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Septic Pelvic Thrombophlebitis Following Laparoscopic Hysterectomy

Authors:
Camran Nezhat at Stanford University
Camran Nezhat
Parastoo Farhady
Parastoo Farhady
Parastoo Farhady
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Madeleine Lemyre at Université Laval
Madeleine Lemyre
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Abstract

The diagnosis of septic pelvic thrombophlebitis is frequently one of exclusion; a suspicion should arise when fever fails to respond to standard broad-spectrum antibiotic therapy and defervesces within 48 hours of the addition of systemic anticoagulation. The risk of a thromboembolic event following minimally invasive surgery is not well defined. We report the first case of septic pelvic thrombophlebitis following laparoscopic hysterectomy in a 51-year-old woman who developed fever on postoperative day 4. The fever workup was negative. The patient's temperature spikes were unresponsive to medical management. A clinical diagnosis of septic pelvic thrombophlebitis was made, and the patient responded excellently to anticoagulation in conjunction with antibiotic therapy. Although rare, septic pelvic thrombophlebitis should be suspected after laparoscopy in patients with appropriate risk factors and persistent fever despite antibiotic therapy. Considerable benefit will be derived from clinical trials that study and provide data on the risk and incidence of thromboembolism after laparoscopic procedures.
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Septic Pelvic Thrombophlebitis Following
Laparoscopic Hysterectomy
Camran Nezhat, MD, Parastoo Farhady, MD, Madeleine Lemyre, MD
ABSTRACT
Background: The diagnosis of septic pelvic thrombo-
phlebitis is frequently one of exclusion; a suspicion
should arise when fever fails to respond to standard
broad-spectrum antibiotic therapy and defervesces within
48 hours of the addition of systemic anticoagulation. The
risk of a thromboembolic event following minimally inva-
sive surgery is not well defined.
Case Report: We report the first case of septic pelvic
thrombophlebitis following laparoscopic hysterectomy in
a 51-year-old woman who developed fever on postoper-
ative day 4. The fever workup was negative. The patient’s
temperature spikes were unresponsive to medical man-
agement. A clinical diagnosis of septic pelvic thrombo-
phlebitis was made, and the patient responded excellently
to anticoagulation in conjunction with antibiotic therapy.
Conclusion: Although rare,septic pelvic thrombophlebi-
tis should be suspected after laparoscopy in patients with
appropriate risk factors and persistent fever despite anti-
biotic therapy. Considerable benefit will be derived from
clinical trials that study and provide data on the risk and
incidence of thromboembolism after laparoscopic proce-
dures.
Key Words: Septic pelvic thrombophlebitis, Laparos-
copy, Hysterectomy, Postoperative fever.
INTRODUCTION
Septic pelvic thrombophlebitis (SPT) was initially de-
scribed at the end of 19th century. The entity was then
frequent and resulted in a 50% rate of mortality. Since
then, with a better understanding of the pathophysiology
of the disease and the availability of new drugs, manage-
ment has evolved greatly and the incidence has been
reduced. Diagnosis continues to be challenging and is
still, usually, one of exclusion. The treatment of SPT has
switched from a surgical excision or ligation of the throm-
bosed veins to a medical approach.
Two types of septic pelvic thrombophlebitis (SPT) have
been described: ovarian vein thrombophlebitis (OVT) and
deep septic pelvic thrombophlebitis (DSPT). These 2 en-
tities share common pathogenic mechanisms and often
occur simultaneously. However, they may differ in their
clinical presentations.
Typically, patients with SPT present with fever within 1
week of delivery or surgery. Septic workup fails to identify
the origin of the fever, which persists despite large-spec-
trum antibiotics. Addition of systemic anticoagulation re-
solves the fever within 48 hours.
To the best of our knowledge in the English-language
literature, SPT has never been reported to be associated
with laparoscopic surgery. We report the first case of SPT
occurring 4 days after a total laparoscopic hysterectomy.
CASE REPORT
A 51-year-old female with previous left salpingo-oo-
phorectomy underwent a difficult laparoscopic hyster-
ectomy with right salpingo-oophorectomy for extensive
endometriosis and menometrorrhagia. Her past medical
history was significant for type 2 diabetes, hyperten-
sion, hypothyroidism, adrenal insufficiency, and a
BMI⬎30. Antibiotic prophylaxis, heparin prophylaxis,
and cortisol replacement were administered periopera-
tively. The patient had transient unexplained asymp-
tomatic sinusal tachycardia up to 124 beats per minute
during the first postoperative night, which improved
spontaneously. She was discharged the following day in
stable condition.
