Intermittent pneumatic compression and pharmacologic thrombosis prophylaxis

Impact of pulmonary embolism on morbidity and mortality in patients undergoing pancreatic surgery

PURPOSE

Postoperative pulmonary embolism (PE) after pancreatic surgery is a potentially life-threatening complication. However, the magnitude of morbidity and mortality of PE is still uncertain. The present study aims to assess the incidence of PE after pancreatic surgery and analyze its impact on the outcome.

METHODS

We conducted a retrospective study including all patients who underwent pancreatic resections between 2005 and 2017. The development of PE was analyzed for a 90-day period following surgery. Risk factors were evaluated using regression models.

RESULTS

The study investigated 947 patients undergoing pancreatic surgery. Overall, 26 (2.7%) patients developed PE. The median body mass index (BMI) of patients with PE was significantly higher (28.1 kg/m² [24.7-31.8] vs. 24.8 kg/m² [22.4-27.8], p < 0.001). Patients with PE had a significantly increased duration of the operation and more often underwent multivisceral resections. The lowest incidence of PE was found after distal or total pancreatectomy (2%). In median, PE occurred on the fifth postoperative day (interquartile range: 3-9). Increased BMI, duration of operation, and postoperative deep venous thrombosis were found to be multivariate risk factors for the development of PE. Importantly, postoperative complications (53.8% vs. 15.1%, p < 0.001) and the 30-day mortality rate were significantly increased in the PE group (19.2% vs. 3.3%, p < 0.001).

CONCLUSIONS

Patients with increased BMI, a history of deep venous thrombosis, and multivisceral resections are a high-risk group for PE after pancreatic surgery. While the absolute incidence and related mortality of PE after pancreatic surgery is low, it is associated with severe sequelae.

Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation

Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem.

A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed.

At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients.

Cite this article: Bone Joint J 2015;97-B:675–80.

Can foot compression under a plaster cast prevent deep-vein thrombosis during lower limb immobilisation?

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (ϕ = 0.71; p = 0.019), leading to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.