Pulmonary embolism following laparoscopic cholecystectomy: report of two cases and review of the literature

Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study

Background

The incidence of deep vein thrombosis (DVT) in hepatocellular carcinoma (HCC) patients after laparoscopic hepatectomy (LH) is unclear, and there is no effective method for DVT risk assessment in these patients.

Methods

The data from the total of 355 consecutive HCC patients who underwent LH were included. A DVT risk algorithm was developed using a training set (TS) of 243 patients, and its predictive performance was evaluated in both the TS and a validation set (VS) of 112 patients. The model was then used to develop a DVT risk nomogram (TRN).

Results

The incidence of DVT in the present study was 18.6%. Age, sex, body mass index (BMI), comorbidities and operative position were independent risk factors for DVT in the TS. The model based on these factors had a good predictive ability. In the TS, it had an area under the receiver operating characteristic (AUC) curve of 0.861, Hosmer-Lemeshow (H-L) goodness of fit p value of 0.626, sensitivity of 44.4%, specificity of 96.5%, positive predictive value (PPV) of 74.1%, negative predictive value (NPV) of 88.4%, and accuracy of 86.8%. In the VS, it had an AUC of 0.818, H-L p value of 0.259, sensitivity of 38.1%, specificity of 98.9%, PPV of 88.9%, NPV of 87.4%, and accuracy of 87.5%. The TRN performed well in both the internal and the external validation, indicating a good clinical application value. The TRN had a better predictive value of DVT than the Caprini score (p < 0.001).

Conclusion

The incidence of DVT after LH was high, and should not be neglected in HCC patients. The TRN provides an efficacious method for DVT risk evaluation and individualized pharmacological thromboprophylaxis.

Effect of various pneumoperitoneum pressures on femoral vein hemodynamics during laparoscopic cholecystectomy

High intra-abdominal pressure and reverse Trendelenburg position during laparoscopic cholecystectomy (LC) are risk factors for venous stasis in lower extremity. Lower limb venous stasis is one of the major pathophysiological elements involved in the development of peri-operative deep vein thrombosis. Low pressure pneumoperitoneum (7-10 mmHg) has been recommended in patients with limited cardiac, pulmonary or renal reserve. The purpose of this study was to observe the effect of various pneumoperitoneum pressures on femoral vein (FV) hemodynamics during LC. A total of 50 patients undergoing elective LC were enrolled and they were prospectively randomized into two groups containing 25 patients each. In group A high pressure pneumoperitoneum (14 mmHg) and in group B low pressure pneumoperitoneum (8 mmHg) was maintained. Comparison of pre-operative and post-operative coagulation profile was done. Preoperative and intraoperative change in femoral vein diameter (FVD) (AP and LAT), cross-sectional area (CSA) and peak systolic flow (PSF) during varying pneumoperitoneum pressure was recorded in FV by ultrasound Doppler. First measurement (pre-operative) was carried out just after the induction of anesthesia before creation of pneumoperitoneum and second measurement (intra-operative) was taken just before completion of surgery with pneumoperitoneum maintained. Changes in coagulation parameters were less significant at low pressure pneumoperitoneum. There was statistical significant difference in the pre-operative and intra-operative values of FVD, CSA and PSF in both groups when analyzed independently (P = 0.00). There was no significant difference in pre-operative values of FVD, CSA and PSF (P > 0.05) among two groups but when the comparison was made between the intra-operative values, there was significant increase in FVD (AP) (P = 0.016), CSA (P = 0.00) and decrease in PSF (P = 0.00) at high pressure pneumoperitoneum. This study provides evidence of using low pressure pneumoperitoneum during LC as changes in FV hemodynamics and coagulation parameters were less pronounced at low pressure pneumoperitoneum.

Coagulation status and the presence of postoperative deep vein thrombosis in patients undergoing laparoscopic cholecystectomy

BACKGROUND

Venous thromboembolism is a relevant social and health care problem because of its high incidence among patients who undergo surgery (20-30% after general surgical operations and 50-75% after orthopedic procedures), its pulmonary embolism-related mortality rate, and its long-term sequelae (postthrombotic syndrome and ulceration), which may be disabling. This study aimed to determine the coagulation status and the presence of postoperative deep vein thrombosis (DVT) in patients undergoing laparoscopic (LC) and open cholecystectomy (OC).

