[Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication]

first, to study the effect of a pneumoperitoneum (12 mm Hg) on femoral venous outflow, second, to evaluate the efficacy of mechanical antistasis devices: intermittent pneumatic compression (IPC), intermittent electric calf muscle stimulation (IECS) and graded compression leg bandages (LB) in reducing venous stasis, third, to determinate the incidence of deep venous thrombosis (DVT) after laparoscopic fundoplications using venous occlusion plethysmography method.

54 patients undergoing elective laparoscopic fundoplications were studied. They were randomized into three groups - 18 patients in each group. The first group received LB, the second group received IECS and the third group IPC during operations. Lower extremity venous blood velocity was evaluated using Doppler ultrasonography during operation. In all 54 patients leg venous outflow was measured 1 day before and 1 day after operation using venous occlusion plethysmography method, in order to detect possible DVT after operation. The blood velocity in the femoral vein without pneumoperitoneum was 20.1 +/- 2.4 cm/s in the IPC group, 20.3 +/- 1.4 cm/s in the IECS group, and 23.9 +/- 1.2 cm/s in the LB group. With the introduction of a pneumoperitoneum (12 mm Hg) and the reverse Trendelenburg position the femoral venous blood velocity was significantly reduced in all groups: 9.3 +/- 0.9 cm/s in IPC group, 9.4 +/- 0.9 cm/s in IECS group, and 9.2 +/- 1.1 cm/s in LB group (p < 0.05). The maximum blood velocity generated by the IPC when a pneumoperitoneum (12 mm Hg) was present was 17.4 +/- 1.9 cm/s, and in the IECS group 14.0 +/- 1.1 cm/s, whereas in the LB group the blood velocity remained the same (9.2 +/- 1.1 cm/s). Calf DVT and pulmonary artery microembolization developed in one patient of the LB group, detected by venous occlusion plethysmography and lung perfusion scintigraphy methods one day after operation.

The femoral vein stasis which appears in laparoscopic fundoplications can be minimized by reducing the intraabdominal pressure during operation, and avoiding reverse Trendelenburg position as much as possible. IPC is more effective than IECS in reducing venous stasis induced by the pneumoperitoneum and the reverse Trendelenburg position. Graded compression by leg bandages is ineffective in patients undergoing laparoscopic gastrofundoplication. With a pneumoperitoneum in place, neither device was able to return the depressed blood flow velocity to the values recorded without a pneumoperitoneum. The incidence of DVT and pulmonary embolism after laparoscopic fundoplications was 1.8 % in our study.