Center for Special Minimally Invasive Surgery, Palo Alto, California, USA (Drs
Nezhat, Lemyre)., Wilmington, Delaware, USA (Dr Farhady).
Address correspondence to: Camran Nezhat, MD, Center for Special Minimally
Invasive Surgery, 900 Welch Road, Suite 403, Palo Alto, CA 94304, USA. Telephone:
650 327 8778, Fax: 650 327 2794.
© 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2009)13:84–8684
CASE REPORT
The patient came back on postoperative day 6 (POD)
reporting fever and chills since POD4, which had gradu-
ally worsened. She denied any respiratory or urinary
symptoms, calf pain, abdominal pain, or vaginal dis-
charge. She reported 10 episodes of diarrhea within 2
days. Temperature on presentation was 39.4
o
C. Lungs,
abdomen, and calves were normal on examination. Office
ultrasound revealed a 51x31x28-mm heterogeneous ten-
der collection at the vaginal cuff.
The patient was admitted for postoperative fever. A com-
plete fever workup was done. Chest radiography, urine
culture, hemoculture, and clostridium difficile essay were
negative, and white blood count was normal. She was
started on intravenous antibiotic therapy (ampicillin, gen-
tamicin, and clindamycin) for suspected infected vaginal
vault hematoma. A pelvic tomodensitometry confirmed a
small triangular structure in the pelvis near the sigmoid
colon. This did not appear to contain significant drainable
fluid. The internal medicine department was consulted for
evaluation of diarrhea and resulting hypokalemia as well
as suboptimal glycemic control. In the absence of im-
provement of the fever, the infectious disease department
was also consulted, and antibiotic therapy was changed to
Zosyn. The patient was subsequently taken to the oper-
ating room on POD11 for a diagnostic laparoscopy. No
evidence of pelvic collection, hematoma, or infection was
found. Pelvic cultures were negative. At this point, as
persistent fever spikes were not otherwise explained, a
clinical diagnosis of septic pelvic thrombophlebitis was
suspected. Doppler sonography of the lower extremities
was negative. On POD12, heparin therapy was added to
the intravenous antibiotic regimen. From this point, the
patient’s temperature normalized. After a 48-hour afebrile
period, both medications were stopped, and the patient
was discharged home in stable condition. She was doing
excellently at 5-week follow-up.
DISCUSSION
The pathophysiology of SPT was initially described in a
cohort of 70 women with fever following obstetric or
gynecologic procedures in 1951.
1
The diagnosis was con-
firmed in each case by exploratory laparotomy, which
demonstrated grossly palpable intravenous thrombus and
seropurulent fluid. Histopathologic study showed perivas-
cular and intimal inflammatory exudates with micro ab-
scesses but rare bacteria.
Clinically, patients with SPT usually present with fever
within 5 days of delivery or surgery, but the onset may be
delayed to up to 3 weeks following the event. Abdominal
or pelvic tenderness is notably absent, and patients usu-
ally appear clinically well between fever spikes. Pulmo-
nary emboli rarely complicate SPT and tend to be limited.
2
The mortality now seems to be below 5%.
3,4
Numerous factors confer increased risk for SPT, such as
pregnancy (1 in 3000),
5
cesarean delivery (1:800 com-
pared with 1:9000 for vaginal delivery),
5
pelvic infection,
induced abortion, pelvic surgery, uterine fibroids, under-
lying malignancy, and hormonal stimulation. Those con-
ditions create an environment where the 3 components of
Virchow’s triad for the pathogenesis of thrombosis (hy-
percoagulable state, venous stasis, and endothelial dam-
age) are present.
SPT is a diagnosis of exclusion. Radiographic imaging,
such as computed tomography or magnetic resonance
imaging, can reveal OVT but is virtually useless for visu-
alizing DSPT. Leukocytosis is modest, and hemocultures
are positive in less than a third of cases revealing mainly
gastrointestinal flora. Suspicion should arise in patients at
risk when spiking fever fails to respond to broad-spectrum
intravenous antibiotic therapy. The resolution of fever
within 48 hours of empiric systemic anticoagulation
should confirm the diagnosis.
