Skip to main content

Advertisement

SpringerLink
Log in

Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation.

Methods

This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020–July 2022) to those who did not (March 2011–March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation.

Results

TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death.

Conclusions

This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.

Graphical Abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Reproduced from Park et al., 2015 [13] under Creative Commons 4.0 License. tPA tissue plasminogen activator, FDP fibrin degradation products

Similar content being viewed by others

References

  1. Welbourn R, Hollyman M, Kinsman R, et al. Bariatric surgery worldwide: baseline demographic description and one-year outcomes from the Fourth IFSO Global Registry Report 2018. Obes Surg. 2019;29(3):782–95.

    Article  PubMed  Google Scholar 

  2. Aiolfi A, Gagner M, Zappa MA, et al. Staple line reinforcement during laparoscopic sleeve gastrectomy: systematic review and network meta-analysis of randomized controlled trials. Obes Surg. 2022;32(5):1466–78.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Shikora SA, Mahoney CB. Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25(7):1133–41.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mocanu V, Dang J, Ladak F, et al. Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry. Surg Obes Related Dis. 2019;15(10):1675–81.

    Article  Google Scholar 

  5. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105–16.

  6. Devereaux PJ, Marcucci M, Painter TW, et al. Tranexamic Acid in Patients Undergoing Noncardiac Surgery. N Engl J Med. 2022;386(21):1986–97.

    Article  CAS  PubMed  Google Scholar 

  7. Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The efficacy of tranexamic acid in total hip arthroplasty: a network meta-analysis. J Arthroplasty. 2018;33(10):3083-9.e4.

    Article  PubMed  Google Scholar 

  8. Koh A, Adiamah A, Gomez D, et al. Safety and efficacy of tranexamic acid to minimise perioperative bleeding in hepatic surgery: a systematic review and meta-analysis. World J Surg. 2022;46(2):441–9.

    Article  PubMed  Google Scholar 

  9. Omori K, Roberts I. Prehospital tranexamic acid for trauma victims. J Intensive Care. 2023;11(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Roberts I, Shakur-Still H, Aeron-Thomas A, et al. Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT. Health Technol Assess. 2021;25(26):1–76.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Lynn W, Ilczyszyn A, Aguilo R, Agrawal S. Standardised sleeve gastrectomy without reinforcement. JSLS: J Soc Laparoendosc Surg. 2018;22(3):e2018.00015. https://doi.org/10.4293/JSLS.2018.00015.

  12. Wu TB, Orfeo T, Moore HB. Computational model of tranexamic acid on urokinase mediated fibrinolysis. PLoS One. 2020;15(5):e0233640.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Park CI, Kim J, Park S, Kim SH. Tranexamic acid in trauma management. J Acute Care Surg. 2015;5:47–51.

    Article  Google Scholar 

  14. Mocanu V, Wilson H, Verhoeff K, et al. Role of tranexamic acid (TXA) in preventing bleeding following sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg. 2023;33:1571–9. https://doi.org/10.1007/s11695-023-06563-w.

    Article  PubMed  Google Scholar 

  15. Myles PS, Smith JA, Forbes A, et al. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017;376(2):136–48.

    Article  CAS  PubMed  Google Scholar 

  16. Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32.

    Article  CAS  PubMed  Google Scholar 

  17. Cunningham-Hill M, Mazzei M, Zhao H, et al. The impact of staple line reinforcement utilization on bleeding and leak rates following sleeve gastrectomy for severe obesity: a propensity and case–control matched analysis. Obesity Surgery. 2019;29(8):2449–63.

    Article  PubMed  Google Scholar 

  18. Iannelli A, Chierici A, Castaldi A, et al. Bioabsorbable glycolide copolymer is effective in reducing staple line bleeding in sleeve gastrectomy. Obes Surg. 2022;32(8):2605–10.

    Article  PubMed  Google Scholar 

  19. Chakravartty S, Sarma DR, Chang A, et al. Staple line bleeding in sleeve gastrectomy—a simple and cost-effective solution. Obes Surg. 2016;26(7):1422–8.

