Skip to main content
SpringerLink
Log in

Are We Missing Treatment Standards for Thromboprophylaxis of the Obese and Super-Obese Patient Population? A Prospective Systematic Cohort Study

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

Abstract

Background

Venous thromboembolism (VTE) is the most frequent 30-day complication in patients with morbid obesity undergoing bariatric surgery. Therefore, there is a need for optimized low molecular weight heparin (LMWH) thromboprophylaxis dosing strategies in order to avoid VTE-associated morbidity and mortality in this patient population.

Objective

The primary goal was to evaluate if a pre-specified enoxaparin dosing regimen in patients undergoing bariatric surgery reaches anti-factor Xa (aFXa) levels in the defined target range (0.2–0.4 U/ml). Second, we aimed to identify biometric and laboratory parameters that might influence the aFXa value.

Methods

A prospective database of 236 patients with obesity who received thromboprophylaxis with enoxaparin was established. These patients were divided into two weight-adjusted groups (group 1 < 150 kg, group 2 ≥ 150 kg). Enoxaparin was administered twice daily; dosing was determined by weight (group 1, 2 × 40 mg/day; group 2, 2 × 60 mg/day). In both groups, the peak aFXa serum level was evaluated 3 days after initiating the thromboprophylaxis.

Results

In group 1 (body mass index (BMI) 42.94 ± 6.84 kg/m2, weight of 121.7 ± 17.49 kg), seventy-one of the included 124 patients (57.25%) reached the aFXa target range of 0.2 to 0.4 U/m. In group 2 (BMI 63.21 ± 10.05 kg/m2, weight of 191.66 ± 33.37 kg), 68 of 112 (60.71%) patients scored prophylactic aFXa range. Multiple regression of the biometric and laboratory parameters showed significance for weight, waist-to-hip ratio, glomerular filtration rate (GFR), creatinine, and HbA1c exclusively in group 1. There was no case of VTE within 3 months after surgery and no case of severe perioperative bleeding in those patients who underwent surgery.

Conclusions

Measurement of the aFXa level helps to define the real prophylactic thromboprophylaxis status in patients with obesity, especially in those with a weight above 150 kg. In patients at risk, the measurement of aFXa should be considered in routine clinical practice.

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
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Chang SH, Freeman NLB, Lee JA, et al. Early major complications after bariatric surgery in the USA, 2003-2014: a systemic review and meta-analysis. Obes Rev. 2018;19(4):529–37.

    Article  PubMed  Google Scholar 

  2. Daigle CR, Brethauer SA, Tu C, et al. Which postoperative complications matters most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcome. SOARD. 2018;14(5):652–7.

    Google Scholar 

  3. Venclauskas L, Maleckas A, Arcelus JI, et al. European guidelines on perioperative venous thromboembolism prophylaxis: surgery in the obese patient. Eu J Anaestesiol. 2018;35(2):147–53.

    Article  Google Scholar 

  4. Hamadi R, Marlow CF, Nasseredidne S, et al. Bariatric venous thromboembolism prophylaxis: an update on the literature. Expert Rev Hematol. 2019;20

  5. Bartlett MA, Mauck KF, Daniels PR. Prevention of venous thromboembolism in patients undergoing bariatric surgery. Vasc Health Risk Manag. 2015;11:461–77.

    PubMed  PubMed Central  Google Scholar 

  6. Shelkrot M, Miraka J, Perez ME. Appropriate enoxaparin dose for venous thromboembolism prophylaxis in patients with extreme obesity. Hosp Pharm. 2014;49(8):740–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Vilahur G et al. New insights into the role of adipose tissue in thrombosis. Cardiovasc Res. 2017;113(9):1046–54.

    Article  CAS  PubMed  Google Scholar 

  8. Chiappetta S, Schaak HM, Wölnerhannsen B, et al. The impact of obesity and metabolic surgery on chronic inflammation. Obes Surg. 2018;28(10):3028–40.