Anticoagulation is advocated for the management of
SPT
2,6
to a goal PTT of 1.5 to 2.0 times the patient’s
baseline. If SPT or emboli are documented radiologically,
anticoagulation should be continued for a longer period.
In the absence of documented clot or underlying throm-
bophilia, most clinicians favor discontinuing heparin fol-
lowing resolution of fever for at least 48 hours. Selection
of antibiotics for management of SPT is extrapolated from
literature addressing postpartum endometritis and should
include activity against Enterobacteriaceae, anaerobes,
and streptococci.
Review of the English-language literature reveals no
reports of previous cases of SPT associated with lapa-
roscopic surgery. The incidence of perioperative deep
and superficial thrombophlebitis is lower after laparo-
scopic compared with open surgery.
7
However, data
are limited and evidence-based guidelines regarding
the need for thromboprophylaxis during laparoscopic
surgery in gynecology are still lacking. There is sub-
stantial variability in the current practices regarding
deep venous thrombosis prophylaxis for minimally in-
vasive surgery.
8
Considerable benefit could be derived
from clinical trials studying the risk of DVT during
different laparoscopic gynecologic surgeries and the
benefit to expect from prophylaxis.
JSLS (2009)13:84–86 85
A high index of suspicion is the cornerstone in the
management of patients with septic pelvic thrombosis.
It seems that minimally invasive surgery may contribute
to its pathogenesis and should be considered as a
risk factor in high-risk patients with compatible clinical
presentation. We hope that this case report can
help physicians become aware of this rare but serious
complication and to avoid delay in diagnosis and treat-
ment.
References:
1. Collins CG, MacCallum EA, Nelson EW, Weinstein BB, Col-
lins JH. Suppurative pelvic thrombophlebitis. Surgery. 1951;30:
298–328.
2. Garcia J, Aboujaoude R, Apuzzio J, Alvarez JR. Septic pelvic
thrombophlebitis: diagnosis and management. Infect Dis Obstet
Gynecol. 2006;2006:15614.
3. Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Post-
partum ovarian vein thrombophlebitis: a review. Obstet Gynecol
Surv. 1991;46:415–427.
4. Williams JW. Ligation of extension of the pelvic veins in the
treatment of puerperal pyemia. Am J Obstet. 1909;59:758–789.
5. Brown TK, Munsick RA. Puerperal ovarian vein thrombo-
phlebitis: a syndrome. Am J Obstet Gynecol. 1971;109:263–273.
6. Josey WE, Staggers SR. Heparin therapy in septic pelvic
thrombophlebitis: a study of 46 cases. Am J Obstet Gynecol.
1974;120:228–233.
7. Nguyen NT, Hinojosa MW, Fayad C, et al. Laparoscopic surgery
is associated with a lower incidence of venous thromboembolism
compared with open surgery. Ann Surg. 2007;246:1021–1027.
8. Beekman R, Crowther M, Farrokhyar F, Birch DW. Practice
patterns for deep vein thrombosis prophylaxis in minimal-access
surgery. Can J Surg. 2006;49:197–202.
Septic Pelvic Thrombophlebitis Following Laparoscopic Hysterectomy, Nezhat C et al
JSLS (2009)13:84–86
86
... It is a potentially deadly subset of septic pelvic thrombophlebitis (SPT) which remains difficult and often misdiagnosed [1]. DSPT is a diagnosis of exclusion and should be considered in the setting of antibiotic-resistant fever 4 hours following delivery in postpartum women [1][2][3]. Here, we present a case of successful diagnosis of DSPT in a 26-year-old primigravid who presented with fever and antibioticresistant leukocytosis following an uncomplicated cesarean delivery. Though data is limited regarding this diagnosis, our case appears to align with others in that the patient appeared non-toxic with negative blood cultures throughout the admission and shared cesarean section as a risk factor. ...
... SPT is a rare condition with a strong correlation with the postpartum period. SPT was first described at the end of the 19th century by a 70-woman cohort researched by von Recklinghausen [1,[3][4]. It is a challenging diagnosis, which is generally characterized by fever and antibiotic resistance. ...
... Due to the notable absence of significant laboratory and imaging findings, SPT has largely been considered a clinical diagnosis, and one of exclusion. Occasionally, CT or MRI may reveal thrombosis in the ovarian veins, however, imaging is often negative in the case of DSPT [3,7]. A recent study noted that blood cultures are negative upward of 97% of the time, as was the case with our patient [2]. ...
