  MJDoust  BDNivison-Smith  I Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy. Arch Surg. 1998;133967- 973
Link to Article
Patel  MIHardman  DTNicholls  DFisher  CMAppleberg  M The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust. 1996;164652- 654656
Lindberg  FBergqvist  DRasmussen  I Incidence of thromboembolic complications after laparoscopic cholecystectomy: review of the literature. Surg Laparosc Endosc. 1997;7324- 331
Link to Article
Mayol  JVincent-Hamelin  ESarmiento  JM  et al.  Pulmonary embolism following laparoscopic cholecystectomy: report of two cases and review of the literature. Surg Endosc. 1994;8214- 217
Link to Article
Alatri  ATronci  MBucciarelli  PMoia  M Venous thromboembolism after laparoscopic surgery: two case reports and review of the literature. Ann Ital Med Int. 1998;1353- 55
Nguyen  NTLuketich  JDFriedman  DMIkramuddin  SSchauer  PR Pulmonary embolism following laparoscopic antireflux surgery: a case report and review of the literature. JSLS. 1999;3149- 153
Wazz  GBranicki  FTaji  HChishty  I Influence of pneumoperitoneum on the deep venous system during laparoscopy. JSLS. 2000;4291- 295
Mall  JWSchwenk  WRodiger  OZippel  KPollmann  CMuller  JM Blinded prospective study of the incidence of deep venous thrombosis following conventional or laparoscopic colorectal resection. Br J Surg. 2001;8899- 100
Link to Article
Stringer  MDSteadman  CAHedges  ARThomas  EMMorley  TRKakkar  VV Deep vein thrombosis after elective knee surgery: an incidence study in 312 patients. J Bone Joint Surg Br. 1989;71492- 497
Demers  CMarcoux  SGinsberg  JSLaroche  FCloutier  RPoulin  J Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med. 1998;15847- 50
Link to Article
Williams  JS  JrHulstyn  MJFadale  PD  et al.  Incidence of deep vein thrombosis after arthroscopic knee surgery: a prospective study. Arthroscopy. 1995;11701- 705
Link to Article
Dahl  OEGudmundsen  TEHaukeland  L Late occurring clinical deep vein thrombosis in joint-operated patients. Acta Orthop Scand. 2000;7147- 50
Link to Article
Jaureguito  JWGreenwald  AEWilcox  JFPaulos  LERosenberg  TD The incidence of deep venous thrombosis after arthroscopic knee surgery. Am J Sports Med. 1999;27707- 710
Small  NC Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4215- 221
Link to Article
Schippinger  GWirnsberger  GHObernosterer  ABabinski  K Thromboembolic complications after arthroscopic knee surgery: incidence and risk factors in 101 patients. Acta Orthop Scand. 1998;69144- 146
Link to Article
Wirth  TSchneider  BMisselwitz  F  et al.  Prevention of venous thromboembolism after knee arthroscopy with low-molecular-weight heparin (reviparin): results of a randomized controlled trial. Arthroscopy. 2001;17393- 399
Link to Article
Zagrodnick  JKaufner  HK Ambulatory thromboembolism prevention in traumatology using self injection of heparin [in German]. Unfallchirurg. 1990;93331- 333
Hjelmstedt  ABergvall  U Phlebographic study of the incidence of thrombosis in the injured and uninjured limb in 55 cases of tibial fracture. Acta Chir Scand. 1968;134229- 234
Spieler  UPreter  BBrunner  U Traumatic thromboses of the deep venous system in recent tibial fractures [in German]. Schweiz Med Wochenschr. 1972;1021535- 1540
Nylander  GSemb  H Veins of the lower part of the leg after tibial fractures. Surg Gynecol Obstet. 1972;134974- 976
Geerts  WHCode  KIJay  RMChen  ESzalai  JP A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;3311601- 1606
Link to Article
Abelseth  GBuckley  REPineo  GEHull  RRose  MS Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma. 1996;10230- 235
Link to Article
Kujath  PSpannagel  UHabscheid  W Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis. 1993;23(suppl 10)20- 26
Reilmann  HWeinberg  AMForster  EEHappe  B Prevention of thrombosis in ambulatory patients [in German]. Orthopade. 1993;22117- 120
Kock  HJSchmit-Neuerburg  KPHanke  JRudofsky  GHirche  H Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet. 1995;346459- 461
Link to Article
Giannadakis  KGehling  HSitter  HAchenbach  SHahne  HGotzen  L Is a general pharmacologic thromboembolism prophylaxis necessary in ambulatory treatment by plaster cast immobilization in lower limb injuries [in German]? Unfallchirurg. 2000;103475- 478
Link to Article
Lassen  MBoris  LBacker  PNakov  RFareed  J Efficacy and safety of low molecular weight heparin (Elivarine) in the prophylaxis of venous thromboembolism inpatients with brace immbolization after injury of the lower extremity. Blood. 2000;96491a

