|Year : 2007 | Volume
| Issue : 3 | Page : 228-230
Pulmonary thromboembolism following laparoscopic cholecystectomy in a patient with preexisting risk factors for deep venous thrombosis
Jyotsna A Goswami1, Aparna S Budhakar2
1 MD, Consultant, Department of Anaesthesiology, Jaslok Hospital and Research Centre, Mumbai 400 026, India
2 MD, FRCA, Consultant, Department of Anaesthesiology, Jaslok Hospital and Research Centre, Mumbai 400 026, India
|Date of Acceptance||16-Apr-2007|
|Date of Web Publication||20-Mar-2010|
Jyotsna A Goswami
Department of Anaesthesiology, Jaslok Hospital and Research Centre, Mumbai 400 026
Source of Support: None, Conflict of Interest: None
We report a case of a forty-five year old male who was admitted fifteen days prior with biliary pancreatitis. He developed pulmonary thromboembolism (PTE) after uneventful laparoscopic cholecystectomy. He was initially treated with intravenous (IV) heparin and inferior vena cava (IVC) filter. Later on he underwent emergency pulmonary embolectomy due to haemodynamic deterioration. There is less incidence of PTE after laparoscopic cholecystectomy, but it becomes high-risk for postoperative thromboembolic complications when it is associated with other risk factors. The purpose of this report is to highlight that preoperative detection of risk factors and thromboprophylaxis in indicated cases can prevent this complication. We also review the incidence of PTE, risk factors and thromboprophylaxis.
Keywords: Laparoscopic cholecystectomy; Thromboembolism, Thromboprophylaxis.
|How to cite this article:|
Goswami JA, Budhakar AS. Pulmonary thromboembolism following laparoscopic cholecystectomy in a patient with preexisting risk factors for deep venous thrombosis. Indian J Anaesth 2007;51:228-30
|How to cite this URL:|
Goswami JA, Budhakar AS. Pulmonary thromboembolism following laparoscopic cholecystectomy in a patient with preexisting risk factors for deep venous thrombosis. Indian J Anaesth [serial online] 2007 [cited 2020 Apr 5];51:228-30. Available from: http://www.ijaweb.org/text.asp?2007/51/3/228/61148
| Introduction|| |
Laparoscopic cholecystectomy is associated with risk of postoperative thromboembolism , ,  due to venous stasis caused by pneumoperitoneum , and reverse trendelenburg position . Pneumoperitoneum may also induce a thrombogenic condition , , . Incidence increases in case of preexisting risk factors. We describe a case where patient developed PTE on first postoperative day after uneventful laparoscopic cholecystectomy.
| Case report|| |
A 45-yr-old, 65-kg male patient with hypertension was scheduled for laparoscopic cholecystectomy. Fifteen days prior to surgery he was admitted in intensive care unit (ICU) with acute biliary pancreatitis for 3 days. No thromboprophylaxis was started. Anaesthesia was induced with midazolam-fentanyl-propofol-atracurium and maintained with O 2 -N 2 O-isofluranefentanyl-atracurium. Immediate perioperative course was uneventful. Next morning he developed sudden onset of severe dyspnoea followed by syncope. SpO 2 was 88% on air. Arterial blood gas confirmed hypoxemia. Chest X-ray was normal. ECG showed S1Q3T3 pattern which is characteristic of pulmonary embolism. D-Dimer was 2000 ng.ml -1. 2-Dimensional echocardiography revealed right atrio-ventricular dilatation with right ventricular dysfunction and mean pulmonary artery pressure (PAP) 35 mmHg with left ventricular ejection fraction of 60%. Venous Doppler study of lower limb showed floating thrombus in superficial femoral vein extending from its mid-part to popliteal vein. PTE was suspected which was confirmed by spiral angiotomography which showed thrombus in both right and left pulmonary vessels [Figure 1], [Figure 2]. He was treated with supplemental oxygen, heparin and filter in IVC. Next day as his haemodynamic status deteriorated he was put on ventilatory support. Inotropic support was started with dopamine. Invasive monitoring were established. Central venous pressure ( CVP ) was 18 mmHg, heart rate 170 minute -1 and arterial blood pressure (ABP) 110/70 mmHg with dopamine infusion at the rate of 8 mg.kg -1 .min -1 . SpO 2 was 95% with FiO 2 of 0.8. He was taken for emergency pulmonary embolectomy. Intraoperatively we continued monitoring of all the parameters and maintained anaesthesia with midazolam, fentanyl, vecuronium and isoflurane-air-oxygen. Embolectomy was done with cardiopulmonary bypass which was uneventful. At the end of surgery he was electively ventilated in the ICU. His trachea was extubated on the third postoperative day. On the ninth day there was sudden deterioration in haemodynamic status due to bleeding from cystic artery which was embolized. However, he developed sepsis and disseminated intravascular coagulation and died on eleventh day.
| Discussion|| |
The risk of thromboembolism after laparoscopic cholecystectomy is still debated. There is wide variation in reported incidences. Low incidence (0-2%) was reported by several authors , whereas Patel et al reported incidence as high as 55% .