    Article  PubMed  Google Scholar 

  20. Klaassen RA, Selles CA, van den Berg JW, et al. Tranexamic acid therapy for postoperative bleeding after bariatric surgery. BMC Obesity. 2018;5(1):36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Alhomoud H. The effect of tranexamic acid on blood loss during laparoscopic sleeve gastrectomy. World J Laparosc Surg. 2016;9(1):30–3.

    Article  Google Scholar 

  22. Brito RM de, Oliveira CMB de, Moura ECR, Campelo GP, Lima RC, Fe CS de M, et al. Tranexamic acid effects in postoperative bleeding outcomes in laparoscopic sleeve gastrectomy: a controlled study. Acta Cir Bras [Internet]. Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia. 2022;37:e370702. https://doi.org/10.1590/acb370702.

  23. Lech P, Michalik M, Waczyński K, et al. Effectiveness of prophylactic doses of tranexamic acid in reducing hemorrhagic events in sleeve gastrectomy. Langenbeck’s Arch Surg. 2022;407(7):2733–7.

    Article  Google Scholar 

  24. Ockerman A, Vanassche T, Garip M, et al. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J. 2021;19(1):54.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Spyridon G, Bhavani P, Dimitrios S. Management of gastrointestinal bleeding following bariatric surgery. Mini-invasive Surg. 2022;6:22.

    Article  Google Scholar 

  26. Bellorin O, Abdemur A, Sucandy I, et al. Understanding the significance, reasons and patterns of abnormal vital signs after gastric bypass for morbid obesity. Obes Surg. 2011;21(6):707–13.

    Article  PubMed  Google Scholar 

  27. Aminian A, Vosburg RW, Altieri MS, et al. The American Society for Metabolic and Bariatric Surgery (ASMBS) updated position statement on perioperative venous thromboembolism prophylaxis in bariatric surgery. Surg Obes Related Dis. 2022;18(2):165–74.

    Article  Google Scholar 

  28. Allen D, Sale G. Lower limb joint replacement in patients with a history of venous thromboembolism. Bone Joint J. 2014;96-B(11):1515–9.

    Article  CAS  PubMed  Google Scholar 

  29. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DAJ, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2):344–50.

    Article  PubMed  Google Scholar 

  30. Colorectal Writing Group for the Surgical Care and Outcomes Assessment Program–Comparative Effectiveness Research Translation Network (SCOAP-CERTAIN) Collaborative. Thromboembolic complications and prophylaxis patterns in colorectal surgery. JAMA Surg. 2015;150(8):712–720.

  31. Agrawal S. Impact of bariatric fellowship training on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass in the first year as consultant surgeon. Obes Surg. 2011;21(12):1817–21.

    Article  PubMed  Google Scholar 

  32. Leeman M, Huisbrink J, Wijnand JMA, et al. Trial protocol: preoperative administration of tranexamic acid in sleeve gastrectomy (PATAS) to reduce haemorrhage rates. A randomised controlled trial. BMJ Open. 2020;10(2):e034572.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Dr. Natasha Das, Bhubaneswar, India, provided substantial editing and formatting services for this manuscript.

Author information

Authors and Affiliations

  1. Department of Bariatric Surgery, Homerton University Hospital, Homerton Row, London, E9 6SR, UK

    Naveed Hossain, Vasha Kaur, Mostafa Mahran, Abdul Quddus & Sanjay Agrawal

  2. Department of Anaesthesia, Homerton University Hospital, Homerton Row, London, E9 6SR, UK

    Santanu Mukhopadhyay & Akshat Shah

Authors
  1. Naveed Hossain
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vasha Kaur
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mostafa Mahran
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Abdul Quddus
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Santanu Mukhopadhyay
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Akshat Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sanjay Agrawal
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sanjay Agrawal.

Ethics declarations

Ethics Approval

This study was registered as an audit in Homerton Hospital R&D. Ethical approval was not required for this retrospective study.

Informed Consent

For this type of study, formal consent is not required.

Conflict of Interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Key points

• This is the largest cohort study of TXA in LSG to date.

• Demonstrates a significant decrease in postoperative bleeding without any increase in VTE risk.

• No significant change in leak rate was demonstrated.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hossain, N., Kaur, V., Mahran, M. et al. Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients. OBES SURG 34, 396–401 (2024). https://doi.org/10.1007/s11695-023-07021-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-023-07021-3

Keywords

Search

Navigation