    Article  PubMed  Google Scholar 

  9. Müller S, Runkel N. Delphi survey: anticoagulation in obese patients. Bariatric surgery consensus on antithrombotic prophylaxis. CHAZ. 2017;3(18):127–32.

    Google Scholar 

  10. Moulin PA, Dutour A, Ancel P, et al. Perioperative thromboprophylaxis in severely obese patients undergoing bariatric surgery: insights from a French national survey. SOARD. 2017;13:320–6.

    Google Scholar 

  11. Rowan BO, Kuhl DA, Lee MD, et al. Anti-Xa levels in bariatric surgery patients receiving prophylactic enoxaparin. Obes Surg. 2008;18:162–6.

    Article  PubMed  Google Scholar 

  12. Ikesaka R, Delluc A, Le Gal G, et al. Efficacy and safety of weight-adjusted heparin prophylaxis for the prevention of acute venous thromboembolism among obese patients undergoing bariatric surgery: a systematic review and meta-analysis. Thromb Res. 2014;133(4):682–7.

    Article  CAS  PubMed  Google Scholar 

  13. Aminian A, Andalip A, Khorgami Z, et al. Who should get extended thromboprophylaxis after bariatric surgery? Ann Surg. 2017;265(1):143–50.

    Article  PubMed  Google Scholar 

  14. Kabrhel C, Varraso R, Goldhaber SZ, et al. Prospective study of BMI and the risk of pulmonary embolism in women. Obesity (Silver Spring). 2009;17(11):2040–6.

    Article  Google Scholar 

  15. Khoursheed M, Al-Bader I, Al-Asfar F, et al. Therapeutic effect of low-molecular weight heparin and incidence of lower limb deep venous thrombosis and pulmonary embolism after laparoscopic bariatric surgery. Surg Lap Endosc Percutan Tech. 2013;23(6):491–3.

    Google Scholar 

  16. Kalfarentzos F, Stavropoulou F, Yarmenitis S, et al. Prophylaxis of venous thromboembolism using two different doses of low-molecular-weight heparin (nadroparin) in bariatric surgery: a prospective randomized trial. Obes Surg. 2001;11(6):670–6.

    Article  CAS  PubMed  Google Scholar 

  17. Scholten DJ, Hoedema RM, Scholten SE. A comparison of two different prophylactic dose regimens of low molecular weight heparin in bariatric surgery. Obes Surg. 2002;12(1):19–24.

    Article  PubMed  Google Scholar 

  18. Munoz_Atienza V, Gil-Rendo A, Amo-Salas M, et al. Extended use of bemiparin as thromboprophylaxis during bariatric surgery: results of anti-factor Xa activity. Surg Obes Relat Dis. 2018;14(3):354–60.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sana Obesity Center of Nordrhein-Westfalen, Hürth, Nordrhein-Westfalen, Germany

    Christine Stier

  2. University Hospital Wuerzburg, Wuerzburg, Germany

    Ann-Cathrin Koschker

  3. University Hospital Leipzig, Leipzig, Germany

    Raphael Stier

  4. Hospital of the Augustinians, Cologne, Germany

    Alexander Sosnierz

  5. Department of Obesity and Metabolic Surgery, Ospedale Evangelico Betania, Naples, Italy

    Sonja Chiappetta

Authors
  1. Christine Stier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ann-Cathrin Koschker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Raphael Stier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alexander Sosnierz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sonja Chiappetta
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the article. CS designed the study and collected data. SC and RS calculated statistics. AK and SC improved the composition of the article with their wealth of knowledge. CS, SC, AK, RS, and AS reviewed and improved the article.

Corresponding author

Correspondence to Christine Stier.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

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

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Stier, C., Koschker, AC., Stier, R. et al. Are We Missing Treatment Standards for Thromboprophylaxis of the Obese and Super-Obese Patient Population? A Prospective Systematic Cohort Study. OBES SURG 30, 1704–1711 (2020). https://doi.org/10.1007/s11695-020-04383-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-020-04383-w

Keywords

Search

Navigation