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Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery

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Abstract

Background

Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery.

Methods

This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups.

Results

There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6–52.2), and median BMI of 44.9 (IQR: 40.9–50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)).

Conclusions

An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.

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Acknowledgements

Author AJR is supported on a training grant by the National Cancer Institute. Surgical Multispecialty Access to Research in Residency Training (SMART) training grant [R38 CA245095].

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Authors and Affiliations

  1. Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Audra J. Reiter

  2. Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Audra J. Reiter, Joanne Prinz, Yan Li, Alexander P. Nagle, Eric S. Hungness & Ezra N. Teitelbaum

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Correspondence to Ezra N. Teitelbaum.

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Disclosure

None related to this project. Audra J. Reiter: Intuitive Surgical, one-time honorarium. Alexander P. Nagle: Baxter. Eric S. Hungness: Intuitive, Baxter, Boston Scientific, Olympus, Ethicon. Ezra N. Teitelbaum: Boston Scientific Education and Consulting. Joanne Prinz and Yan Li: none.

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Reiter, A.J., Prinz, J., Li, Y. et al. Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery. Surg Endosc 37, 6983–6988 (2023). https://doi.org/10.1007/s00464-023-10219-2

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