INTRODUCTION:
Deep venous thrombosis is a condition where there is development of thrombus in the vein of deep venous system, mostly affecting lower limbs. Deep venous thrombosis is not a rare entity as we think. It is a much more common but often underestimated and under recognised. These are because of the lack of standardisation in all health facilities. That too in general surgery, where it often goes unnoticed because of less suspicion. So to get an idea about DVT in patients undergoing open cholecystectomy, which is one of the common operations done in our hospital, I have done this study.
BACKGROUND:
DVT causes lot of morbidity and mortality. It affects both patient and health faculty, in terms of time, money, materials and often lives in case of pulmonary embolism. To conclude the patient risk for developing DVT, who are undergoing open cholecystectomy in our institution, I have assessed the patients in a prospective manner.
OBJECTIVE:
1. To study the incidence of DVT in patients undergoing open cholecystectomy, who are otherwise free of obvious risk for DVT, for a period of one year from June 2011 to July 2012 in our general surgery department.
2. To form a protocol for whom the pharmacological methods of thrombo prophylaxis are to be started.
Why cholecystectomy in particular?
1. Common major surgery in our hospital.
2. Common risk factors to both like Fatty, fourty etc so Prone for DVT.
3. Reverse Trendelenberg position for Cholecystectomy (as 40% of DVT starts on table itself).
4. The immobilisation following surgery due to upper abdomen incision.
5. To prevent pulmonary embolism from its root level, as pulmonary embolism has high mortality.
6. If the guidelines, suggested by this study are accepted it may be used for future protocols.
MATERIALS AND METHODS:
All the patients planned for cholecystectomy were subjected to following Investigations.
Radiological investigation:
• Doppler – for all patients,
• X ray chest / CT chest – if suspicion of PE.
Bio chemical investigations:
• Lipid profile,
• Complete hemogram,
• PT/INR,
• Liver function test,
• Renal function test,
• ESR.
History wise:
• h/o DVT/PE
• Family history of connective tissue disorder,
• Cancer surgery,
• Immobilisation,
• OCP intake,
• Post partum,
• h/o sepsis,
• varicose veins.
Clinically patient is examined in a symptom oriented manner.
Study cohort:
Totally 68 open cholecystectomy done in out department. 30 – Eligible after initial screening, 13 – Diabetic patients, 8 – Diabetic with hypertension, 2 – Septicaemia, 8 – Obesity (>30 BMI), 2 – Altered liver function with low protein, 1 – Varicose veins, 3 – h/o unknown leg swelling, h/o local treatment and drug intake in last 3 months 1 – h/o DVT.
Inclusion criteria:
The patients who are all undergoing open cholecystectomy, with following indications without any risk factor for DVT:
1. Calculus cholecystitis without septicaemia,
2. Cholelithiasis,
3. Acute cholecystitis with or without calculus without septicaemia,
4. CBD stone,
5. Mucocele Gallbladder.
Exclusion criteria:
1. Patients with DVT obvious risk factors,
2. Patients with Co morbid conditions known to cause DVT.
CONCLUSION:
The patients who had indications for cholecystectomy, and had undergone surgery, who otherwise had no risk factors for DVT, developed DVT with the incidence of 1/30 in our hospital.
In my study, I have excluded all the DVT risk patients.
But the sample size and its representation about various population groups are not adequate. So with this experience further studies are to be done.
So it is better to start some form of mechanical method of prophylaxis to all patients undergoing cholecystectomy, as the immobilisation is expected from pain due to upper abdomen incision, obesity, females and other risk factors, then according to post operative clinical findings and investigations if any is positive for DVT, further management is to be done.
Because cholecystectomy is done for patients are also found to have risk factors for DVT as it is shared by both.
In the presence of some risk factors for DVT, the patient should be started on pharmacological method of prophylaxis.
But ultimately, all the patients undergoing cholecystectomy should be given the basic measures like adequate hydration, adequate analgesia, and identification of risk factors, early ambulation, both active and passive flexion exercises and proper information to patients on the clinical presentation of DVT