Beyond Postpartum Fever: Case Report Uncovering Deep Septic Pelvic Thrombophlebitis
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Deep septic pelvic thrombophlebitis (DSPT) is a rare postpartum condition that should be considered in the setting of postpartum fever and may prove to be a challenging diagnosis. Here, we report the case of a 26-year-old female who presented with fever and antibiotic-resistant leukocytosis following an uncomplicated cesarean delivery. After ruling out pulmonary embolism and other causes of septicemia and considering the overall negative imaging studies, the patient received a clinical diagnosis of DSPT and recovered well following antibiotic augmentation and anticoagulation.
View
... Typically, patients with OVT appear clinically ill, with fever and abdominal pain located on the side of the affected vein, flank or back, within one week after delivery or surgery [3,6]. Patients with DSPT usually present three to five days after delivery or surgery with an unfocalized fever, which may be the only symptom; that symptom commonly persists despite antibiotics. ...
... The diagnosis of SPT poses a challenge, given that there is no definitive laboratory test for it. Leukocytosis is modest and blood cultures are positive in less than a third of cases [6]. In this case, analytical parameters of inflammation improved after triple antibiotic therapy, although patient's clinical condition was unchanged. ...
... Treatment of this disorder includes antibiotic therapy and anticoagulation, although there is no consensus on this [1,4,5]. The selection of antibiotics for managing SPT is extrapolated from the literature on postpartum endometritis, since at the time when a presumptive diagnosis of SPT is made, most patients will have already been receiving broad-spectrum parenteral antibiotics to cover the common pathogens of endometritis [5,6]. The duration of the antibiotic therapy is not strictly defined [5]. ...
Postpartum septic pelvic thrombophlebitis after caesarean delivery: a case report
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  • Mar 2018
Septic pelvic thrombophlebitis is a rare puerperal complication. It is an important differential diagnosis of postpartum fever and abdominal pain and although the condition is well known its diagnosis can be challenging. We report a case of a 41-year-old woman with fever and right abdominal pain three days after an uncomplicated caesarean delivery. Clinical, laboratory and imaging exams were unremarkable and the patient was treated for endometritis. In the absence of improvement despite an antibiotic adjustment, a clinical diagnosis of septic pelvic thrombophlebitis was made, and the patient presented a good response to anticoagulation in conjunction with broad-spectrum antibiotic therapy.
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... İnsidansı 1/1000 ile 1/3000 arasında görülmektedir (1). Hastalık sıklıkla sezaryen ile doğumlarda görülse de vaginal doğum, pelvik cerrahi ve enfeksiyonlar ile malignite durumlarında da görülmektedir (2). Tanıda görüntüleme yöntemleri öncelikli olmakla birlikte bazı olgularda antikoagulan tedaviye yanıt ile de tanı konulabilmektedir. ...
... Bu olgumuzda pelvik inflamatuar enfeksiyona sekonder gelişmiş OVT olgusunu tartışmayı amaçladık. (2,9). Hastalığın tedavisinde, olası bakterileri içine alan geniş spektrumlu antibiyoterapiye antikoagulan tedavinin eklenmesi uygun görülmektedir (10). ...
Pelvik inflamatuar hastalık sonrası gelişen ovaryan ven tromboflebiti: Bir olgu sunumu
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Ovaryan ven tromboflebiti (OVT) pelvik hastalıklara ovaryan damarlarda trombozun eşlik ettiği nadir bir hastalıktır. Hastalık sıklıkla sezaryen, vaginal doğum, pelvik cerrahi ve enfeksiyonlar ile malignite durumlarında görülmektedir. Cerrahi ile tedavisi mümkün olsa da günümüzde antibiyoterapi ve antikoagulan tedavi kabul görmektedir. Bu olgumuzda pelvik inflamatuar enfeksiyona sekonder gelişmiş ovaryan ven tromboflebiti olgusunu tartışmayı amaçladık.
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... 101 Venous drainage post-Csection can also spread infection, generating septic pelvic thrombophlebitis. 102 Pelvic thrombophlebitis is usually refractory to broadspectrum antibiotics alone and requires anticoagulation with broad polymicrobial coverage. [102][103][104] Liberal use of postpartum CT has significantly impacted management. ...