METHODS

Prospectively, 114 patients were randomized into two groups. group 1 (58 patients undergoing LC) and group 2 (56 patients who are undergoing OC). The coagulation parameters (prothrombin time [PT], partial thromboplastin time [PTT], D-dimer, prothrombin F1 + 2, antithrombin III, and factor VII) were monitored preoperatively and during the operation, then 24 and 72 h after the operation. The patients in both groups underwent color duplex scan examination preoperatively, then 3 and 7 days after surgery to establish the presence of DVT. None of the patients in either group received thrombosis prophylaxis.

RESULTS

In the LC group, postoperative DVT developed in four patients (6.9%; in the calf veins of 3 patients and in the popliteal vein of 1 patient). In the OC group, nine patients (16.07%) had postoperative DVT (in the calf veins of 7 patients and in the popliteal and femoral veins of 2 patients). The plasma levels of monitored parameters in the patients of both groups were altered, but the difference between the groups was not statistically significant. For the patients in both groups who experienced DVT, only the decrease of factor VII had statistical significance (p < 0.05).

CONCLUSIONS

The incidence of postoperative DVT among the patients who underwent OC was higher than among the patients who underwent LC (p < 0.05). The decrease in factor VII among the patients who underwent surgery could be a potentially useful parameter indicating the patients at high risk for developing DVT.

Acute Pulmonary Embolism Following Laparoscopic Ovariectomy: A Case Report

Laparoscopic surgery is usually considered to be less invasive when compared to traditional laparotomy, and is regarded as a relatively low-risk procedure for postoperative complications because of the reduced surgical stress and earlier mobilization. However, we describe a 47-year-old woman who presented with acute respiratory distress, drowsy consciousness, and circulatory collapse shortly after gynecologic laparoscopic ovariectomy for removing an ovarian teratoma at a local hospital. After resuscitation, the patient was transferred to our emergency department. Immediate bedside electrocardiographic and echocardiographic examination results led to acute pulmonary embolism being quickly diagnosed. The patient received subsequent intensive care with smooth course. Although pulmonary embolism is rare after laparoscopic surgery, early detection and quick treatment are important in the management of this life-threatening complication and offer good prognosis. The risk of pulmonary embolism after gynecologic laparoscopic surgery remains unclear. Therefore, the decision to provide prophylaxis is up to the individual physician, and should take into consideration the patient's individual risk factors and comorbidities.

Twenty-five simple ways to increase insufflation performance and patient safety in laparoscopy

Technical aspects of laparoscopic insufflation technique and interaction among patient, technique, and physician can affect the performance of laparoscopy and patient safety. A variety of laparoscopic equipment was evaluated regarding insufflation performance in laboratory measurements and/or in an intraoperative computer-based data-acquisition model for intraabdominal pressure, gas flow, and temperature. In this article, we present 25 suggestions for improving insufflation performance and increasing patient safety. These tips may help avoid and solve insufflation problems and malfunction, over- and under-pressure peaks, laparoscopic hypothermia, and gas embolism, and shorten operation room and anesthesia time, thereby saving time, money, and physician stress.

Survey of the use of thromboprophylaxis in laparoscopic surgery in Denmark

BACKGROUND

The aim of this study was to determine the current use of thromboprophylaxis for laparoscopic surgery in Denmark.

METHODS

Postal questionnaires were sent to all Danish surgical departments that performed laparoscopic surgery according to the National Laparoscopic Cholecystectomy Database.

RESULTS

There was a written protocol for thromboprophylaxis in 93 per cent of the responding departments. In 37 per cent thromboprophylaxis was used for all patients undergoing laparoscopic surgery; only 7 per cent used thromboprophylaxis sporadically. All departments used low molecular weight heparin, 74 per cent in combination with graduated compression stockings. The criteria for using thromboprophylaxis varied greatly; in many departments conversion of the procedure to an open operation was not considered a criterion. Some 20 per cent of the departments reported previous thromboembolic complications following laparoscopic surgery.

CONCLUSION

Despite the widespread use of thromboprophylaxis, symptomatic thromboembolic complications were reported from several departments. Further studies are needed to determine whether laparoscopic surgery should be considered a high-risk procedure.

