Información del artículo
La enfermedad tromboembólica venosa (ETV) postoperatoria constituye una complicación que afecta aproximadamente a 1 de cada 4 pacientes quirúrgicos generales intervenidos y que no reciben medidas para su prevención. Además del riesgo de embolismo pulmonar, fatal en muchos casos, los pacientes que sufren ETV están expuestos a desarrollar complicaciones a largo plazo, tales como síndrome postrombótico o hipertensión pulmonar crónica. Por otra parte, la ETV postoperatoria suele ser asintomática o producir manifestaciones clínicas que se atribuyen a otros procesos, por lo que muchas veces esta complicación pasa desapercibida para el cirujano que intervino al paciente. Así pues, la mejor estrategia consiste en una eficaz prevención de la ETV, utilizando para ello las medidas profilácticas adecuadas al nivel de riesgo tromboembólico del paciente. Existe suficiente evidencia de que la ETV se puede prevenir mediante métodos farmacológicos, entre los que destacan la heparina y sus derivados, y con métodos mecánicos como las medias elásticas o los sistemas de compresión neumática intermitente de los miembros inferiores.
Con objeto de reducir en lo posible la incidencia de ETV postoperatoria, se han propuesto estrategias que incluyen la combinación de fármacos y métodos mecánicos, nuevos fármacos antitrombóticos, o prolongar la duración de la profilaxis en los casos de muy alto riesgo, como los operados por cáncer. Otro aspecto importante es el del momento óptimo de inicio de la profilaxis con los fármacos anticoagulantes, con objeto de conseguir un equilibrio adecuado entre la eficacia antitrombótica y el riesgo de presentación de complicaciones hemorrágicas. En este artículo revisamos la evidencia disponible para intentar optimizar en lo posible la prevención de la ETV en cirugía general y en algunos grupos especiales, como la cirugía laparoscópica, de corta estancia y de la obesidad.
Palabras clave:
Compresión neumática intermitente
Enfermedad tromboembólica venosa postoperatoria
Heparina
Heparinas de bajo peso molecular
Prevención
Tromboembolismo pulmonar
Trombosis venosa profunda
El Texto completo está disponible en PDF
Bibliografía
[1]
Sandler DA, Martin J.F..
Autopsy proven pulmonary embolism in hospital patients: Are we detecting enough deep vein thrombosis?.
J Roy Soc Med, 82 (1989), pp. 203-205
[2]
Linblad B, Eriksson A, Bergqvist D..
Autopsy-verified pulmonary embolism in a surgical department: Analysis of the period from 1951 to 1968.
Br J Surg, 78 (1991), pp. 849-852
[3]
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et-al..
Prevention of venous thromboembolism: The seventh ACCP conference on antithrombotic and thrombolytic therapy.
Chest, 126 (2004), pp. S388-S400
[4]
Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et-al..
Venous thromboembolism, (VTE) in Europe. The number of VTE events and associated morbidity and mortality.
Thromb Haemost, 98 (2007), pp. 756-764
[5]
Collins R, Scrimgeour A, Yusuf S, Peto R..
Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopaedic, and urologic surgery.
N Engl J Med, 318 (1988), pp. 1162-1173
[6]
Prandoni P, Lensing A.W.A, Cogo A, Cuppini S, Villalta S, Carta M, et-al..
The long-term course of acute deep venous thrombosis.
Ann Intern Med, 125 (1996), pp. 1-7
[7]
Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F, et-al..
Incidence of chronic thromboemboilic pulmonary hypertension after pulmonary embolism.
N Engl J Med, 350 (2004), pp. 2257-2264
[8]
Arcelus JI, Monreal M, Caprini JA, Guisado JG, Soto MJ, Núñez MJ, et-al..
Clinical presentation and time-course of postoperative venous thromboembolism: Results from the RIETE Registry.
Thromb Haemost, 99 (2008), pp. 546-551
[9]
Stein PD, Henry J.W..
Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy.
Chest, 108 (1995), pp. 978-981
[10]
Kakkar VV, Corrigan TP, Fossard DP, Shelton MG, Thirlwall J..
Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicenter trial.
Lancet, 2 (1975), pp. 45-51
[11]
Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts W.H..
Deep vein thrombosis and its prevention in critically ill adults.
Arch Intern Med, 161 (2001), pp. 1268-1279
[12]
Mismetti P, Laporte S, Darmon JY, Buchmüller A, Decousus H..
Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.
Br J Surg, 88 (2001), pp. 913-930
[13]
Haas S, Wolf H, Kakkar AK, Fareed J, Encke A..
Prevention of fatal pulmonary embolism and surgical mortality in surgical patients. A randomized double-blind comparison of LMWH with unfractionated heparin.
Thromb Haemost, 94 (2005), pp. 814-819
[14]
Agnelli G..
Prevention of venous thromboembolism in surgical patients.
Circulation, 110 (2004), pp. S4-S12
[15]
Bergqvist D, Burmark US, Flordal PA, Frisell J, Hallböök T, Hedberg M, et-al..
Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 XaI units in 2070 patients.