... 102 Pelvic thrombophlebitis is usually refractory to broadspectrum antibiotics alone and requires anticoagulation with broad polymicrobial coverage. [102][103][104] Liberal use of postpartum CT has significantly impacted management. In a retrospective cohort study of 238 postpartum patients, the use of CT resulted in alteration of antibiotic therapy in 10%, addition of low-molecular weight heparin (LMWH) in 12%, and surgical intervention in 17%. ...
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The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.
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... Septic pulmonary emboly (SPE) (13%) and metastatic abscess were reported as the two important complications of SPT. [13] Also, some studies reported other complications such as the clot clogging iliofemoral or renal vein by reverse flow. [14,15] In addition, septic thrombi and embolies are the source of bacteremia and they can be fatal if not treated. ...
A rare complication developing after delivery: septic pelvic thromboembophlebitis
Article
Full-text available
  • Apr 2020
Objective In this case report, we aimed to discuss a septic pelvic thromboembophlebitis (SPT) case detected 20 days later who had the previous history of cesarean section and had an intrauterine stillbirth vaginally at 30 weeks of gestation. Case(s) A 24-year old patient, who admitted to the emergency service with the complaints of fever and pain in the lower right abdomen and was reported to have a 4 cm formation consistent with thrombus on the right ovarian vein wall in the computed tomography (ST), was hospitalized for follow-up and treatment. The patient whose thrombus showed remission in the check-up tomography scan after the broad-spectrum antibiotherapy and anticoagulant treatment was discharged on the 10th day. The treatment of the patient who did not develop any complication in the follow-ups was completed with recover. Conclusion In conclusion, SPT is a complication which is seen rarely in both obstetric and gynecologic practices. SPT is a disease which may lead to fatal outcomes by late diagnosis but satisfying results with early diagnosis. Abdominal pain and fever symptoms should come to mind in all cases after delivery or operation.
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... The incidence of OVT after gynecological surgery is unknown. Regarding minimally invasive surgery, there is only one case report of SPT after laparoscopic hysterectomy [6]. ...
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An abundance of literature has demonstrated that Coronavirus Disease 2019 (COVID-19) contributes to a hypercoagulable state that is associated with venous thromboembolic events. Data on post-operative complications following mild COVID-19 infection is limited. We report a case of ovarian vein thrombosis (OVT) following pelvic surgery in a patient with a recent mild COVID-19 infection. The patient presented with complaints of fever and worsening right-sided abdominal pain postoperatively and was found to have a right OVT. Thrombophilia workup was negative. The hypercoagulable state of patients diagnosed with COVID-19 may have implications on postoperative complications after gynecologic surgery even in cases of mild infection. Further research is needed to determine the optimal thromboembolic prophylaxis for patients undergoing pelvic surgery after COVID-19 infection.
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... It is reported in gynecologic abdominal and pelvic surgery, malignancy, pelvic inflammatory disease and inflammatory bowel diseases and other conditions that can cause thrombus formation in the ovarian veins [3][4][5]. With the increased trend of laparoscopic gynecologic surgeries, OVT is also reported in patients who had undergone minimally invasive surgeries [6][7]. ...
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Ovarian Vein Thrombosis (OVT) is an extremely rare and uncommon thrombotic condition commonly attributed to the postpartum period. We report a case of a 30 yr old P2002 who presented with one day history of fever, chills, vomiting, abdominal and left flank pain. Patient had a preterm vaginal birth at 34 weeks gestation, four days prior to her presentation. Patient was febrile on presentation with left CVA tenderness and diffuse abdominal tenderness. Pelvic Ultrasound showed enlarged uterus 14.7cm x 10.9cm x 8.5cm consistent with a postpartum uterus, with heterogeneous endometrium 2.3 cm, no retained products and normal adnexa. CT scan with contrast showed fluid along the anterior aspect of the left anterior kidney, left psoas muscle and extending down to the left side of the uterus and extending to the region of the left renal vein which confirmed left ovarian thrombosis. A CT Chest with contrast and bilateral lower extremity Doppler ruled out pulmonary embolism and deep vein thrombosis, respectively.The patient was admitted, treated with antibiotics and therapeutic dose of low molecular weight heparin (Enoxaparin) and responded well. Patient was discharged home on oral apixaban. The clinical presentation of OVT is non-specific and can be similar to that of acute pyelonephritis. Physicians should have a high index of suspicion in postpartum patients presenting with flank pain and imaging techniques such as MRI, CT scan and ultrasound should be used to help in making the diagnosis.
