Abstract
Background
In the morbidly obese population that undergoes bariatric surgery, venous thromboembolism (VTE) is the leading cause of morbidity and mortality. Certain factors place a patient at higher risk for VTE. No consensus exists on VTE screening or prophylaxis for the high-risk patient. This report describes the results of a survey on VTE screening and prophylaxis patterns in high-risk bariatric surgery.
Methods
Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were queried on factors that identified bariatric patients as high risk for VTE and on routine screening and prophylaxis practices. This included mechanical and chemical prophylaxis, duration of therapy, and use of inferior vena cava (IVC) filters.
Results
Of the 385 surgeons who responded to the survey, 81 % were bariatric surgeons, and the majority managed more than 50 cases annually. One or more of the following risk factors qualified patients as high risk: history of VTE, hypercoagulable status, body mass index (BMI) exceeding 55 kg/m2, partial pressure of arterial oxygen (PaO2) lower than 60 mmHg, and severe immobility. Preoperative screening of patients for VTE was practiced routinely by 56 % of the surgeons, and 92.4 % used preoperative chemoprophylaxis. The most common agent used preoperatively was heparin (48 %), and Lovenox was most commonly used postoperatively (49 %). Whereas 48 % of the patients discontinued chemoprophylaxis at discharge, 43 % continued chemoprophylaxis as outpatients, and 47 % routinely screened for VTE postoperatively. Use of IVC filters was routine for 28 % of the patients, who most commonly removed them after 1–3 months.
Conclusions
This study describes current practice patterns of VTE screening and prophylaxis in high-risk bariatric surgery. Nearly all surgeons agree on risk factors that qualify patients as high risk, but only half routinely screen patients preoperatively. Preoperative VTE chemoprophylaxis is used by nearly all surgeons, but the duration of therapy varies. Use of IVC filters is not routine, and postoperative screening was performed by less than half of the respondents. An understanding of current practice patterns yields insight into the rates of VTE and shows variability in the need for evidence-based prophylaxis and standardized screening.
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References
ASMBS (2010) Metabolic and Bariatric Surgery Fact Sheet. http://s3.amazonaws.com/publicASMBS/Resources/Fact-Sheets/Metabolic-Bariatric-Surgery-Fact-Sheet-ASMBS2012.pdf
Flegal KM, Carroll MD, Ogden CL, Curtin LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. J Am Med Assoc 303:235–241
Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT (2003) Complications after laparoscopic gastric bypass: a review of 3,464 cases. Arch Surg 138:957–961
Abdollahi M, Cushman M, Rosendaal FR (2003) Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost 89:493–498
Di Minno G, Mannucci PM, Tufano A, Palareti G, Moia M, Baccaglini U, Rudelli G, Giudici GA (2005) The first ambulatory screening on thromboembolism: a multicentre, cross-sectional, observational study on risk factors for venous thromboembolism. J Thromb Haemost 3:1459–1466
Kucher N, Tapson VF, Goldhaber SZ (2005) Risk factors associated with symptomatic pulmonary embolism in a large cohort of deep vein thrombosis patients. J Thromb Haemost 93:494–498
Stein PD, Beemath A, Olson RE (2005) Obesity as a risk factor in venous thromboembolism. Am J Med 118:978–980
Goldhaber SZ, Grodstein F, Stampfer MJ, Manson JE, Colditz GA, Speizer FE, Willett WC, Hennekens CH (1997) A prospective study of risk factors for pulmonary embolism in women. J Am Med Assoc 277:642–645
Keenan CR, White RH (2005) Age as a risk factor for venous thromboembolism after major surgery. Curr Opin Pulm Med 11:398–402
Wu EC, Barba CA (2000) Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg 10:7–13 discussion 14
Frezza EE, Wachtel MS (2006) A simple venous thromboembolism prophylaxis protocol for patients undergoing bariatric surgery. Obesity Silver Spring 14:1961–1965
Gugliotti DV (2006) What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery? IMPACT consults. Proceedings of the 2nd Annual Cleveland Clinic Perioperative Medicine Summit. Cleve Clin J Med 73(1 (Electronic Suppl)):S17–S18
Kalfarentzos F, Stavropoulou F, Yarmenitis S, Kehagias I, Karamesini M, Dimitrakopoulos A, Maniati A (2001) Prophylaxis of venous thromboembolism using two different doses of low-molecular-weight heparin (nadroparin) in bariatric surgery: a prospective randomized trial. Obes Surg 11:670–676
Miller MT, Rovito PF (2004) An approach to venous thromboembolism prophylaxis in laparoscopic Roux-en-Y gastric bypass surgery. Obes Surg 14:731–737
Spyropoulos AC, Anderson FA Jr, Fitzgerald G, Decousus H, Pini M, Chong BH, Zotz RB, Bergmann JF, Tapson V, Froehlich JB, Monreal M, Merli GJ, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA (2011) Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest 140:706–714
Prystowsky JB, Morasch MD, Eskandari MK, Hungness ES, Nagle AP (2005) Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery 138:759–763 discussion 763–755
Bauer KA (2001) The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med 135:367–373
Overby DW, Kohn GP, Cahan MA, Galanko JA, Colton K, Moll S, Farrell TM (2009) Prevalence of thrombophilias in patients presenting for bariatric surgery. Obes Surg 19:1278–1285
Zavorsky GS, Hoffman SL (2008) Pulmonary gas exchange in the morbidly obese. Obes Rev 9:326–339
Boone KA, Cullen JJ, Mason EE, Scott DH, Doherty C, Maher JW (1996) Impact of vertical banded gastroplasty on respiratory insufficiency of severe obesity. Obes Surg 6:454–458
Rocha AT, de Vasconcellos AG, da Luz Neto ER, Araujo DM, Alves ES, Lopes AA (2006) Risk of venous thromboembolism and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery. Obes Surg 16:1645–1655
Hamad GG, Choban PS (2005) 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 15:1368–1374
Barba CA, Harrington C, Loewen M (2009) Status of venous thromboembolism prophylaxis among bariatric surgeons: have we changed our practice during the past decade? Surg Obes Relat Dis 5:352–356
Gargiulo NJ III, Veith FJ, Lipsitz EC, Suggs WD, Ohki T, Goodman E (2006) Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures. J Vasc Surg 44:1301–1305
PREPIC Study Group (2005) Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 112:416–422
Vaziri K, Devin Watson J, Harper AP, Lee J, Brody FJ, Sarin S, Ignacio EA, Chun A, Venbrux AC, Lin PP (2011) Prophylactic inferior vena cava filters in high-risk bariatric surgery. Obes Surg 21:1580–1584
Disclosures
Howard I. Pryor II, Adam Singleton, Elissa Lin, Paul Lin, and Khashayar Vaziri have no conflict of interest or financial ties to disclose.
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Pryor, H.I., Singleton, A., Lin, E. et al. Practice patterns in high-risk bariatric venous thromboembolism prophylaxis. Surg Endosc 27, 843–848 (2013). https://doi.org/10.1007/s00464-012-2521-z
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DOI: https://doi.org/10.1007/s00464-012-2521-z