Fibrinolytic activity in laparoscopic cholecystectomy

The aim of this study was to examine the fibrinolytic activity in laparoscopic cholecystectomy (LC) to determine whether changes occur that might indicate a greater risk of thrombosis. The study was carried out in 20 patients who had undergone laparoscopic surgery for cholelithiasis without complications. The average age was 59.4 years (34-77 years). Seventy-five percent were women. The mean operating time was 70 minutes (35-120 minutes). Pneumoperitoneum at 14 mm Hg was maintained in all patients, and they were in 30 degrees reverse Trendelenburg position. Postoperative mobilization was obtained before 24 hours, and patients were discharged 48 hours after surgery. The control group was composed of 12 patients, evenly distributed by age, sex, and length of surgery, who had undergone Bassini herniorrhaphy without complications or relapses. The following hemostatic parameters were studied: plasma fibrinolytic activity (PFA), euglobulin fibrinolytic activity (EFA), tissue-type plasminogen activator (t-PA), fast-acting plasminogen activator inhibitor-1 (PAI-1), and D-dimer (D-D). Samples were obtained at the following times: (1) under basal conditions the day before surgery, (2) preoperatively, (3) at the end of surgery, (4) 24 hours after surgery, and (5) on the seventh day following surgery. No patient had clinical manifestations of thromboembolic disease immediately after surgery or during an average follow-up period of 16 months (range 15-18 months). Analysis of the results of global fibrinolysis showed that fibrinolytic activity was enhanced only in the postoperative period (third sample) of the LC patients. The fraction of euglobulins enhances fibrinolytic activity in both groups in the third sample with regard to the other determinations; the LC patients showed a higher degree of significance (p<0.005). A significant increase of postoperative t-PA in both groups was found, being more significant in the LC group (p<0.005). In the PAI-1 values, no significant differences existed between either determinations or groups. A significant increase in D-dimer (p<0.05) occurred in the immediate postoperative period (third sample) and 24 hours later (fourth sample), returning to normal basal values on the seventh day. No significant differences were found between the two groups. These results seem to indicate that LC produces an increase in the fibrinolytic activity in plasma as a result of the liberation of tissue plasminogen activator from the venous endothelium, which could indicate hypocoagulability during the immediate postoperative period and, therefore, signify less thrombotic risk for patients undergoing this procedure.

Thromboembolism prophylaxis during laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to determine current UK practice with regard to thromboembolism prophylaxis during laparoscopic cholecystectomy.

METHODS

Postal questionnaires were sent to 800 members of the Association of Surgeons; replies were received from 551 surgeons (69 per cent) of whom 417 practised laparoscopic cholecystectomy.

RESULTS

Heparin was prescribed to all patients by 74 per cent, and selectively by 20 per cent, of respondents. Surgeons who performed fewer than ten laparoscopic cholecystectomies per annum were significantly less likely to use heparin (P < 0.001) and more likely to believe that heparin produces significant adverse bleeding (P < 0.01). Thirty per cent of respondents used low molecular weight heparin. Stocking to deter thromboembolism were used by 74 per cent, and pneumatic compression by 37 per cent. Indications for heparin varied considerably and were not influenced by Thromboembolic Risk Factors (THRIFT) guidelines. Only 20 per cent of respondents considered that thromboembolism was a problem; 91 per cent reported that they had never experienced a thromboembolic complication following laparoscopic cholecystectomy.

CONCLUSION

The rate of thromboembolism after laparoscopic cholecystectomy is unknown but most surgeons believe the risk is very low. Surgeons' attitudes towards thromboembolism prophylaxis are variable, but most experienced surgeons use low-dose heparin.

Laparoscopic cholecystectomy: the experience of community hospital

BACKGROUND

The practice of laparoscopic cholecystectomy in a community hospital is presented. The morbidity of the procedure is analysed and recommendations for improvement are made. Laparoscopic cholecystectomy was introduced into this 200 bed community hospital in October 1990. All five general surgeons accredited to the hospital agreed to participate in a quality assurance programme to determine the incidence of complications and to make recommendations for improvement.

METHODS

The records of all 534 patients having laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed, and all complications recorded.