Figures

Tables

Table Graphic Jump LocationTable 1. Prospective Studies on the Frequency of Deep Vein Thrombosis (DVT) After Laparoscopic Cholecystectomy
Table Graphic Jump LocationTable 2. Frequency of Deep Vein Thrombosis (DVT) After Elective Knee Surgery*
Table Graphic Jump LocationTable 3. Frequency of Deep Vein Thrombosis (DVT) (Phlebographic Diagnosis) After Lower Limb Fracture (Tibial)
Table Graphic Jump LocationTable 4. Frequency of Deep Vein Thrombosis (DVT) in Patients Wearing Lower Limb Plaster Casts

References

Lindberg  FRasmussen  ISiegbahn  ABergqvist  D Coagulation activation after laparoscopic cholecystectomy in spite of thromboembolism prophylaxis. Surg Endosc. 2000;14858- 861
Link to Article
Rahr  HBFabrin  KLarsen  JFThorlacius-Ussing  O Coagulation and fibrinolysis during laparoscopic cholecystectomy. Thromb Res. 1999;93121- 127
Link to Article
Bounameaux  HHicklin  LDesmarais  S Seasonal variation in deep vein thrombosis. BMJ. 1996;312284- 285
Link to Article
Caprini  JAArcelus  JILaubach  M  et al.  Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. Surg Endosc. 1995;9304- 309
Kopanski  ZCienciala  AUlatowski  ZMicherdzinski  J Comparison of thrombosis rate after laparoscopic and conventional interventions with the I(125) fibrinogen test [in German]. Wien Klin Wochenschr. 1996;108105- 110
Krasinski  ZGabriel  MOszkinis  GDzieciuchowicz  LBegier-Krasinska  B Thrombophlebitis profunda in patients after conventional and laparoscopic cholecystectomy [in German]. Langenbecks Arch Chir Suppl Kongressbd. 1998;1151105- 1106
Lord  RVHugh  TBColeman  MJDoust  BD The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust. 1996;165402discussion 402-403
Lord  RVLing  JJHugh  TBColeman  MJDoust  BDNivison-Smith  I Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy. Arch Surg. 1998;133967- 973
Link to Article
Patel  MIHardman  DTNicholls  DFisher  CMAppleberg  M The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust. 1996;164652- 654656
Lindberg  FBergqvist  DRasmussen  I Incidence of thromboembolic complications after laparoscopic cholecystectomy: review of the literature. Surg Laparosc Endosc. 1997;7324- 331
Link to Article
Mayol  JVincent-Hamelin  ESarmiento  JM  et al.  Pulmonary embolism following laparoscopic cholecystectomy: report of two cases and review of the literature. Surg Endosc. 1994;8214- 217
Link to Article
Alatri  ATronci  MBucciarelli  PMoia  M Venous thromboembolism after laparoscopic surgery: two case reports and review of the literature. Ann Ital Med Int. 1998;1353- 55
Nguyen  NTLuketich  JDFriedman  DMIkramuddin  SSchauer  PR Pulmonary embolism following laparoscopic antireflux surgery: a case report and review of the literature. JSLS. 1999;3149- 153
Wazz  GBranicki  FTaji  HChishty  I Influence of pneumoperitoneum on the deep venous system during laparoscopy. JSLS. 2000;4291- 295
Mall  JWSchwenk  WRodiger  OZippel  KPollmann  CMuller  JM Blinded prospective study of the incidence of deep venous thrombosis following conventional or laparoscopic colorectal resection. Br J Surg. 2001;8899- 100
Link to Article