Br J Surg, 82 (1995), pp. 496-501
[16]
Agnelli G, Bergqvist D, Cohen AT, Gallus AS, Gent M, PEGASUS investigators..
Randomized clinical trail of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery.
Br J Surg, 92 (2005), pp. 1212-1220
[17]
Samama CM, Albadalejo P, Benhamou D, Bertin-Maghit M, Bruder N, Doublet JD, et-al..
Venous thromboembolism prevention in surgery and obstetrics: Clinical practice guidelines.
Eur J Anaesthesiol, 23 (2006), pp. 95-116
[18]
Sociedad Española de Anestesiología-Reanimación y Terapéutica del Dolor. Guía clínica de fármacos inhibidores de la hemostasia y anestesia neuroaxial. Rev Esp Anestesiol Reanim. 2005;52:413-20..
[19]
Cohen AT, Bailey CS, Alikhan R, Cooper D.J..
Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty: A meta-analysis.
Thromb Haemost, 85 (2001), pp. 940-941
[20]
Eikelboom JW, Quinlan DJ, Douketis J.D..
Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: A meta-analysis of the randomised trials.
Lancet, 358 (2001), pp. 9-15
[21]
Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, et-al..
Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer.
N Engl J Med, 346 (2002), pp. 975-980
[22]
Lausen I, Jensen R, Jorgensen LN, Rasmussen MS, Lyng KM, Andersen M, et-al..
Incidence and prevention of deep venous thrombosis occurring late after general surgery: Randomised controlled study of prolonged thromboprophylaxis.
Eur J Surg, 164 (1998), pp. 657-663
[23]
Rasmussen M.S..
Preventing thromboembolic complications in cancer patients alter surgery: A role for prolonged thromboprophylaxis.
Cancer Treat Rev, 28 (2002), pp. 141-144
[24]
Rasmussen MS, Jorgensen LN, Wille-Jorgensen P, Nielsen JD, Horn A, Mohn AC, et-al..
Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery.
J Thromb Haemost, 4 (2006), pp. 2384-2390
[25]
Bottaro Rasmussen MS, Wille-Jorgensen P, Jorgensen L.N..
Extended out-of-hospital low molecular weight heparin prophylaxis against venous thromboembolism in patients after cancer operations.
J Thromb Haemost, 3 (2005),
[26]
Akl EA, Terrenato I, Barba M, Sperati F, Muti P, Schünemann J..
Extended perioperative thromboprophylaxis in patients with cancer.
Thromb Haemost, 100 (2008), pp. 1176-1180
[27]
Turpie A.G.G..
Oral, direct factor Xa inhibitors in development for the prevention and treatment of thromboembolic diseases.
Artherioscler Thromb Vasc Biol, 27 (2007), pp. 1238-1247
[28]
Di Nisio M, Middeldorp S, Büller H.R..
Direct thrombin inhibitors.
N Engl J Med, 353 (2005), pp. 1028-1040
[29]
Bounameaux H..
The novel anticoagulants: Entering a new era.
Swiss Med Wkly, 139 (2009), pp. 60-64
[30]
Amaragiri SV, Lees T.A..
Elastic compression stockings for prevention of deep vein thrombosis.
Cochrane Database Systematic Review, 3 (2000),
[31]
Clagett GP, Reisch J.S..
Prevention of venous thromboembolism in general surgical patients. Results of a meta-analysis.
Ann Surg, 208 (1988), pp. 227-240
[32]
Vanek V.W..
Meta-analysis of effectiveness of intermittent pneumatic compression devices with a comparison of thigh-high to knee-high sleeves.
Am Surg, 64 (1998), pp. 1050-1058
[33]
Ramos R, Salem BI, de Pawlikowski MP, Coordes C, Eisenberg S, Leidenfrost R..
The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery.
Chest, 109 (1996), pp. 82-85
[34]
Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy D.J..
Combined intermittent pneumatic compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients.
Cochrane Database Syst Rev, 4 (2008),
[35]
Turpie AG, Bauer K, Caprini JA, Comp PC, Gent M, Muntz JE, Apollo Investigators..
Fondaparinux combined with intermittent pneumatic compression versus intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: A randomized, double-blind comparison.
J Thromb Haemost, 5 (2007), pp. 1854-1861
[36]
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et-al..
Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition).
Chest, 133 (2008), pp. S381-453
[37]
Maíllo CL, Martín E, López J, Jover JM, Martínez J, Margalet I, et-al..
Efecto del neumoperitoneo en la hemodinámica venosa durante la colecistectomía laparoscópica. Influencia de la edad de los pacientes y del tiempo de la cirugía.
Med Clin (Barc), 120 (2003), pp. 330-334
[38]
Caprini JA, Arcelus JI, Laubach M, Size G, Hoffman KN, Coats RW, et-al..
Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy.
Surg Endosc, 9 (1995), pp. 304-309
[39]
Diamantis T, Tsiminikakis N, Skordylaki A, Samiotaki F, Vernadakis S, Bongiorni C, et-al..
Alterations of hemostasis after laparoscopic and open surgery.
Hematology, 12 (2007), pp. 561-570
[40]
Milic DJ, Pejcic VD, Zivic SS, Jovanovic SZ, Stanojkovic ZA, Jankovic RJ, et-al..