RESULTS

Of the 534 cases reviewed in the study 470 were considered uncomplicated and 64 patients experienced a total of 85 postoperative complications. The death of one patient was caused by a pulmonary embolus and another patient experienced a myocardial infarction. Twenty patients has postoperative atelectasis or pneumonia and urinary infection or retention occurred in seven. Complications of laparoscopic cholecystectomy requiring a conversion to open cholecystectomy occurred in eight patients, biliary complications occurred in 18 and 11 required re-operation.

CONCLUSIONS

Three areas of concern were identified. They were the incidence of major biliary injury (0.37% of all cases) and its management, the role of cholangiography, and the incidence and prophylaxis of deep venous thrombosis and pulmonary embolism. Recommendations for improvement in these areas were made.

Hemodynamic effects of intermittent pneumatic compression of the lower limbs during laparoscopic cholecystectomy

BACKGROUND

The effects of surgical pneumoperitoneum on lower-limb venous hemodynamics have already been studied; however, the effects of intermittent compression boots are not known in such venous-stasis conditions.

METHODS

In 12 volunteers and 12 patients, the venous hemodynamic effects of intermittent leg compression were studied under external abdominal pressure or during laparoscopic cholecystectomy, respectively. Femoral venous diameter and velocity were measured. Venous pressure was monitored during the surgical procedures.

RESULTS

External abdominal pressure of 50 mm Hg and pneumoperitoneum were found to increase the diameter (17% in the volunteers and 14% in the patients) and decrease peak velocity (49% and 32%, respectively) in the femoral vein. Femoral pressure was increased (106%) during pneumoperitoneum. In both venous-stasis circumstances, intermittent compression of the legs restored venous flow velocity, but had no effect on vessel diameter and pressure.

CONCLUSIONS

The lower-limb venous hemodynamic changes were similar during external abdominal pressure or pneumoperitoneum, and the flow velocity decrease was intermittently reversed by pneumatic compression boots.

Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy

Patients who undergo laparoscopic cholecystectomy (LC) are operated on under general anesthesia, in a reverse Trendelenburg position, with 12-15-mmHg pneumoperitoneum. All of these factors can induce venous stasis of the legs, which may lead to postoperative deep-vein thrombosis (DVT). The objectives of this study were to assess the degree of hypercoagulability and to determine the rate of postoperative DVT in a group of 100 patients in whom LC was completed. Whole-blood thrombelastography (TEG) and plasma-activated partial thromboplastin time (PTT) determination were carried out preoperatively and on the 1st postoperative day. All patients received pre-, intra-, and postoperative graduated compression stockings and sequential pneumatic compression devices until fully ambulatory. Twenty-six percent of the patients with a risk score > 4, or a post-operative TEG index > +5.0, received subcutaneous heparin (5,000 units b.i.d.), beginning in the postoperative period and continuing for 4 weeks as an outpatient. A complete venous duplex scan of both legs was performed on the 7th postoperative day, at the time of their office visit. Our results revealed significant postoperative hypercoagulability for the TEG index (P < 0.005) and for PTT (P < 0.05). One patient had an asymptomatic DVT (1%), and no side effects from the mechanical or pharmacological prophylaxis occurred in this series. These data suggest that the low incidence of thrombosis in the face of theoretical and laboratory evidence of postoperative hypercoagulability may reflect an effective prophylactic regime.(ABSTRACT TRUNCATED AT 250 WORDS)

National survey on laparoscopic cholecystectomy in Spain. Results of a multiinstitutional study conducted by the Committee for Endoscopic Surgery (Associación Española de Cirujanos)

We present a joint study conducted by the Committee for Endoscopic Surgery in Spain. Sixty-nine surgeons reported 2,342 laparoscopic cholecystectomies (LCs) performed until November 1992. The conversion rate was 5.1%. The overall morbidity was 7.1%. The biliary morbidity was 0.45%: Seven severe bile duct injuries were recognized at laparoscopy (0.28%) and four lesions were postoperatively diagnosed (0.16%). Bile leak unrelated to bile duct lesion occurred in 14 patients (0.7%), leading to five reoperations. The mortality was 0.12% and was unrelated to the laparoscopic approach in two cases. The risk factors for biliary complications were obesity, previous history of jaundice, and previous hospital admissions. Surgeon experience was defined by 50 LCs performed and the overall complication rate presented a statistically significant relation to surgeon experience (P < 0.001).