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

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Abstract

Background

Morbidly obese patients are at increased risk for venous thromboembolism (VTE) after bariatric surgery. Perioperative chemoprophylaxis is used routinely with bariatric surgery to decrease the risk of VTE. When bleeding occurs, routine chemoprophylaxis is often withheld due to concerns about inciting another bleeding event. We sought to evaluate the relationship between perioperative bleeding and postoperative VTE in bariatric surgery.

Methods

The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) dataset between 2012 and 2014 was queried to identify patients who underwent bariatric surgery. Gastric bypass (n = 28,145), sleeve gastrectomy (n = 30,080), bariatric revision (n = 324), and biliopancreatic diversion procedures (n = 492) were included. Univariate and multivariate regressions were used to determine perioperative factors predictive of postoperative VTE within 30 days in patients who experience a bleeding complication necessitating transfusion.

Results

The rate of bleeding necessitating transfusion was 1.3%. Bleeding was significantly more likely to occur in gastric bypass compared to sleeve gastrectomy (1.6 vs. 1.0%) (p < 0.0001). For all surgeries, increased age, length of stay, operative time, and comorbidities including hypertension, dyspnea with moderate exertion, partially dependent functional status, bleeding disorder, transfusion prior to surgery, ASA class III/IV, and metabolic syndrome increased the perioperative bleeding risk (p < 0.05). Multivariate analysis revealed that the rate of VTE was significantly higher after blood transfusion [Odds Ratio (OR) = 4.7; 95% CI 2.9–7.9; p < 0.0001). Predictive risk factors for VTE after transfusion included previous bleeding disorder, ASA class III or IV, and COPD (p < 0.05).

Conclusions

Bariatric surgery patients who receive postoperative blood transfusion are at a significantly increased risk for VTE. The etiology of VTE in those who are transfused is likely multifactorial and possibly related to withholding chemoprophylaxis and the potential of a hypercoagulable state induced by the transfusion. In those who bleed, consideration should be given to reinitiating chemoprophylaxis when safe, extending treatment after discharge, and screening ultrasound.

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Funding

The funding was provided by Medical College of Wisconsin Division of General Surgery.

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Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, USA

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

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  1. Alexander W. Nielsen
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  2. Melissa C. Helm
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  3. Tammy Kindel
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  4. Rana Higgins
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  5. Kathleen Lak
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  6. Zachary M. Helmen
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  7. Jon C. Gould
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Corresponding author

Correspondence to Jon C. Gould.

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Disclaimer

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and the hospitals participating in the ACS-NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Disclosures

Dr. Jon Gould is a consultant for Torax Medical. Tammy Kindel, Rana Higgins, Kate Lak, Alexander Nielsen, Melissa Helm, and Zachary Helmen have no conflicts of interest or financial ties to disclose.

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Nielsen, A.W., Helm, M.C., Kindel, T. et al. Perioperative bleeding and blood transfusion are major risk factors for venous thromboembolism following bariatric surgery. Surg Endosc 32, 2488–2495 (2018). https://doi.org/10.1007/s00464-017-5951-9

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  • DOI: https://doi.org/10.1007/s00464-017-5951-9

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