There are various risk factors  described. Depending on these factors surgical patients have been classified into four risk groups by American College of Clinical Pharmacy (ACCP) . As per ACCP our patient fitted into high risk group as he was in the age group of 40-60 years, immobilized prior to surgery and his surgery lasted more than 30 minutes. Still he was neither screened for DVT nor provided thromboprophylaxis. Apart from patient risk factors there are some risk factors related to the surgery itself In 1993, Jorgensen et al  reported 3 cases of venous thromboembolism (VTE) among 438 laparoscopic cholecystectomies in spite of using thromboprophylaxis with heparin and compression stockings. The author pointed out that the reverse Trendelenburg position was the responsible factor. Beebe et al  analyzed 8 patients to evaluate the effect of pneumoperitoneum on various parameters and observed significant increase in femoral venous pressure, decrease in venous pulse and reduction in blood flow velocity after pneumoperitoneum, which came back to normal after 5 minutes of deflation. Prisco et al  investigated haemostatic alterations in 8 patients and demonstrated thrombogenicity.
Regarding thromboprophylaxis, Bradburry et al  in a survey in England and Ireland in 1993 showed that 400 surgeons out of 417 used thromboprophylaxis commonly with heparin. Tvedskov et al  conducted a similar survey in Denmark, in which all 46 surgeons used prophylaxis and LMWH was the drug of choice. In a randomized, double-blind prospective study, Okuda et al  compared the use of heparin and intermittent pneumatic compression (IPC) versus IPC alone in relation to thrombogenesis and suggested that the combined therapy was more effective. ACCP has laid a guideline for thromboprophylaxis in different surgical risk group . Recently, Society of American Gastrointestinal Endoscopic Surgeons (SAGES) in their website  mentioned that until adequate data becomes available, the recommendations for open surgical procedures should be followed when the same procedures are accomplished via laparoscopic access. It was failure on our part as a team that we overlooked the risk factors and did not use thromboprophylaxis. We conclude that there is low but definite risk of VTE after laparoscopic procedure which should not be underestimated. Detailed preoperative evaluation, risk stratification and thromboprophylaxis in indicated cases will help to prevent this dreadful complication.
| References|| |
|1.||Holzheimer RG. Laparoscopic procedures as a risk factor of deep venous thrombosis, superficial ascending thrombophlebitis and pulmonary embolism - case report and review of the literature. Eur J Med Res 2004; 9: 417-22. |
|2.||Vecchio R, Cacciola E, Martino N, Cacciola RR, MacFadyen BV. Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy. Surg Endosc 2003; 17: 428-33. |
|3.||Schaepkens VR, Van Hee RH, Weyler JJ. Deep venous thrombosis after laparoscopic cholecystectomy and prevention with nadroparin. Surg Endosc 2002; 16: 184-187. |
|4.||Lindburg F, Berggvist D, Rasmussen I. Incidence of thromboembolic complications after laparoscopic cholecystectomy; Review of the literature. Surg Laparosc Endosc 1997; 7: 324-31. |
|5.||Jorgensen JO, Lalak NJ, North L, et al. Venous stasis during laparoscopic cholecystectomy. Surg Laparosc Endosc 1994; 4: 128-33. |
|6.||Prisco D, Gaudio AR, Carla R, et al. Videolaparoscopic cholecystectomy induces a hemostasis activation of lower grade than does open surgery. Surg Endosc 2000; 14: 170-74. |
|7.||Blake AM, Toker SI, Dunn E. Deep venous thrombosis prophylaxis is not indicated for laparoscopic cholecystectomy. JSLS 2001; 5: 215-9. |
|8.||Lord R VN, Ling J, Hugh TB, et al. Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy. Arch Surg 1998; 133: 967-73. |
|9.||Patel MI, Hardman DTA, Nichols D, Fisher CM, Appleberg M. The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust 1996; 164: 652-656. |
|10.||Bates SM, Ginsberg JS. Clinical practice. Treatment of deepvein thrombosis. N Engl J Med 2004; 351: 268-77. |
|11.||Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic therapy. Chest 2004: 126 (3 suppl): 338S-400S. |
|12.||Jorgensen JO, Lalak NJ, North L, et al. Thromboembolic complications of laparoscopic cholecystectomy. BMJ 1993; 306: 518-9 |
|13.||Beebe DS, McNevin MP, Crain JM, et al. Evidence of venous stasis after abdominal insufflation for laparoscopic cholecystectomy. Surg Gynecol Obstet 1993; 176: 443-47. |
|14.||Bradburry AW, Can YC, Darzi A, Stansby G. Thromboem bolism prophylaxis during laparoscopic cholecystectomy. Br J Surg 1997; 84: 962-4. |
|15.||Tvedskov TF, Rasmussen MS, Jorgensen PW. Survey of the use of thromboprophylaxis in laparoscopic surgery in Denmark. Br J Surg 2001; 88: 1413-6. |
|16.||Okuda Y, Kitajima T, Egawa H. A combination of heparin and IPC device may be more effective to prevent DVT in the lower extremities after laparoscopic cholecystectomy . Surg Endosc 2002; 16: 781-4. |
|17.||The Society of American Gastrointestinal and Endoscopic Surgeons. Sages Position Statement: Global statement on deep venous thrombosis prophylaxis during laparoscopic surgery. www.sages.org/sg pub c.html. |
[Figure 1], [Figure 2]