Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery

Nielsen, Alexander; Helm, Melissa C.; Kindel, Tammy L.; Higgins, Rana M.; Lak, Kathleen; Helmen, Zachary M; Gould, Jon C.

doi:10.1007/s00464-017-5951-9

Cited by 36 publications

(19 citation statements)

References 23 publications

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“…Congestive heart failure, paraplegia, dyspnea at rest, and re‐operation are associated with the highest risk of postdischarge DVT. Postoperative bleeding and subsequent transfusion after bariatric surgery are also associated with increased VTE risk, most likely due to withholding chemoprophylaxis .…”

Section: Executive Summarymentioning

confidence: 99%

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

326

464

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Objective The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. Methods Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. Results New or updated topics in this CPG include: contextualization in an adiposity‐based chronic disease complications‐centric model, nuance‐based and algorithm/checklist‐assisted clinical decision‐making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Conclusions Bariatric procedures remain a safe and effective intervention for higher‐risk patients with obesity. Clinical decision‐making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

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Section: Executive Summarymentioning

confidence: 99%

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

326

464

View full text Add to dashboard Cite

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“…While transfusions were not necessary in any of the patients in this study, additional surgical clips and intraabdominal surgical gauze were necessary to mitigate bleeding to maintain patient safety during the surgical procedure. Intraoperative bleeding and subsequent blood transfusions have been associated with VTE risk in bariatric surgery [40] . The association of minor to moderate bleeding not requiring transfusion, and the risk of VTE is unknown, yet does not mitigate the possibility of a likely positive correlation.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulant activity of enoxaparin and unfractionated heparin for venous thromboembolism prophylaxis in obese patients undergoing sleeve gastrectomy

Brunetti

Wassef

Sadek

et al. 2019

Surgery for Obesity and Related Diseases

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Background: One risk of bariatric surgery is venous thromboembolism and the optimal strategy to reduce risk requires further clarification. Objectives: The objectives of this study were to identify antiXa goal attainment with the institutional standard chemoprophylaxis, analyze discordance between antiXa and thrombin generation assay (TGA) in terms of adequacy of anticoagulation, and to identify correlations between patient characteristics or covariates and markers of coagulation status. Setting: Large academic medical center in Northeastern United States. Methods: A total of 60 sleeve gastrectomy patients were enrolled in this institutional review board-approved, prospective cohort study. Patients received the institutional standard prophylactic therapy (subcutaneous enoxaparin 40 mg twice daily or unfractionated heparin [UFH]). The UFH dose was weight based, 5000 units ( < 120 kg) or 7500 units ( ≥120 kg) every 8 hours. Various measures of coagulation status were measured at or near steady state. Results: Patients receiving enoxaparin achieved goal antiXa more frequently compared with the UFH group, and statistical significance was demonstrated (93.8 % versus 4.5%, respectively; P < .0001). Target endogenous thrombin potential reduction from baseline was more frequently obtained in the enoxaparin group versus UFH (50% versus 27.7%, respectively; P = .12). AntiXa was below the limit of detection for the majority of UFH patients; while TGA suggested patients did experience anticoagulation at some level of effectiveness. Endogenous thrombin potential change in the enoxaparin group was correlated to several measures of body composition. Conclusions:Patients receiving enoxaparin achieved goal antiXa more often versus UFH. There was discordance between antiXa and TGA-based assessment of coagulation status. TGA may provide a more robust assessment of the adequacy of chemoprophylaxis. (Surg Obes Relat Dis 2019;15:363-373.)

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“…anastomotic leaks) [ 16 ] contribute to prolonged immobility that increases the risk of VTE. In addition, major bleeding (more likely in gastric bypass vs sleeve gastrectomy) that necessitates blood transfusion might also significantly increase the risk of VTE (Odds Ratio 4.7; 95% CI 2.9–7.9) [ 17 ]. Conversion to open surgery had the greatest impact on VTE, suggesting that perioperative factors like exposure to tissue factor by larger wounds have great bearing on VTE [ 18 ].…”

Section: Introductionmentioning

confidence: 99%

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Ansari

El-Ansari

2020

Annals of Medicine and Surgery

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Background Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality. Methods This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions. Results VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies. Conclusion VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

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Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery

Cited by 36 publications

References 23 publications

Anticoagulant activity of enoxaparin and unfractionated heparin for venous thromboembolism prophylaxis in obese patients undergoing sleeve gastrectomy

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

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