Stringer  MDSteadman  CAHedges  ARThomas  EMMorley  TRKakkar  VV Deep vein thrombosis after elective knee surgery: an incidence study in 312 patients. J Bone Joint Surg Br. 1989;71492- 497
Demers  CMarcoux  SGinsberg  JSLaroche  FCloutier  RPoulin  J Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med. 1998;15847- 50
Link to Article
Williams  JS  JrHulstyn  MJFadale  PD  et al.  Incidence of deep vein thrombosis after arthroscopic knee surgery: a prospective study. Arthroscopy. 1995;11701- 705
Link to Article
Dahl  OEGudmundsen  TEHaukeland  L Late occurring clinical deep vein thrombosis in joint-operated patients. Acta Orthop Scand. 2000;7147- 50
Link to Article
Jaureguito  JWGreenwald  AEWilcox  JFPaulos  LERosenberg  TD The incidence of deep venous thrombosis after arthroscopic knee surgery. Am J Sports Med. 1999;27707- 710
Small  NC Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4215- 221
Link to Article
Schippinger  GWirnsberger  GHObernosterer  ABabinski  K Thromboembolic complications after arthroscopic knee surgery: incidence and risk factors in 101 patients. Acta Orthop Scand. 1998;69144- 146
Link to Article
Wirth  TSchneider  BMisselwitz  F  et al.  Prevention of venous thromboembolism after knee arthroscopy with low-molecular-weight heparin (reviparin): results of a randomized controlled trial. Arthroscopy. 2001;17393- 399
Link to Article
Zagrodnick  JKaufner  HK Ambulatory thromboembolism prevention in traumatology using self injection of heparin [in German]. Unfallchirurg. 1990;93331- 333
Hjelmstedt  ABergvall  U Phlebographic study of the incidence of thrombosis in the injured and uninjured limb in 55 cases of tibial fracture. Acta Chir Scand. 1968;134229- 234
Spieler  UPreter  BBrunner  U Traumatic thromboses of the deep venous system in recent tibial fractures [in German]. Schweiz Med Wochenschr. 1972;1021535- 1540
Nylander  GSemb  H Veins of the lower part of the leg after tibial fractures. Surg Gynecol Obstet. 1972;134974- 976
Geerts  WHCode  KIJay  RMChen  ESzalai  JP A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;3311601- 1606
Link to Article
Abelseth  GBuckley  REPineo  GEHull  RRose  MS Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma. 1996;10230- 235
Link to Article
Kujath  PSpannagel  UHabscheid  W Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis. 1993;23(suppl 10)20- 26
Reilmann  HWeinberg  AMForster  EEHappe  B Prevention of thrombosis in ambulatory patients [in German]. Orthopade. 1993;22117- 120
Kock  HJSchmit-Neuerburg  KPHanke  JRudofsky  GHirche  H Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet. 1995;346459- 461
Link to Article
Giannadakis  KGehling  HSitter  HAchenbach  SHahne  HGotzen  L Is a general pharmacologic thromboembolism prophylaxis necessary in ambulatory treatment by plaster cast immobilization in lower limb injuries [in German]? Unfallchirurg. 2000;103475- 478
Link to Article
Lassen  MBoris  LBacker  PNakov  RFareed  J Efficacy and safety of low molecular weight heparin (Elivarine) in the prophylaxis of venous thromboembolism inpatients with brace immbolization after injury of the lower extremity. Blood. 2000;96491a

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