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... O diagnóstico é desafiador e ainda é por exclusão. 1,5 Os exames de imagem são fundamentais para elucidação diagnóstica, incluindo ultrassonografia com doppler, TC e RNM. É típica a persistência do quadro febril apesar de antibioticoterapia e a melhora clínica após uma média de 48 horas de anticoagulação associada. ...
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Septic pelvic thrombophlebitis (SPT) was initially diagnosed and described in the late 1800's. The entity had a high incidence and mortality during this period of time, and a surgical therapeutic approach was the treatment of choice. Since then, the diagnosis, incidence, and management of the entity evolved. This evolution followed the development of newer diagnostic tools such as computed tomography (CT), magnetic resonance imaging (MRI), and a better understanding of the pathophysiology of the disease. The treatment of SPT has had significant changes as well, from a surgical approach at the end of the 19th century to a medical approach after the 1960's. By using an adequate broad-spectrum antibiotic therapy, mortality has decreased. However, controversy in the management of this entity remains even till today.
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Laparoscopic Surgery Is Associated With a Lower Incidence of Venous Thromboembolism Compared With Open Surgery
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Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.
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Heparin Therapy in Septic Pelvic Thrombophlebitis: A Study of 46 Cases
Article
  • Oct 1974
  • AM J OBSTET GYNECOL
Heparin anticoagulation was evaluated in 46 postpartum, postabortal, or postoperative patients with septic pelvic thrombophlebitis. Criteria for diagnosis, in addition to the characteristic temperature course, were radiologic evidence of septic pulmonary emboli (15 cases) or persistence of spiking fever despite antibiotic therapy. Response to heparin plus antibiotics was good in all but four patients, three of whom were found at laparotomy to have associated septic complications requiring surgical treatment. The fourth had a severe anaerobic streptococcus and bacteroides septicemia and died despite treatment which included inferior vena cava ligation and hysterectomy. Heparinization appears to be a safe and effectual alternative to venous ligation in the management of septic thrombophlebitis of the pelvic veins.
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  • AM J OBSTET GYNECOL
Puerperal ovarian vein thrombophlebitis is a condition which usually presents as a syndrome consisting of lower abdominal pain, fever, and a characteristic abdominal mass. This syndrome occurs in about 0.18 per cent of puerperas, usually has its onset in the first week postpartum, and is usually best treated with anticoagulants and antibiotics. It occurs more often on the right than on the left. We offer a theory to explain the etiology of this condition and its dextropreponderance.
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Practice patterns for deep vein thrombosis prophylaxis in minimal-access surgery
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  • Jul 2006
  • CAN J SURG
There are no comprehensive evidence-based guidelines for deep vein thrombosis (DVT) prophylaxis in patients undergoing minimal-access surgery (MAS). We completed a cross-sectional survey of general surgeons practising in Ontario, in order to establish current practice patterns for DVT prophylaxis for MAS procedures. The mean duration of practice of respondents was 15.4 years, with most (67.0%) practising outside an academic centre. For minor MAS, most surgeons do not give DVT prophylaxis (73.8% in laparoscopic cholecystectomy and 63.7% in laparoscopic inguinal hernia repair). For major MAS, a minority of surgeons do not give DVT prophylaxis (4.1% in laparoscopic colorectal surgery and 13.6% in laparoscopic splenectomy). However, there remains considerable variation in the mechanism (pharmacological, mechanical), approach and duration (perioperative, postoperative) of DVT prophylaxis among respondents in all case scenarios evaluated. Academic surgeons and surgeons in practice for 15 years or less are more aggressive with preoperative heparin administration. There is substantial and important variability in the current practice of general surgeons with respect to DVT prophylaxis for MAS. Considerable benefit will be derived from clinical trials that provide data to establish appropriate DVT prophylaxis guidelines for MAS.
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Ligation of extension of the pelvic veins in the treatment of puerperal pyemia
  • Jan 1909
  • 758-789
  • Jw Williams
Williams JW. Ligation of extension of the pelvic veins in the treatment of puerperal pyemia. Am J Obstet. 1909;59:758 –789.
Postpartum ovarian vein thrombophlebitis: a review
  • Jan 1991
  • 415-427
  • Dr Dunnihoo
  • Jw Gallaspy
  • Rb Wise
  • Wn Otterson
Dunnihoo DR, Gallaspy JW, Wise RB, Otterson WN. Postpartum ovarian vein thrombophlebitis: a review. Obstet Gynecol Surv. 1991;46:415– 427.