Coagulation status and the presence of postoperative deep vein trombosis in patients undergoing laparoscopic cholecystectomy.
Surg Endosc, 21 (2007), pp. 1588-1592
[41]
Cheung HS, Chung CC, Yau KK, Siu WT, Wong SK, Chiu E, et-al..
Risk of deep vein thrombosis following laparoscopic rectosigmoid cancer resection in Chinese patients.
Asian J Surg, 31 (2008), pp. 63-68
[42]
Bergqvist D, Lowe G..
Venous thromboembolism in patients undergoing laparoscopic and arthroscopic surgery and in leg casts.
Arch Intern Med, 162 (2002), pp. 2173-2176
[43]
Ljungström K.-G..
Is there a need for antithrombotic prophylaxis during laparoscopic surgery? Not always.
J Thromb Haemost, 3 (2005), pp. 212-213
[44]
Rasmussen M.S..
Is there a need for antithrombotic prophylaxis during laparoscopic surgery? Always.
J Thromb Haemost, 3 (2005), pp. 210-212
[45]
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)..
Global Statement on deep vein thrombosis prophylaxis during laparoscopic surgery.
Surg Endosc, 13 (1999), pp. 200
[46]
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)..
Guidelines for deep venous thrombosis prophylaxis during laparoscopic surgery.
Surg Endosc, 21 (2007), pp. 1007-1009
[47]
Tincani E, Piccoli M, Turrini F, Crowther MA, Melotti G, Bondi M..
Video laparoscopic surgery: Is out-of-hospital thromboprophyaxis necessary?.
J Thromb Haemost, 3 (2005), pp. 214-215
[48]
Riber C, Alstrup N, Nymann T, Bogstad JW, Wille-Jørgensen P, Tønnesen H..
Postoperative thromboembolism after day-case herniorrhaphy.
Br J Surg, 83 (1996), pp. 420-421
[49]
Enoch S, Woon E, Blair S.D..
Thromboprophylaxis can be omitted in selected patients undergoing varicose veinsurgery and hernia repair.
Br J Surg, 90 (2003), pp. 818-820
[50]
Wasowicz-Kemps DK, Biesma DH, Schagen van Leuween J, van Rashorst B..
Prophylaxis of venous thromboembolism in general and gynecologic day surgery in the Netherlands.
J Thromb Haemost, 4 (2006), pp. 269-271
[51]
Beekman R, Crowther M, Farrokhyar F, Birch D.W..
Practice patterns for deep vein thrombosis prophylaxis in minimalaccess surgery.
Can J Surg, 49 (2006), pp. 197-202
[52]
Grupo corporativo de ASECMA sobre tromboprofilxis en CMA. Recomendaciones de tromboprofilaxis en cirugía mayor ambulatoria. Cir May Amb. 2006;11:11-7..
[53]
Blaszyk H, Björnsson J..
Factor V Leiden and morbid obesity in fatal postoperative pulmonary embolism.
Arch Surg, 135 (2000), pp. 1410-1413
[54]
Hirsh J, Raschke R..
Heparin and low-molecular-weight-heparin. The seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest, 126 (2004), pp. S188-S203
[55]
Nguyen NT, Owings JT, Gosselin R, Pevec W, Lee SJ, Goldman C, et-al..
Systemic coagulation and fibrinolysis after laparoscopic and open gastric bypass.
Arch Surg, 136 (2001), pp. 900-916
[56]
Rocha AT, de Vasconcellos AG, da Luz Neto ER, Araújo DM, Alves ES, Lopes A.A..
Risk of venous thromboembolism and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery.
Obes Surg, 16 (2006), pp. 1645-1655
[57]
Hamad GG, Bergqvist D..
Venous thromboembolism in bariatric surgery patients: An update of risk and prevention.
Surg Obes Dis, 3 (2007), pp. 97-102
[58]
Sapala JA, Wood MH, Schuhknecht MP, Sapala M.A..
Fatal pulmonary embolism after bariatric operations for morbid obesity: A 24-year retrospective analysis.
Obes Surg, 13 (2003), pp. 819-825
[59]
Gonzalez R, Haines K, Nelson LG, Gallagher SF, Murr M.M..
Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass.
Surg Obes Relat Dis, 2 (2006), pp. 30-35
[60]
Scholten DJ, Hoedema RM, Scholten S.E..
A comparison of two diferent prophylactic dose regimens of low molecular weight heparin in bariatric surgery.
Obes Surg, 12 (2002), pp. 19-24
[61]
Prystowsky JB, Morasch MD, Eskandari MK, Hungness ES, Nagle A.P..
Prospective analysis of the incidence of deep vein thrombosis in bariatric surgery patients.
Surgery, 138 (2005), pp. 759-765
[62]
Hamad GG, Choban P.S..
Enoxaparin for thromboprophylaxis in morbidly obese patients undergoing bariatric surgery: Findings of the prophylaxis against VTE outcomes in bariatric surgery patients receiving enoxaparin (PROBE) study.
Obes Surg, 15 (2005), pp. 1368-1374
